Also indexed as: Stools (Loose)
Any attack of frequent, watery stools is called diarrhea. It can be
triggered by many different conditions. Acute diarrhea is often caused
by an infection and may require medical management. The primary role of
nutrition in acute diarrhea is to prevent depletion of fluid, sodium,
potassium, and calories. Replenishment of all four has been achieved with
“rehydration solutions” and with a variety of foods, from salted
soup to peeled scraped apple to rice gruel. However, the need
for rehydration requires direct medical supervision. Therefore,
nutritional approaches to overcoming depletion of fluid, sodium,
potassium, and calories are not discussed here, but rather should be
discussed with a doctor. Diarrhea-induced low blood sugar, dehydration, or
electrolyte imbalance can be serious or even life-threatening,
particularly if prolonged in children.
A healthcare provider should be consulted if diarrhea continues for
more than a few days, as it may indicate a more serious health condition.
Diarrhea alternating with constipation may be a sign of irritable bowel
syndrome (IBS).
What are the symptoms of diarrhea? Normal
bowel habits vary considerably from person to person depending on age,
diet, cultural factors, and individual physiology. However, loose watery
stools occurring three or more times in one day is generally considered
abnormal. In some instances, diarrhea may be accompanied by cramping
abdominal pain, nausea, vomiting, fever, loss of appetite, and bloody or
foul-smelling stools.
Conventional treatment options: Rest and
fluid replacement (sometimes with the use of oral rehydration solutions
such as Pedialyte®, Ceralyte®, or Infalyte®) are often recommended. Severe
diarrhea, especially in children and the elderly, may require
hospitalization for urgent fluid and electrolyte replacement to correct
dehydration. Medicines to stop diarrhea, such as loperamide (Imodium®),
(Pepto Bismol®), attapulgite (Kaopectate®),
diphenoxylate (Lomotil®, Lonox®, Motofen®), and opiates (,
paregoric) may be prescribed in some cases.
Dietary changes that may be helpful: Some
foods contain sugars that are absorbed slowly, such as fructose in fruit
juice or sorbitol in dietetic confectionery. Through a process called
osmosis, these unabsorbed sugars hold onto water in the intestines,
sometimes leading to diarrhea. 1 By reading labels, people with
chronic non-infectious diarrhea can easily avoid fruit juice, fructose,
and sorbitol to see if this eliminates the problem. People who are
lactose intolerant—meaning they lack the enzyme needed to digest milk
sugar—often develop diarrhea after consuming
or
. People whose lactose intolerance is the cause of diarrhea
will rid themselves of the problem by avoiding milk and ice cream or in
many cases by taking
, the enzyme needed to digest lactose. Lactase is available in
a variety of forms in pharmacies (and in grocery stores in the form of
lactase-treated milk).
Large amounts of vitamin C or magnesium found in supplements can also
cause diarrhea, although the amount varies considerably from person to
person. Unlike infectious diarrhea, diarrhea caused by high amounts of
vitamin C or magnesium is not generally accompanied by other signs of
illness. The same is true when the problem comes from sorbitol or
fructose.2 In these cases, avoiding the offending supplement or
food brings rapid relief.
Drinking several cups of
per day causes diarrhea in some people.3 People with
chronic diarrhea who drink coffee should avoid all coffee for a few days
to evaluate whether coffee is the culprit.
Allergies and food sensitivities are common triggers for diarrhea.4
For example, some infants suffer diarrhea when fed cow’s
-based formula but improve when switched to
-based formula.5 People with chronic diarrhea not
attributable to other causes should discuss the possibility of food
sensitivity with a doctor.
Some doctors recommend a diet called the BRAT diet for acute bouts of
diarrhea. BRAT stands for bananas, rice, apples and toast. These foods are
mild, well-tolerated and good sources of fiber, potassium and other
nutrients that may be helpful in diarrhea. The efficacy of this diet has
not been evaluated in clinical trials.
Nutritional supplements that may be helpful:
An organism related to brewer’s yeast, Saccharomyces boulardii (Sb),
is widely used in Europe to prevent antibiotic-induced diarrhea. It is
also available as a supplement in the United States. Animal research with
Sb shows interference with Clostridium difficile, a common
bacterial cause of diarrhea. 6 In double-blind trials, Sb has
prevented antibiotic-induced 7 and other forms of infectious
diarrhea. 8 An intake of 500 mg four times per day has been used
in some of this research. Sb has also helped tourists prevent traveler’s
diarrhea, according to double-blind research. 9 In one trial,
positive results were obtained at amounts as low as 150–450 mg per day. 10
Even diarrhea caused by Crohn’s disease has partially responded to Sb
supplementation in double-blind research. 11 While not every
trial shows efficacy, 12 the preponderance of evidence clearly
supports the use of Sb in people with diarrhea caused by antibiotics or
infection. Seriously ill patients should consult with their doctor before
supplementing with Sb, as rare but serious cases of infection caused by Sb
in such patients has been reported. 13Beneficial bacteria,
such as lactobacilli and bifidobacteria, normally live in a healthy colon,
where they inhibit the over-growth of disease-causing bacteria.14
Diarrhea flushes intestinal microorganisms out of the digestive tract,
leaving the body vulnerable to opportunistic infections. Replenishing with
acidophilus and other beneficial probiotic bacteria can help resolve the
diarrhea and prevent new infections.15 The effective amount of
probiotic bacteria depends on the strain used, as well as the
concentration of viable organisms.
