My strategy to prevent or mitigate symptoms of irritable bowel syndrome is multipronged: medications, tailored diet plan, exercise, and stress management.

More than two years after being diagnosed with irritable bowel syndrome (IBS), I have finally found a way 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.

### Diarrhoea

I have diarrhoea-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 first quarter of 2018, violent, explosive, and often unpredictable Type 7 diarrhoea, was my main problem. This was limiting my lifestyle; I always had to be prepared to skip to the loo at short notice. I still travelled interstate and overseas but it required careful planning so that I knew what to do if I felt the runs coming. Even when not travelling far, I’d still be mindful of the restrooms in the vicinity.

By late 2017, I had identified some triggers of diarrhoea episodes, e.g. spicy foods and dairy products, though such episodes could also occur quite spontaneously. The diarrhoea was often associated with blood and mucus in my stools. At that time, I hadn’t been diagnosed with ulcerative colitis (UC) yet, and therefore had not started being treated for my UC. After taking mesalazine (mesalamine; 5-aminosalicylate (5-ASA)) for a few weeks, the blood and mucus disappeared but not the diarrhoea, which suggested to me 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. This happened at least five times per week. This sensation usually did not result 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 diarrhoea—I call this bowel urgency. It was impossible to distinguish between rectal tenesmus and bowel urgency until I sat on the dunny, which basically meant I always had to assume I was about to have another episode of diarrhoea. This wasn’t so much of 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 neighbourhood. 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 there was something coming out and to 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 sensation was the harbinger of diarrhoea.

### 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 10 days on average. Almost always, when these symptoms occur, they come on around midnight or a bit after, and last for perhaps two or three hours, resolving spontaneously. They are associated with abdominal pain.

#### Food Triggers

There are some foods that clearly cause accumulation of gas in my belly if consumed in decent quantity. As examples, I’ll list some under the different food groups:

Dairy

• Whole milk (I haven’t drunk low-fat or skimmed milk for more than 25 years.)

Fruits

• Mangoes
• Apples
• Watermelon
• Durian

Grains, beans and legumes

• Glutinous rice
• Commercial bread—all varieties: white, wholemeal, multi-grain

Vegetables

• Sweet corn
• Onions
• Garlic
• Mushrooms

Processed foods

• 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 removed these trigger foods from my diet almost completely. I say “almost” because, occasionally, I sneak in a small quantity of, say, French fries or salmon pieces, without any untoward effect. On the other hand, there are some foods I will not eat, e.g. onions and garlic, or anything that I know contains either.

### Abdominal Pain

My abdominal pain, when I experience it, is colicky in nature, and located on the left side of my abdomen (most common), right iliac fossa (less common), or both (rarely). It is always associated with bloating, and the severity of the pain proportional to the extent of bloating. I never actively treat gas build-up or pain; I prefer to just sit it out and wait till the symptoms go away on their own.

### Fatigue

I sometimes experience periods of fatigue, the duration of which ranging between hours and a few days. The fatigue can be quite debilitating. In the absence of any obvious cause or precipitating factor, I associate fatigue with my IBS. 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. As such, my UC symptoms complicated matters. Nevertheless, the persistence of gastrointestinal symptoms after resolution of pus and blood in 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. Further, IBS may be “marginally associated” with inflammatory bowel disease.

## Ulcerative Colitis: A Potential Confounding Factor

Some symptoms could have been caused by either IBS or ulcerative colitis (which was diagnosed just before my diagnosis of IBS), or both at the same time:

• Rectal tenesmus
• Abdominal pain
• Diarrhoea

However, it did seem that my ulcerative colitis had been effectively treated within a month of commencing mesalazine. And at that time, I had residual symptoms which I attributed to IBS. These symptoms seem to improve after I started taking medications for IBS (Liblan and amitriptyline), though 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:

• The routine that I describe below was optimized for me after many months of trial and error. The results of all the small (and large) tests of change were carefully documented in a diary—this is me applying the Plan-Do-Study-Act (PDSA) cycle to my everyday life. IBS is also 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 be rewarded with their best possible results.

• The changes I made were done carefully and gradually over time. Anyone who tries doing what I do in a short time period, say, a few months, may cause inadvertent harm to themselves. If unsure, please consult your doctor before making any drastic changes to your daily routine.

• My progress has been medically monitored, in that I have been seeing my gastroenterologist in his outpatient clinic regularly and I have had blood tests (among other investigations) done periodically. I recommend the same for anyone considering emulating any of the drastic changes I made.

• This regimen works only when I am home and not travelling. When I’m on the road, I set my meal and exercise times around the schedule of the assignment. This usually involves 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 over time.

My strategy focuses on a few things simultaneously:

## Identification and Elimination of Trigger Foods

Around the time of initial diagnosis, it quickly became apparent that some foods tended to cause 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 item I consume
• Level of emotional or mental stress
• Whether I am at home or out-of-town (which, in turn, affects my entire routine: diet, exercise, sleep, etc.)

In addition, a food item that seems acceptable initially may cause a flare-up on the next few occasions I try it. Conversely, something to which my body reacts adversely the first time may be fine on subsequent goes.

Finally, the question of whether any food item triggers my IBS symptoms often depends on the quantity I consume. For example, I am probably going to be OK consuming half a ripe (sweet) mango but not a whole fruit. A few morsels of raw salmon, e.g. that found in a serving of salmon sushi, are going to be digested without any difficulty, but a pot of Ishikari nabe (salmon and vegetable hot pot), with plenty of salmon pieces in it, is probably not going to be OK.

