CHRONIC FATIGUE IMMUNE
DYSFUNCTION SYNDROME
慢性疲劳免疫综合症
(CFIDS)
Also Referred to as:
YEAST SYNDROME or YEAST RELATED ILLNESS
By Elmer M. Cranton, M.D.
Copyright © 2007 Elmer M. Cranton, M.D.
Terminology varies widely between different practitioners and differing
theories of cause. The acronym "CFIDS" will be used in this article to
refer to a clinical syndrome which can cross the boundaries and
involve, more or less, any of the below:
CHRONIC FATIGUE IMMUNE DYSFUNCTION SYNDROME — CFIDS —
CHRONIC FATIGUE SYNDROME — CANDIDA ALBICANS SYNDROME —
CANDIDIASIS — MYALGIC ENCEPHALITIS — EPSTEIN-BARR
SYNDROME — FOOD ALLERGY — MONILIA — ENVIRONMENTAL
ILLNESS — SICK BUILDING SYNDROME — ECOLOGICAL ILLNESS —
CHEMICAL SENSITIVITY — ALLERGIC TENSION FATIGUE
SYNDROME — HYPERACTIVITY SYNDROME — ATTENTION DEFICIT
DISORDER — DYSLEXIA — ASTHMA — HYPOGLYCEMIA — POST FLU
SYNDROME — MERCURY TOXICITY — HEAVY METAL TOXICITY
介绍
A variety of widely diverse symptoms, seemingly unrelated, affecting
many different parts of the body, are now believed to be caused, at
least in part, by an overloaded immune system and immunologic
dysfunction. A stressed-out and malfunctioning immune system is felt
to be an important and treatable cause of many the above listed
conditions. Chronic fatigue and nervous tension are almost always
present.
很多各样的症状看起来似乎没什么关系，它们影响着许多身体的不同部分，然而现
在至少可以在一个方面确信的是，它们是由于免疫系统超负荷或者是免疫系统缺陷
的原因导致。
A number of case histories are presented in the patients own words
on another page.
这里有一页病人自己讲述的病情历史报告（上面的链接）。
The treatment plan described here was empirically developed by the
author over many years and has brought relief to hundreds of patients
who been treatment failures elsewhere. Benefits have sometimes been
dramatic and complete, after attempts with many other therapies had
failed.
这里所讲述的治疗计划是经过作者多年的经验所总结而成，并缓解了数以百计的病
人，其中有痊愈的、也有效果卓越的，他们曾经尝试过许多其他的效法却并无效
果。
Chronic fatigue is increasing experienced in the industrialized nations
throughout the world. Related immune dysfunction is becoming an
epidemic. This increase in the latter part of the twentieth century
parallels proliferation of stress to immunity from food allergy,
environmental, nutritional, pharmaceutical, and lifestyle factors.
慢性疲劳在工业化国家继续保持着增长势头，于此相关的免疫功能失调正在成为一
个流行病。而 20 世纪后期以来，食物过敏、环境问题、营养、药物以及生活方式
这些因数正是促进这个增长的主要原因。
It has been observed that over 60% of Americans needlessly suffer
from some form of delayed food allergy, food intolerance or
environmental sensitivity, causing chronic health problems, as partially
outlined in the list below. Food and chemical sensitivity are associated
with a large number of chronic conditions, either as a cause or
a contributing factor. These include:
有超过 60%的美国人正不必要的遭受着食物过敏和环境敏感所带来的慢性健康问
题，本文将其中特别明显的列在下面。食物和化学物质的敏感性与一系列的慢性条
件相关，其中既有主要原因也有次要原因，它们包括：
Anxiety (acute or chronic)
Arthritis (osteoarthritis especially)
Asthma
Nasal and sinus congestion
Attention Deficit Disorder
Learning and behavior disorders
Bed wetting
Bloating
Bronchitis
Celiac Disease
Non-tropical sprue
Ulcerative colitis
Chronic Fatigue
Constipation
Cystic fibrosis
Depression
Diarrhea
Gastritis
Headaches
Hyperactivity Disorder
Inflammatory Bowel Disease
Insomnia
Irritable Bowel Syndrome
Itchy skin problems
Malabsorption
Migraine
Sleep disturbances
Water retention
Weight control problems
Sexual dysfunction
Infertility
Menstrual disorders
And many more
焦虑
关节炎
哮喘
鼻窦炎
注意力难以集中
学习和行为混乱
尿床
肿胀
支气管炎
腹腔疾病
非热带口炎性腹泻
溃疡性结肠炎
慢性疲劳
便秘
胆囊纤维症
沮丧
痢疾
胃炎
头痛
混乱
肠炎
失眠
肠动
皮肤瘙痒
吸收不良
偏头痛
睡眠不安
保水性
体重问题
性功能失调
不育
月经失调
许多其他……
The diagnosis as listed above may be correct but treatment can often
be easier and more successful by also following this protocol.