The combination of bifidobacteria and Strep thermophilus
(found in certain yogurts) dramatically reduces the incidence of acute
diarrhea in hospitalized children.16 Active-culture yogurt,
milk fermented with Lactobacillus casei and other sources of
probiotic bacteria may prevent antibiotic-induced diarrhea.17
18 19
As mentioned in the dietary changes section above, if lactose
intolerance is the cause of diarrhea, supplemental use of
prior to consuming milk or milk-containing products can be
helpful.20 Cheese rarely has enough lactose to cause symptoms
in lactose-intolerant people. Lactase products are available that can be
chewed while drinking
or added to milk directly.
The malabsorption problems that develop during diarrhea can lead to
deficiencies of many vitamins and minerals.21 For this reason,
it makes sense for people with diarrhea to take a multivitamin-mineral
supplement. Two of the nutrients that may not be absorbed efficiently as a
result of diarrhea are zinc and vitamin A, both needed to fight
infections. In third world countries, supplementation with zinc and
vitamin A has led to a reduction in, or prevention of, infectious diarrhea
in children.22 Whether such supplementation would help people
in better nourished populations remains unclear.
supplementation has been shown to alter immune function
and the flora living in the intestine, and may relieve infectious
diarrhea. Three capsules or tablets of brewer’s yeast three times per day
for two weeks was reported to improve three cases of infectious diarrhea
caused by Clostridium difficile.23 Animal research has
confirmed that brewer’s yeast helps fight this unfriendly bacterium.24
(Note that real brewer’s yeast is not identical to nutritional, or torula,
yeast and that when asking for “brewer’s yeast” in health food stores,
people are often directed toward these other products. Real brewer’s yeast
is bitter, whereas other health food store yeasts have a more pleasant
taste.)
might be useful for certain types of infectious diarrhea. In
a double-blind trial, children with diarrhea caused by a rotavirus were
treated with immunoglobulins extracted from colostrum derived from cows
immunized with rotavirus. Compared with the placebo, colostrum extract
significantly reduced the amount of diarrhea and the amount of oral
rehydration solution required. The rotavirus was eliminated from the stool
significantly more rapidly in the colostrum group than in the placebo
group (1.5 days, vs. 2.9 days).25
In addition to a positive effect against acute rotavirus diarrhea,26
there is also evidence that specific forms of colostrum (derived from
specially immunized cows or those with confirmed presence of specific
antibodies) are effective against diarrhea caused by Cryptosporidium
parvum, Helicobacter pylori, Escherichia coli, and
Clostridium difficile.27 28 29
30 31 However, it is not known whether
commercially-available colostrum provides significant amounts of the
specific immunoglobulins that are active against these organisms.
Furthermore, unless the immunoglobulins are present in high enough
concentrations, the preparation is not likely to be effective.32
Acute diarrhea can damage the lining of the intestine. Folic acid can
help repair this damage. In one preliminary trial, supplementing with very
large amounts of folic acid (5 mg three times per day for several days)
shortened the duration of acute infectious diarrhea by 42%.33
However, a double-blind trial failed to show any positive effect with the
same level of folic acid.34 Therefore, evidence that high
levels of folic acid supplementation will help people with infectious
diarrhea remains weak.
It is known vitamin A supplements support immune function and prevent
infections. This is true, however, only under some circumstances. Vitamin
A supplementation can also increase the risk of infections,
according to the findings of a double-blind trial.35 In a study
of African children between six months and five years old, a 44% reduction
in the risk of severe diarrhea was seen in those children given four
100,000–200,000 IU supplements of vitamin A (the lower amount for those
less than a year old) during an eight-month period. On further
investigation, the researchers discovered that the reduction in diarrhea
occurred only in children who were very malnourished. For children who
were not starving, vitamin A supplementation actually increased
the risk of diarrhea compared with the placebo group. The vitamin
A-supplemented children also had a 67% increased risk of coughing
and rapid breathing, and signs of further lung infection, although this
problem did not appear in children infected with the AIDS virus. These
findings should be of concern to American parents, whose children are not
usually infected with HIV or severely malnourished. Such relatively
healthy children fared poorly in the African trial in terms of both the
risk of diarrhea and the risk of continued lung problems. Vitamin A
provided no benefit to the well-nourished kids. Therefore, it makes sense
not to give vitamin A supplements to children unless there is a
special reason to do so, such as the presence of a condition causing
malabsorption (e.g., celiac disease).
Are there any side effects or interactions? Refer to the
individual supplement for information about any side effects or
interactions.
