Over two years after being diagnosed with irritable bowel syndrome (IBS), I have finally discovered how to keep my IBS symptoms at bay.
My IBS Symptoms
IBS is a chronic functional gastrointestinal disorder with heterogeneous symptoms; people with IBS present with different symptomology. I’ll describe mine below.
I have diarrhea-predominant IBS (IBS-D); I very rarely suffer from constipation, and, if I do, it’s almost certainly because of mild dehydration.
Between the third quarter of 2017 and the first quarter of 2018, my major problem was violent, explosive, and often unpredictable Type 7 diarrhea.
The constant threat of having diarrhea limited my lifestyle; I always had to be prepared to skip to the loo at short notice. I still traveled interstate and overseas, but it required careful planning to know what to do if I felt the runs coming. Even when not traveling far, I’d still be mindful of the restrooms in the vicinity.
By late 2017, I had identified some triggers of diarrhea episodes, e.g., spicy foods and dairy products, though such attacks could also occur spontaneously. Blood and mucus in my stools often accompanied the diarrhea. I hadn’t been diagnosed with ulcerative colitis (UC) yet and therefore had not started treatment for my UC. After taking mesalazine (mesalamine; 5-aminosalicylate (5-ASA)) for a few weeks, the blood and mucus disappeared but not the diarrhea, which suggested the latter was probably unrelated to UC or UC was only partly contributing to the problem.
Rectal Tenesmus and Bowel Urgency
For all of 2018 and most of 2019, I frequently experienced the sensation of having to open my bowels urgently. I felt this sensation at least five times per week. This sensation rarely resulted in any poop coming out (often, it was just gas, if anything) – I call this rectal tenesmus. Much less often, the sensation in the rectum would be a prelude to full-blown diarrhea – I call this bowel urgency. It was impossible to distinguish between rectal tenesmus and bowel urgency until I sat on the dunny, which meant I always had to assume I was about to have another episode of diarrhea. This uncertainty wasn’t an issue while I was indoors (which was 95% of the time) since I’d invariably have immediate access to a restroom, but it was a real problem when I was out running in the neighborhood. Whenever I experienced that strange rectal sensation during a run – which happened often and unpredictably – it was the cue for me to sprint home to sit on the toilet just in case something was coming out and avoid an embarrassing scene in public. As mentioned above, often, it would be a false alarm, merely a sensation that the rectum was about to explode. But on the rare occasion, the feeling was the precursor of diarrhea.
Bloating and Flatulence
Abdominal bloating and excessive flatulence were frequent symptoms, i.e., at least four times a week, until the end of last year (2019). Though they have improved significantly since about November 2019, I still experience them occasionally these days, i.e., less than once every ten days. When these symptoms occur, they come on around midnight or a bit after and last for perhaps two or three hours, resolving spontaneously. I usually have abdominal pain with the bloating and flatulence.
Some foods cause the accumulation of gas in my belly if consumed in a decent quantity. I’ll list some examples in the different food groups:
- Whole milk (I haven’t drunk low-fat or skimmed milk for over 25 years.)
Grains, beans, and legumes
- Glutinous rice
- Commercial bread – all varieties: white, wholemeal, multi-grain
- Sweet corn
- Canned baked beans
- Deep-fried foods
- Salmon head miso soup (served in many Japanese restaurants)
- Beetroot and carrot juice
- Celery juice
Naturally, once confirmed through trial and retrial, I expunged these trigger foods from my diet. I say “almost” because, occasionally, I sneak in a small quantity of French fries or salmon pieces with no untoward effect. There are some foods I will not eat, e.g., onions and garlic, or anything that I know contains either.
My abdominal pain, when I experience it, is colicky and on the left side of my abdomen (most common), right iliac fossa (less common), or both (rarely). The pain is always associated with bloating, and its severity is proportional to the extent of bloating. I never actively treat gas build-up or abdominal discomfort; I prefer to sit it out and wait till the symptoms go away on their own.