Symptoms of autism and Down's syndrome can also be helped.
以上所列举的诊断可能是正确的，然而如果能够及早按照这里的方法治疗那么将更
可能成功，对于自闭症和【Down】症状也能有效。
Symptoms of CFIDS are commonly misdiagnosed as neurotic or
psychosomatic. A variety of diagnostic terms are used to describe this
variable constellation of symptoms, or syndrome. A common
denominator, collectively referred to as CFIDS, is immunologic
dysfunction, often accompanied in women by hormonal imbalance.
Premenstrual symptoms and fertility problems can be related.
慢性疲劳免疫综合症常常被误诊为精神病患者或者心理相关疾病。有许多医用名词
来描述这些症状，最终也都归结为 CFIDS，也就是慢性疲劳免疫综合症，女性荷
尔蒙失调也常常于此相关，包括经前综合症和生育相关问题。
Great improvement in hundreds of patients has followed the treatment
program described below. Because there are no specific laboratory
tests to confirm a diagnosis in advance, medical history and response
to a trial of therapy remains the only way to make the diagnosis.
在经过下面所描述的疗法后，在数以百计的病人身上产生了巨大的效果。这里不需
要任何化验去确认之前提及的那些诊断，因为经验和尝试依然是做出诊断的唯一途
径。
This paper and the program of therapy described is unproven and
anecdotal by strict scientific criteria. Conclusions herein are based on
the author's personal observations and success in treating hundreds
patients with symptoms of CFIDS. Many of those patients had failed to
respond to multiple prior treatment programs. What is described here
is eclectic, based on experience with patients. Much was learned from
the patients themselves and not from medical schools or elaborate
scientific research.
本文以及所描述的疗法从严格科学的角度讲可以说是未经证明的偏方。此处的结论
都是基于作者个人的观点以及有此类症状的数百个病人的成功治疗。这些病人在之
前的多项治疗并无效果。在此所描述的是选择性的，并基于临床经验，其中许多是
从病人自身总结而来，而不是来自于书本和科研。
This treatment regimen often works in practice. It is safe and
inexpensive, relative to the cost of the many prior unsuccessful
treatments. Not all patients respond. Significant improvement occurs
in only about half of patients. Unfortunately, it is not possible to know
in advance who will respond and who will not. Of the non-responders,
many would not follow instructions or found it impossible to avoid
offending substances in their diet or environment.
相比那些之前不成功的治疗来说，这个养身疗法可行、安全、廉价。并非所有的病
人都有效果，只有大约一半的病人能有明显的改进。不幸的是，我们并不能提前知
道谁有效还是谁无效。对于那些无效的人而言，许多人不能遵行指示而行或者做不
到改变其饮食结构和环境。
Nothing in medicine is 100% effective. The scientific basis for the
observations, recommendations, and conclusions in this paper is
hypothetical. Blinded placebo controlled studies have not been done.
Most physicians would consider the conclusions and recommendations
in this paper as experimental at best and pure quackery and
exploitation at worst. Medical insurance commonly often refuses to
reimburse the costs.