### FODMAPs

On May 22, 2019, upon hearing of my struggles with IBS, a relative suggested I had a look at the Monash University low-FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet. The concept of FODMAPs made interesting reading and, at least in theory, a low-FODMAP diet sounds logical.

However, after more than a year trying out different foods in both the high-FODMAP and low-FODMAP lists, I can categorically say that, in my case, the Monash University Low FODMAP Diet can only be used as a 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 tended to be 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 supposedly 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 actually quite intolerable, e.g. sweet corn, canned beetroot, and many breads. On the other hand, I learnt that some foods on the high-FODMAP list (“red light”) list 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 without any ill-effect. As another example, rye is regarded as a high FODMAP grain. However, I have been eating rye sourdough bread or German rye sourdough bread daily for the past two months without any problem. To the contrary, I believe the sourdough bread, especially the German rye variety, has improved my sense of well-being on a day-to-day basis.

German rye sourdough bread is one of my staple foods.

Yin's Wholefood Manufactory @Tanjung Bungah, Penang, Malaysia. This is where I pick up sourdough bread twice a week. We try and support local businesses as much as possible.

## 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. This 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 certain 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 are not in my daily diet (e.g. spicy potato wedges, Coca-Cola)
• Stuff 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 don’t like 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 little 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 flavour to the meal without any untoward effect. The addition of raisins to my breakfast depends on their availability in the kitchen and doesn’t happen often—less than once a week on average.

### Lunch (Mid-afternoon)

Lunch is the biggest and longest meal of the day for me, sometimes stretching over 2 or 3 hours.

• 1$\frac 3 4$ cups of steamed brown rice, equivalent to about $\frac 2 3$ cup of uncooked rice
• 1 Asian sea bass (also called barramundi), steamed; 2 tablespoons of soy sauce poured on the fish after it is steamed—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$\frac 1 2$ 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
I eat one medium-sized Asian sea bass, also known as barramundi, steamed, almost every day.

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, in addition to the above)

• 1 cup of hot sweetened black tea, 1 tablespoon of sugar added

### Dinner

I don’t eat anything after my late afternoon tea. In other words, “dinner” or “supper” are excluded from my daily diet plan.

### Intermittent Fasting

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 during a nine-hour, 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 decided to try out this daily fasting pattern after a trip to Singapore in late July 2019, during which I had an episode of bowel urgency followed by diarrhoea 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 done for any of the commonly purported benefits, such as fat loss, increased production of human growth hormone, improved insulin sensitivity, and autophagy. Instead, my purpose of time-restriced 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:

1. If I don’t eat, I won’t suffer any IBS symptom.

2. 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, if any, during normal waking hours and not around the time 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 my bedtime.

I have gained much from the 15:9 regimen:

• Improved daily productivity (after making some adjustments to my routine), mainly because I don’t have to worry about fitting in dinner in the evening.

• Greater flexibility as to when I do my daily exercise workout. A late-night workout (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 a nine-hour period 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 to include in my daily diet, I effectively exclude less healthy food options, which I might consume if I allowed myself to eat at any time of the day. 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 better sleep overnight.

• Increased confidence that I can get on top of my IBS.

#### 15:9 Diet Versus 16:8 Diet

You might be wondering why 15:9 and not a 16:8 (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, during which I allowed myself to eat, was too restrictive—I was frequently pressured to complete tasks, including the task of eating everything I wanted to eat, hurriedly. On the other hand, when I gave myself nine hours instead, I could comfortably fit in all my meals, work, errands, and even exercise. Therefore, I found that the 15:9 diet easier to stick with while still meeting my objectives for intermittent fasting.

## Exercise Program

Physical exercise is a big part of my overall strategy to overcome the effects of IBS. In addition to its well-known health benefits, regular exercise helps me to 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 3 consecutive days of exercise), I plan to engage in 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 metres
• 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. Having managed to avoid significant exercise-induced injury for more than 18 consecutive months, there are only a few situations that would force me to take the day off from exercise:

• 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; or
• 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 workout and I cannot (reasonably) fit my workout 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 to reduce the incidence of diarrhoea and abdominal pain but the symptoms did not disappear. Hence, my attention to what I ate.

### Meteospasmyl

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 thereafter. This drug was incredibly helpful in relieving my gassy symptoms while I continued to figure out my optimal diet plan. I have had to take Meteospasmyl only 5 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 urinary symptoms I experienced in March 2020, I stopped taking Liblan (chlordiazepoxide + clidinium bromide) and amitriptyline. Despite my prostate problem being a thing in 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. 10 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.

## Stress Management

My IBS tends to play up when I’m feeling more emotional or psychological stress than usual. Sometimes, these moments are quite unavoidable, e.g. competing priorities, tight travel schedules, multiple reports due at the same time, interpersonal conflicts. So 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
• Practising the art of saying “No”
• Having hobbies—cycling, chess, home DIY projects

## Summary

My battle with IBS has been a real struggle the past two and a half years. Nevertheless, employing a multipronged approach that avoids identified trigger foods, includes a “safe” daily diet plan, incorporates a moderately vigorous exercise program, emphasizes medication adherence, and promotes evidence-based stress management techniques, I believe I am finally beginning to seize the initiative.