I sometimes experience periods of fatigue, the duration of which ranges between hours and a few days. The fatigue can be pretty debilitating. I associate fatigue with my IBS with no apparent cause or precipitating factor. I have not found a remedy for this symptom; fortunately, it goes away on its own and never lasts more than a few days.
Diagnosis of Irritable Bowel Syndrome
IBS is a diagnosis of exclusion. My UC symptoms complicated matters – see below. The persistence of gastrointestinal symptoms after the resolution of pus and blood on my stools and the combination of nocturnal colicky abdominal pain associated with bloating and flatulence seemed to suggest IBS. It also appeared that I was at risk of IBS, given my history of idiopathic gastroparesis – both are functional gastrointestinal disorders. Further, IBS may be “marginally associated” with inflammatory bowel disease.
Ulcerative Colitis: A Potential Confounding Factor
A few of my symptoms could have been because of either IBS or ulcerative colitis (which was diagnosed just before my diagnosis of IBS), or both at the same time:
- Rectal tenesmus
- Abdominal pain
However, my ulcerative colitis had responded to treatment with mesalazine. And I had residual symptoms, which I attributed to IBS. These symptoms seemed to improve after I started taking medications for IBS (Liblan and amitriptyline). However, their amelioration could also have been an extension of the clinical improvement of my UC.
My Strategy to Cope With Irritable Bowel Syndrome
Below, I’ll outline my strategy for dealing with IBS.
Just a few disclaimers:
- I optimized the routine below after many months of trial and error. In applying the Plan-Do-Study-Act (PDSA) cycle, I carefully documented the results of all the small (and large) tests of change in a diary. IBS is highly heterogeneous in terms of pathogenesis and clinical manifestations. It is unlikely that another IBS patient who follows what I do to a tee will have the best possible results.
- I made the changes carefully and gradually. Anyone who tries doing what I do in a short period, say, a few months, may cause unintentional harm to themselves. If unsure, please consult your doctor before drastically changing your daily routine.
- A team of healthcare professionals, including highly experienced specialist consultants, monitors my progress. For example, I have regularly seen my gastroenterologist in his outpatient clinic, and I have had blood tests (among other investigations) done periodically. I recommend the same for anyone considering emulating the changes I made.
- This regimen works when I am home and not traveling. I set my meal and exercise times around the project’s schedule when I’m on the road. While away from home, my diet and exercise usually involve quite elaborate planning and some compromise.
- My formula for minimizing my IBS symptoms is an ongoing, dynamic process. Depending on several factors, e.g., the progression of my IBS, the symptoms I’m experiencing, changes in my work schedule, and the results of further small tests of change, my daily regimen is likely to evolve.
My strategy focuses on a few things simultaneously:
- Identification and elimination of trigger foods
- A core daily diet
- An exercise program
- Strict medication compliance
- Stress management
Identification and Elimination of Trigger Foods
Around the time of initial diagnosis, it quickly became apparent that some foods caused flare-ups. Recording my list of trigger foods was/is not as easy as it looks. Each item on the list requires testing and retesting because my body’s reaction to the same food may not be the same depending on a few other factors, e.g.:
- Time of day
- Other foods I eat around the same time
- The amount of the food items I consume
- Level of emotional or mental stress
- Whether I am at home or out-of-town (which affects my entire routine: diet, exercise, sleep, etc.)
In addition, a food item that seems acceptable initially may cause a flare-up on the subsequent few occasions I try it. Conversely, something to which my body reacts adversely the first time I eat it may be acceptable on subsequent goes.
Finally, whether any food item triggers my IBS symptoms often depends on the quantity I consume. For example, I will probably be OK consuming half a ripe (sweet) mango but not the whole fruit. A few morsels of raw salmon, e.g., found in a serving of salmon sushi, will be digested with no difficulty. A pot of Ishikari nabe (salmon and vegetable hot pot), with plenty of salmon pieces in it, is probably not OK.