世上没有百分百疗效的药物。本文的观察、建议和结论的科学基础是假设。绝大多
数医师会认为本文的结论和建议是经验主义、江湖医术和骗人的把戏。医疗保险通
常会拒绝报销这些费用。
The most frequent and incapacitating symptom in patients with CFIDS
is fatigue, without an evident cause. Depression or other mental
dysfunction is commonly present, but may be an effect of the
underlying illness rather than the primary diagnosis. Physical
examination and laboratory tests are seldom diagnostic.
CFIDS 病人最常见的症状就是疲惫，却找不到一个明显的原因。消沉或者其他心
理失调也常常相随，相对主要诊断而言，这更可能是疾病之下的影响，身体的检验
和化验常常并无诊断价值。
Adverse reactions to many otherwise desirable and nutritious foods
(so-called food allergy) are common. Sensitivity to chemical fumes,
perfumes, solvents, and other substances is also very common.
Respiratory allergy, nasal and sinus congestion, and hay fever may or
may not be present. Digestive tract symptoms, urinary symptoms, and
musculoskeletal pain are common.
食物的副作用非常普遍（也就是所谓的食物过敏）。化学气体、溶剂和其他物质的
过敏也十分常见。呼吸过敏、鼻窦炎、还有发烧这些症状可能有或者没有，而消化
道相关、泌尿相关和肌肉疼痛等症状却是常见的。
By reducing stress on the immune system, and by keeping that stress
to a minimum for several months, many patients who have suffered
with symptoms for many years have found relief. Significant reduction
of immune system stress and relief of related symptoms can be
accomplished by following the treatment program described below. A
hypothetical mechanism of action is offered, but the treatment
protocol is based on observations of what works in practice, not on
theory.
通过减轻免疫系统的压力并保持数月，许多常年遭受那些症状的病人得到了缓解。
可以通过下面所讲的疗法来实现对免疫系统明显的减压。这个方法是基于对病人的
实际观察，而不是基于理论。
There is no easy way to do this. Because of the non-specific nature of
symptoms, a thorough initial evaluation with laboratory testing are
important to rule out other unsuspected causes. But there are no
reliable tests that can be done in advance, to diagnose specific
sensitivities.
然而，要完成这些并非易事，因为不是特别显著的症状，为了排除其他的可能原
因，一个彻底的生化检验十分重要。然而事先却没有可靠的检验可以做。
On many occasions, patients who may have found partial relief based
on blood tests, skin tests, adrenal tests, etc., have subsequently
discovered up to 40% false positives and/or 40% false negative results
from testing alone. They usually find that there is much more to their
problems by following the full protocol described below―a program
that is as useful for diagnosis as it is for treatment.
在很多情况下，病人可能在验血、做皮试、肾上腺检验等等之后发现 40%的假阳
性或 40%的假阴性的结果而稍感安慰。在经历下面的疗法以后他们通常发现在他
们身上有更多的问题。
YEAST AND FUNGUS
酵母菌
Yeast and other microscopic fungal organisms compose a normal part
of the body's internal ecology. They are normally well tolerated by a
healthy immunity. If they increase in number, however, they cause
additional stress to the immune system. Is is widely recognized that
mold, including yeast and fungi, are among the most allergic of
environmental exposures.
酵母和其他真菌有机体是人体内生态系统的一部分。一个健康的免疫系统通常可以
和它们友好共存。然而，如果它们的数量增加，就会给免疫系统带来额外的压力。
霉菌，包括酵母菌，是最容易引起过敏问题的，这是一个普遍认识。
It is a medical fact that every healthy person will react allergically to
Candida albicans, a common yeast, also called Monilia. A clinical test
for normal immunity requires injecting a small amount of Candida
(Monilia) yeast extract under the skin and observing for a raised, red
allergic reaction over several days. If that reaction does not occur, the
patient is diagnosed as "anergic," indicating that the immune system is
not functioning. In other words, a healthy human body is expected to
react allergically to Candida yeast unless immunity is paralyzed or
non-functional. This universal reactivity to Candida albicans is
evidence that the presence of yeast in the body creates stress to the
immune system. If Candida increases, immune stress increases.
