Probiotics: Pre-Trip Panacea?

The probiotic supplement Florastor has a following, if not much evidence that it helps prevent travelers' diarrhea.
The probiotic supplement Florastor has a following, if not much evidence that it helps prevent travelers' diarrhea.
By Jennifer Huget
Special to The Washington Post
Sunday, March 25, 2007

You're finally taking that long-dreamed-of trip to Mexico, and one thing's for sure: You don't want a bout of diarrhea to force you off the beach or out of the ruins. So you pack your Pepto-Bismol and your hand sanitizer. Should you also stash a supply of helpful bacteria?


The jury's out as to whether probiotics -- "pro" for good, "biotics" for microscopic living organisms -- can help ward off travelers' diarrhea, or TD, which affects 20 percent or more of travelers to developing countries, according to estimates from the Centers for Disease Control and Prevention (CDC).

TD, like many domestic forms of diarrhea, occurs when pathogenic (bad) bacteria, parasites or viruses enter the digestive system. They upset the balance of "flora," or naturally occurring bacteria, in the gut; as the bad bacteria overcome the good guys, you get sick.

TD is characterized by four or more loose or watery bowel movements in a day; it can be accompanied by cramps, nausea, fever and other un-vacation-friendly symptoms. Most cases are caused by eating food or drinking water infected with such pathogens as E. coli. A traveler's risk of getting TD depends largely on his destination. Developed nations = low risk, underdeveloped countries = higher risk. The whole mess usually runs its course in a couple of days. But those days can seem very long indeed, especially when they're cutting into your touring time.

In theory, populating your gut with healthy bacteria or yeasts can help combat those disease-causing organisms. The notion has gained currency in recent decades in the world of alternative medicine and even in mainstream commerce, where products such as Dannon's new Activia yogurt, enhanced with probiotics, are proliferating like happy bacteria. But although science has begun to establish probiotics' utility in treating some maladies, including varieties of diarrhea caused by antibiotic use and those associated with Crohn's disease, nobody has quite demonstrated that popping probiotics while traveling can keep the runs on the run.

That's not stopping Biocodex, purveyor of the probiotic supplement Florastor, from suggesting -- in carefully crafted language -- that its product, taken twice daily before, during and for a few days after a trip, can help keep your bowels healthy. The product's regulation as a dietary supplement by the U.S. Food and Drug Administration prohibits any out-and-out claims that it can prevent TD without supporting science.

In any event, Florastor, available since 2003 in the United States but widely used in Europe for the past 50 years, has a following, if not much evidence to support a role in preventing TD. A single study, published in the journal Travel Medicine International in 1989, suggests a modest benefit associated with taking a probiotic yeast related to Florastor's active ingredient.

But few scientists are convinced.

"I don't know of any legitimate or upstanding author on this topic who would support using probiotics this way," says Sherwood Gorbach, professor of public health and medicine at Tufts University School of Medicine in Boston. "There is uniformly no evidence supporting the use of probiotics against travelers' diarrhea." Probiotics, he says, "are safe, and people use them. But if you're looking for scientific evidence, it's not there."

Mary Ellen Sanders, executive director of the International Scientific Association for Probiotics and Prebiotics, agrees. "I am not aware of any controlled human studies that strongly support the use of probiotics and their ability to prevent travelers' diarrhea," she says.

But, she adds, probiotic supplements are safe and cheap (50 Florastor capsules cost about $35 on, so they offer "very low-risk, low-cost extra insurance" against TD, especially for people who are prone to the illness. "I can't see a downside to encouraging people" to take preventive probiotics, Sanders says. Sanders serves as scientific consultant to many makers of probiotic-containing products.

The travel-medicine community takes a measured view.

Mark Wise, a travel-medicine specialist and author of "The Travel Doctor: Your Guide to Staying Healthy While You Travel" (Firefly Books, 2002), says Florastor, for instance, might be used as a backup plan.

"I sort of focus on the 'boil it, bottle it, peel it, cook it or forget it' " mantra that many travel doctors prescribe for avoiding illness while traveling, Wise explains. "But most people will make mistakes sometimes, going to a resort and having salad anyway, because they trust it." Since he knows he can't save all his clients from making such mistakes, he sends them with Imodium (whose active ingredient, loperamide, decreases stool output) and Cipro (the wide-spectrum antibiotic ciprofloxacin) to slow diarrhea and kill off the offending bacteria. Nor would he discourage their taking a probiotic.

But Fran Lessans, president and chief executive of the network of Passport Health travel health clinics, is concerned that people might rely on unproven probiotics rather than arm themselves with proven treatments. "We always recommend something [like Cipro] from the quinolones family of drug, an anti-motility agent [such as Imodium] and an oral rehydration solution" to treat the dehydration that often results from diarrhea. "It's good to have something with you before you go," she says. "Trying to find something in a foreign country where you don't speak the language" can only add to your woes. As for packing a probiotic, Lessans says, "We don't discourage it. It won't hurt you. But don't rely on it."

The, er, bottom line? "I don't think there's a downside" to taking probiotics, Wise says. "People are welcome to use them, as long as they understand that it doesn't entitle them to drink whatever they want or eat whatever they want."

Jennifer Huget writes about health for The Post.

© 2007 The Washington Post Company