On May 22, 2019, upon hearing of my struggles with IBS, a relative suggested I look at the Monash University low-FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet. The concept of FODMAPs was interesting, and, at least in theory, a low-FODMAP diet sounds logical.
However, after more than a year of trying out foods in both the high-FODMAP and low-FODMAP lists, I can categorically say that, in my case, the Monash University Low FODMAP Diet works best as a rough guide. A year ago, I did my best to follow the diet as closely as possible. Most of the guide, i.e., what to avoid/reduce and what was good to eat, was spot-on, in that my body was more sensitive to the listed high-FODMAP foods, and it seemed to tolerate the low-FODMAP foods. But over a few months, I realized that some foods that contained low levels of short-chain carbohydrates and were, therefore, considered “safe foods” (indicated by a ‘green light’ in the Monash University FODMAP Diet app) were intolerable. These foods include sweet corn, canned beetroot, and many types of bread. Some foods on the high-FODMAP list (“red light”) are perfectly tolerable, even when eaten in high quantities. For example, I eat at least the equivalent of five medium-sized ripe (sometimes even overripe) bananas every morning with a large bowl of oatmeal. I sometimes eat up to a dozen medium-sized ripe bananas in a day with no ill effect. As another example, rye is a high FODMAP grain. However, I have been eating rye sourdough bread or German rye sourdough bread daily for the past two months with no problem. On the contrary, I believe the sourdough bread, especially the German rye variety, has improved my sense of well-being.
Core Daily Diet
At the end of last year, after more than a year and a half of experimenting with various foods, I found a daily diet plan that worked well for me and all but eliminated my IBS symptoms. Finding this diet was no easy journey – the process of elimination and substitution was tedious and often resulted in symptoms at the end of the day, i.e., around midnight.
The following is what I eat almost every day, after which I can be sure I will not experience any IBS-related symptoms. I consume other things not listed below – these items fall into one of the following categories:
- Foods that I know my body can tolerate but are not in my daily diet, e.g., soy pudding
- Stuff I like to eat or drink that is not in my daily diet (e.g., spicy potato wedges, Coca-Cola)
- Things I am trying out as a test
Breakfast (Late morning)
- 1 bowl of oatmeal plus 5 medium-sized bananas
- 2 soft boiled eggs; 2 teaspoons of soy sauce added
- 1 cup of French press coffee, 1 tablespoon of sugar added
I have my oatmeal with the equivalent of five medium-sized ripe (or sometimes overripe) bananas sliced. (I’m not too fond of the taste of unripe bananas, which is low in short-chain carbohydrates and, therefore, safe(r) to eat on a low-FODMAP diet.) The oatmeal is made from one cup of rolled oats and about two cups of water (only), cooked in a rice cooker until the mixture is a creamy and soft consistency with a bit of texture. The taste may be too bland for some people, but I like my oatmeal this way.
Sometimes, my wife throws in a palmful of raisins to the concoction – this adds flavor to the meal without any untoward effect. The addition of raisins to my breakfast happens less than once a week.
Lunch is the most substantial and most protracted meal of the day for me, sometimes stretching over 2 or 3 hours.
- 1 3/4 cups of steamed brown rice, equivalent to about 2/3 cup of uncooked rice
- 1 Asian sea bass (also called barramundi), steamed; 2 tablespoons of soy sauce poured on the fish after cooking it – about 500–550 grams raw
- Okra, also known as ladies’ fingers, steamed – about 200 grams raw
- French beans, steamed – about 200 grams raw
- Green-leaved amaranth, called “bayam” locally, steamed – about 225–250 grams raw
- 1 Tomato, steamed – about 100–125 grams raw
- 1 1/2 cups of mint leaves, eaten whole and raw
- Fruit – papaya, peeled, seeded, and diced – about 400 grams; or 1 medium-sized orange, peeled (I avoid eating papaya on consecutive days due to a history of carotenosis from consuming an excessive amount of papaya and carrots in the fourth quarter of 2018.)