这是一个医学事实，就是每一个健康的人都会对白假丝酵母（一个普通的酵母菌，
也称作念珠菌）产生过敏。临床试验，对一个正常的免疫体皮下注射少量的假丝酵
母菌，就会看到鼓起、红色的过敏反应，并会持续几天。如果一个病人没有这样的
反应，那么就诊断为‘无变应性的’，表明他的免疫系统不正常。换句话说就是，
除非免疫系统瘫痪或不正常，一个健康的身体就应该对假丝酵母菌产生过敏反应。
这种对白假丝酵母菌的反应就是酵母菌在体内会对免疫系统带来压力的证据。如果
假丝酵母菌增加，免疫系统的压力也随着增加。
For purposes of simplification, all species of yeast and fungus, which
grow in the human body, are collectively lumped together in this paper
as "yeast."
为了方便，在本文中，将那些在人体内的所有种类的酵母菌和真菌全部称为酵母
菌。
Many pharmacological, dietary, environmental and life-style factors
encourage growth of yeast in body's of people in industrialized
countries. When yeast overgrowth becomes obvious, it is easily
diagnosed as an infection and treated appropriately with anti-fungal
medicines. More commonly, however, yeast colonization increases,
especially in the large intestine, but is not adequate to diagnose an
infection. It is an ecological imbalance in the body that adds to total
load on the immune system.
在工业国家，许多药物、饮食、环境和生活方式等因素都刺激着体内的酵母菌的增
长。当酵母菌过度增长以至于很明显，就很容易诊断为真菌感染并给予适当的抗菌
药物。然而，更为广泛的是，酵母菌更多的在大肠内繁殖，以致不被诊断为感染。
这是体内的生态不平衡，而且这个负担又加到了免疫系统的身上。
Treatment with a combination of prescription medicines to eliminate
yeast from the body, combined with other dietary and lifestyle
strategies to remove other stresses from the immune system, can
successfully treat CFIDS in many cases. This program has helped
hundreds of Dr. Cranton's patients who had previously been
unresponsive to treatment elsewhere.
利用处方药物将酵母菌从身体排除，并结合其他饮食和生活方式来消除对免疫系统
的压力，在许多情况下可以有效治疗 CFIDS。这个疗法已经帮助了 Carnton 手下
数以百计的病人，他们经历过其他无用的治疗。
Yeast overgrowth is partly iatrogenic (caused by the medical
profession) and can be caused by antibiotics and cortisone medications.
A diet high in sugar also promotes overgrowth of yeast. A highly
refined and chemicalized diet now common in industrialized nations
not only promotes growth of yeast, but is also deficient in many of the
essential vitamins and minerals needed by the immune system.
Chemical colorings, flavorings, preservatives, stabilizers, emulsifiers,
etc., add more to stress on the immune system.
酵母菌的过度繁殖一部分是因为医生的治疗而引起的，也有可能是因为抗生素和可
的松之类的药物导致，高糖的食物也是一个因素。高提炼加工的食物如今在工业国
家十分普遍，它们不仅仅增加了酵母菌，而且十分缺乏免疫系统所需的维生素和矿
物质。色素、调味剂、防腐剂、稳定剂、乳化剂等等，都给免疫系统带来了负担。
The most effective and long-lasting treatment for CFIDS has proven to
be a four-pronged approach: (1) a combination three anti-fungal
medicines, taken together; (2) a diet that avoids many commonly
eaten foods to which the immune system is often sensitized; (3)
avoidance of environmental pollutants, fumes, fragrances, food
additives, etc. and, (4) supplemental vitamins, minerals and trace
elements to support immunity. That program reduces stress on the
immune system in many ways while providing nutritional support. It
has been found most effective to continue treatment for several
months to allow normal immunity to recover and allow normally
present bacteria to repopulate the digestive tract after yeast have
been eliminated.