Herbs that may be helpful: The following
recommendations are for milder forms of diarrhea. For more serious cases
of diarrhea, proper medical evaluation and monitoring should occur before
taking any herbal supplements. An extract from stem bark latex of Sangre
de drago (Croton lechleri), an herb from the Amazon basin of
Peru, has demonstrated significant anti-diarrheal activity in preliminary36
37 and double-blind trials. Double-blind research has
demonstrated the extract’s effectiveness for traveler’s diarrhea,38
non-specific diarrhea,39 and diarrhea associated with
infection and AIDS.40 41 For traveler’s
diarrhea and nonspecific diarrhea, amounts ranging from 125 mg to 500 mg
taken four times daily for two days have proven effective. However, in one
trial, only the 125 mg four times daily amount (but not higher amounts)
was effective for acute nonspecific diarrhea.42 The reasons for
the failure of higher amounts in this study is not known. Very high
amounts of these extracts (350–700 mg four times daily for seven or more
days) were used in the trials involving people with
and AIDS. Such levels of supplementation should always be
supervised by a doctor. Most of this research on Sangre de Drago is
unpublished, and much of it is derived from manufacturers of the formula.
Further double-blind trials, published in medical journals, are needed to
confirm the efficacy reported in these studies.
Carob is rich in tannins that have an astringent or binding effect on
the mucous membranes of the intestinal tract. A double-blind trial has
suggested it may be particularly useful for young children and infants
with diarrhea.43 Some healthcare professionals recommend 15
grams of carob powder is mixed with applesauce (for flavor) when given to
children. Carob can also be used for treating adult diarrhea.
While
from dietary or herbal sources is often useful for constipation,
it may also play a role in alleviating diarrhea. For example, 9–30 grams
per day of
(an excellent source of fiber) makes stool more solid
and can help resolve symptoms of non-infectious diarrhea.44
Alginic acid, one of the major constituents in bladderwrack (Fucus
vesiculosus), is a type of dietary fiber and as a result may
potentially help relieve diarrhea. However, human studies have not been
done on how effective bladderwrack is for this condition.
Other astringent herbs traditionally used for diarrhea include
blackberry leaves, blackberry root bark, blueberry leaves, and red
raspberry leaves.45 Raspberry leaves are high in tannins and,
like blackberry, may relieve acute diarrhea. A close cousin of the
blueberry, bilberry, has been used traditionally in Germany for adults and
children with diarrhea.46 Only dried berries or juice should be
used—fresh berries may worsen diarrhea.
Cranesbill has been used by several of the indigenous tribes of North
America to treat diarrhea. The tannins in cranesbill likely account for
the anti-diarrheal activity47 —although there has been little
scientific research to clarify cranesbill’s constituents and actions.
In laboratory experiments, a tannin in
,
known as ellagitannin, inhibited intestinal secretion,48 which
may help resolve diarrhea. Oak is well regarded in Germany, where it is
recommended (along with plenty of electrolyte-containing fluids) to treat
mild, acute diarrhea in children.49
Due to of its supposed antimicrobial activity, goldenseal has a long
history of use for infectious diarrhea. Its major alkaloid, berberine
(also found in barberry and Oregon grape), has been shown to improve
infectious diarrhea in some double-blind trials.50 Negative
studies have generally focused on people with cholera, while positive
studies investigated viral diarrhea or diarrhea due to strains of E.
coli. These studies generally used 400–500 mg berberine one to three
times per day. Because of the low amount of berberine in most goldenseal
products, it is unclear how effective the whole root or root extracts
would be in treating diarrhea.
Chamomile may reduce intestinal cramping and ease the irritation and
inflammation associated with diarrhea, according to test tube studies.51
Chamomile is typically taken as a tea. Many doctors recommend dissolving
2–3 grams of powdered chamomile or adding 3–5 ml of a chamomile liquid
extract to hot water and drinking it three or more times per day, between
meals. Two to three teaspoons (10–15 grams) of the dried flowers can be
steeped in a cup of hot water, covered, for ten to fifteen minutes as
well.
has been used traditionally in the Ayurvedic system for
diarrhea probably due to its anti-inflammatory and antimicrobial actions,
although human studies have not confirmed this use.
Herbs high in mucilage, such as marshmallow or slippery elm, may help
reduce the irritation to the walls of the intestinal tract that can occur
with diarrhea. A usual amount taken is 1,000 mg of marshmallow extract,
capsules, or tablets three times per day. Marshmallow may also be taken as
a tincture in the amount of 5–15 ml three times daily.
Sweet annie has been used traditionally to treat infectious diarrhea
and malaria. However, more modern studies have used the isolated
constituent artemisinin and it is unclear how effective the herb is in
managing diarrhea.
Are there any side effects or interactions? Refer to the
individual herb for information about any side effects or interactions.
Other integrative approaches that may be helpful: Acupuncture may be
useful for the treatment of diarrhea, particularly in infants. A
preliminary study of acupuncture treatment in 1,050 cases of infantile
diarrhea found 95% were relieved with one to three treatments.52
Similar results have been reported in other preliminary trials53
54 and case reports.55 56 A controlled
trial of acupuncture for the treatment of infantile diarrhea compared
scalp acupuncture or traditional body acupuncture with drug therapy,
primarily antibiotics. The cure rate for scalp and body acupuncture was
significantly higher (90% and 89%) than that of drug treatment (46%).57
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