- 1 cup of hot sweetened black tea, 1 tablespoon of sugar added
Mint leaves were the latest addition to my daily diet. It seems to help my digestion and reduce gas build-up.
Late Afternoon Tea (Late afternoon or early evening)
- 3 slices of German rye sourdough bread (about 200 grams in total)
- 1 cup of French press coffee, 1 tablespoon of sugar added or 1 cup of hot sweetened black tea, 1 tablespoon of sugar added
Optional: (depending on my mood, besides the above)
- 1 cup of hot sweetened black tea, 1 tablespoon of sugar added
I eat nothing after my late afternoon tea. In other words, “dinner” or “supper” is excluded from my daily diet plan.
In the first week of August 2019, i.e., about 11 months ago, I started time-restricted feeding, a form of intermittent fasting. I eat as much as I want in 9 hours, usually from late morning till early evening (e.g., 10.30 a.m.–7.30 p.m.), and perform a water fast for the remainder of the day. So this might be called a 15:9 diet – 15 water fasting hours cycled by 9 non-fasting hours.
I tried out this daily fasting pattern after a trip to Singapore in late July 2019. I had an episode of bowel urgency followed by diarrhea at Changi Airport’s Terminal 3 a couple of hours before the scheduled departure time of my flight home. It was a close call, and I had to do something to prevent a similar incident.
For me, intermittent fasting was/is not for the commonly purported benefits, such as fat loss, increased production of human growth hormone, improved insulin sensitivity, and autophagy. Instead, my purpose for time-restricted eating was more practical – reducing my IBS symptoms.
The original idea of trying out this diet fad, conceived on my flight home on July 31, 2019, was based on two premises:
- If I don’t eat, I won’t suffer any IBS symptoms.
- If I must eat and, therefore, risk having IBS symptoms, I should be allowed to choose what time of the day I have those symptoms. I prefer to have my symptoms during regular waking hours and not when I go to bed (which was happening before I started my daily time-restricted fasting). Following this logic, I should wrap up eating around 7 p.m. or earlier – this would allow ample time for my bowels to play up before bedtime.
I have gained much from the 15:9 regimen:
- Improved daily productivity (after making adjustments to my routine), mainly because I don’t have to worry about fitting in dinner in the evening.
- I have greater flexibility when I do my daily exercise workout. Late-night training (around 11 p.m. or 12 midnight) is now possible, whereas it would have been impossible if I had dinner after 7 p.m. (which I used to do).
- Ability to travel and work out-of-town (I time my non-fasting hours so that the at-risk hours don’t overlap with scheduled travel, business meetings, presentations, workshops, etc.)
An unexpected benefit of my daily fasting plan is an improved sense of well-being. I don’t know how this is the case, but here are some hypotheses:
- The amount of food I can eat within nine hours is limited, at least in the short term, by the internal volume of my stomach, appetite-suppressing gut peptides, and probably other regulatory mechanisms. Therefore, by prioritizing the cleanest food in my daily diet, I effectively exclude less healthy food options that I might consume if I allowed myself to eat at any time. These “less healthy” options may include excessive simple sugars, fats (all kinds), and food additives – these substances, in turn, could make me feel lousy.
- Better control of my IBS reduces suffering during the day and allows for better sleep overnight.
- Increased confidence that I can get on top of my IBS.
15:9 Diet Versus 16:8 Diet
You might wonder why I employ a 15:9 and not a 16:8 diet (16 hours of water fasting alternating with eight hours of non-fasting) – the latter is far more commonly discussed on the Internet. When I first started this form of intermittent fasting, I stuck to the 16:8 diet. After a couple of months of trying to adapt to the diet plan, I found the eight-hour window I allowed myself to eat was too restrictive. I frequently felt pressured to hurriedly complete tasks, including eating everything I wanted to eat. On the other hand, I could comfortably fit in all my meals, work, errands, and even exercise when I gave myself nine hours instead. Therefore, I found the 15:9 diet easier to stick with while still meeting my objectives for intermittent fasting.