经过验证，对于 CFIDS 最为有效和持续的治疗方法是基于以下 4 个方面：1）三
种抗真菌的药物组合，一起服用；2）良好的饮食结构，避免那些给免疫系统带来
负担的食物；3）避开环境污染、烟、香气、食物添加剂等；4）补充维他命，矿
物质和跟踪元素以帮组免疫系统。这套程序在很多方面为免疫系统减压，最有效果
的是持续这样的治疗数月之久，以帮助免疫系统恢复正常，在酵母菌被剔除之后普
通细菌再生与体内。
Most of what the author writes about this condition stems directly from
experience treating patients. The existence of and treatment for CFIDS
is still considered controversial in medical centers.
这里作者所写的多数源自治疗病人的经验。在医学界关于 CFIDS（慢性疲劳综合
症）的治疗依然存在争议。
OCCULT FUNGAL PATHOGENS
神秘的真菌病原体
Yeast and fungal infections of the skin, mouth, nails, vagina, and
digestive tract have long been recognized and are easy to diagnose,
but a relationship has only recently been discovered between yeast
colonization, often sub-clinical and otherwise unapparent, with a wide
variety of disabling symptoms.(1-8)
酵母菌和真菌，常见于皮肤、口腔、鼻子、阴道以及消化道感染，已经是一个普遍
认识，而且认为易于诊断，然而最近才有发现酵母菌常见于轻症临床和其他许多不
明显症状中。
Yeast and molds belong to a broad family of plant life called fungus.
Mildew, bread mold, and mushrooms are also types fungus. All yeast
are fungi (plural of fungus) but all fungi are not yeast. The terms
"yeast," "fungus" and "mold" are often used interchangeably. They all
share allergic potential and immunological properties.
酵母菌和霉菌都属于植物中菌类大家族。霉菌、发面的酵母、蘑菇都属于菌类。所
有的酵母菌都属于真菌，而真菌不一定是酵母菌。酵母菌、真菌、霉菌这三个名词
通常可以作为近似词交替使用。他们都有潜在的免疫相关的属性。
The most widely present single-cell fungal organism (yeast) is Candida
albicans (formerly called Monilia), which exists quite normally in low
concentrations on the skin and inside the digestive, respiratory and
reproductive organs. Because Candida is a normal constituent of
human micro-ecology, the mere presence of Candida is not sufficient
to make a diagnosis of "infection." It is always present.
当前最为普遍的单细胞真菌生物体（酵母菌）就是白假丝酵母（学名：念珠菌），
通常聚集在皮肤、消化系统、呼吸道以及生殖器官上。假丝酵母菌是人体微生态系
统的一个普通成员，少量的假丝酵母菌不足以称为‘感染’。它们常在。
A healthy person will tolerate normally present Candida. However,
yeast and other fungi release many bioactive and allergenic
substances into the body, which increase to exceed tolerance as yeast
increase. These substances can be toxic, allergic, and hormonal in
nature.
一个健康的人可以容许正常数量的假丝酵母菌的存在。然而，酵母菌和其他真菌释
放出许多可以引起过敏的生物活性物质来，当酵母菌增加的时候就需要更多的忍
受。这些物质可能是有毒的、过敏的或者会刺激荷尔蒙。
Substances released by yeast include:
酵母菌所释放的物质包括：
1) Allergens, which react classically, causing symptoms of itching,
hives, skin rashes, nasal congestion, cough, bronchitis, irritable bowel,
and asthma. More than 70 distinct allergic molecules have been found
to be produced by Candida albicans.(4)
1) 过敏原，也就是常见反应，皮肤瘙痒、皮疹、鼻子堵塞、咳嗽、支气管炎、肠
颤、哮喘。目前明确的有超过 70 中可以引起过敏的物质是由假丝酵母菌产生的。
2) Fungal poisons (mycotoxins) include aflatoxin, ergot poisoning
and mushroom poisoning. The list ofknown mycotoxins is very long
and not widely recognized.(9) Dr. Iwata, in Japan, has icataloged
many toxins produced by Candida albicans, which poison the nervous
and immune systems.(10) Acetaldehyde (similar to formaldehyde) is
also secreted by Candida albicans and is one potential cause of yeastrelated symptoms.(11) Immune system abnormalities have long been
associated with Candida.(12) Other incurable diseases of unknown
cause, presumed immunologic, such as psoriasis and multiple sclerosis,
have been reported to improve, sometimes dramatically, following
anti-fungal therapy.(13-14)
2) 真菌毒素，包括黄霉毒素、麦角菌毒、蘑菇中毒。真菌毒素的种类相当多，而
且也没有被广泛认识。在日本，伊瓦塔博士分类出了许多有白假丝酵母菌所产生的
毒素，可以破坏神经系统和免疫系统。假丝酵母菌也会分泌出乙醛（类似于甲
醛），这是产生酵母菌相关症状的潜在物质。长久以来，免疫系统的异常问题都与
假丝酵母菌有着关连。其他未知原因不能治愈的疾病，例如牛皮癣、多硬化症，也
可以假定为免疫相关，因为有报告证明抗真菌疗法对他们有效，而且有时效果明
显。
3) Hormonally active molecules are also produced by Candida.
