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It is hypothesised that these mechanisms occur in a spiralling, progressive way, toppling the hosts homeostatic equilibrium ( Gut dysbiosis ME/CFS patients often have gastrointestinal (GI) symptoms (189) with gut inflammation (190), gut microbiome dysbiosis (191) and changes in the gut microbiome (191, 192)

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Symptoms of vitamin B12 deficiency include: In most cases of vitamin B12 deficiency, the body has not absorbed the required amount through digestion for several reasons

Most of our patients benefit from combining two or three of these mechanisms in a structured plan rather than chasing one modality alone

Hepatology 58, 762776