Physical exercise is a big part of my overall strategy to overcome the effects of IBS. Besides its well-known health benefits, regular exercise helps me manage stress and maintain mental awareness and focus.
My exercise program is easy to describe. Other than scheduled rest days (generally one rest day after three consecutive days of exercise), I do one of the following activities each day:
- Rowing – currently: 77 minutes (no break), stroke rate 17 or 18 strokes per minute, average pace 2 minutes 10 seconds per 500 meters
- Running – currently: 10.5 km in 62 minutes
- Road cycling – currently: 32 km in 65 minutes
I’ve been quite successful in sticking to the program. There are only a few situations that would force me to take the day off from exercise:
- Significant exercise-induced injury
- Fatigue (I periodically experience debilitating fatigue, which prevents me from exercising)
- Work or work-related travel
- Being at a location where any form of physical workout is impossible
- Something I have prioritized over my workout, which I cannot attend to at a time before or after the period I would otherwise do my exercise, and I cannot (reasonably) fit my training at any other time during the day
Strict Medication Compliance
I was diagnosed with IBS in March 2018, soon after the diagnosis of UC was made, and was commenced on Liblan (chlordiazepoxide 5 mg, clidinium bromide 2.5 mg), 1 tablet in the morning, and amitriptyline, 10 mg at bedtime. These two drugs helped reduce the incidence of diarrhea and abdominal pain, but the symptoms did not disappear. Hence, my attention to what I ate.
Despite my best efforts, my nocturnal bloating and abdominal pain were still troublesome towards the end of last year (2019). That was when my gastroenterologist prescribed Meteospasmyl (alverine citrate 60 mg and simeticone 300 mg in one capsule). I took one Meteospasmyl capsule every evening for a month and on a p.r.n. basis afterward. This drug was beneficial in relieving my gassy symptoms while I continued to figure out my optimal diet plan. I have had to take Meteospasmyl only five times since December 2019, e.g., when I had severe bloating after eating a traditional pork meat-filled rice dumpling (called “bak chang” among the locals in Penang).
Medications I Take for My IBS
Due to the urinary symptoms I experienced in March 2020, I stopped taking Liblan (chlordiazepoxide + clidinium bromide) and amitriptyline. Despite my prostate problem being a thing of the past, I haven’t gone back to taking amitriptyline. My gastroenterologist has recommended I resume taking it only if I feel it is necessary (which I haven’t). On the other hand, I recommenced Liblan, 1 tablet every morning, soon after my urinary problems resolved, i.e., ten days after I stopped the drug, because I was experiencing some colicky abdominal pain mid-afternoon.
Therefore, my current medications to treat IBS are:
- Liblan, 1 tablet every morning before breakfast
- Meteospasmyl, 1 capsule p.r.n.
I have been super vigilant with all the medications prescribed by my doctors.
My IBS tends to play up when I feel more emotional or psychological stress. Sometimes, these moments are pretty unavoidable, e.g., competing priorities, tight travel schedules, multiple reports due simultaneously, and interpersonal conflicts. I do my best to deal with what comes along and try not to be overly stressed over things beyond my control.
Overall, I would say that I have managed my stress levels reasonably well by paying attention to the basics, e.g.
- Proper nutrition
- Sleep hygiene
- Regular exercise
- Healthy relationships
- Good time management
- Practicing the art of saying “No”
- Having hobbies – cycling, chess, home DIY projects
My battle with IBS has been a real struggle the past two and a half years.
Nevertheless, I believe I am finally beginning to seize the initiative by employing a multi-pronged approach. My strategy includes:
- Avoiding identified trigger foods
- Following a “safe” daily diet plan
- Incorporating a moderately vigorous exercise program
- Emphasizing medication adherence
- Promoting evidence-based stress management techniques