Symptoms related to the female reproductive system, including PMS,
cystic breast disease, infertility, and reduced sex drive, have been
reported to improve following treatment with anti-fungal medications.
Those observations are evidence for interference with normal
hormonal function by yeast and fungus overgrowth.
3) 荷尔蒙激活分子也是由假丝酵母菌生产的。女性生殖系统相关的症状，包括经
前综合症、囊性乳腺病、不育症、性欲减少，在使用抗真菌疗法后有效。这些例子
都是真菌过度繁殖所带来荷尔蒙失调的证据。
There are many different strains of Candida albicans. Different strains
produce widely different toxins, allergens and hormone-like substances.
Patients also vary widely in their sensitivity and response to those
substances. This results in a wide diversity of ill-defined yeast-related
symptoms in CFIDS. The seemingly neurotic nature of many such
complaints has delayed more widespread recognition of this clinical
syndrome. Response to therapy of CFIDS following anti-fungal
medications does provide evidence for a direct causal relationship
between yeast and symptoms.
白假丝酵母菌有许多不同的种类，不同种类生产不同的毒素、过敏原、激素类的物
质。病人对这些物质也有着不同的过敏反应。这就导致了如 CFIDS 所列举的各种
各样的真菌相关症状。许多此类申诉被视为神经病，而这推迟了更广泛的承认这一
临床综合征。对于 CFIDS 所采用的抗真菌疗法的效果为酵母菌和症状的关联提供
了证据。
Many physicians are unaware of lasting adverse effects caused by
routinely prescribed medications such as antibiotics. Antibiotic therapy
for minor colds and runny noses is a common practice. People
routinely receive multiple courses of broad-spectrum antibiotics
throughout life or are injected with long-acting corticosteroid medicine
for joint or muscle pain.
许多医生并不清楚一些日常药物例如抗生素所产生的持续的副作用。抗生素疗法对
于小感冒、流鼻涕来说还行。人们习惯于日常使用各类抗生素或者因为关节痛、肌
肉痛就注射皮质类固醇药。
Once established, sub-clinical colonization with yeast in the body may
persist unrecognized for many years. Antibiotics, such as tetracycline,
can greatly increase yeast in the colon after only a few days.
一旦确立了，亚临床病人可能多年都不会意思到酵母菌在他的体内。诸如四环素之
类的抗生素可以就在几天内极大的增加酵母菌在结肠中的数量。
Yeast is well recognized to cause vaginitis in women, diaper rash and
thrush in infants. Yeast and fungus are also common causes of other
skin infections including athlete's foot, jock itch, ringworm, paronychia,
intertrigo, anal itching, seborrhea (dandruff), tinea versicolor and
onychomycosis (causing fingernail and toenail deformities). Those
conditions are rarely considered serious, although many women
troubled by persistent or recurrent vaginitis would state otherwise.
人们通常知道酵母菌导致女性的阴道炎、尿布疹、以及幼儿鹅口疮。酵母菌和真菌
常见于皮肤感染（包括足癣、股癣、轮癣、甲沟炎、擦烂红斑、肛门瘙痒、皮脂溢
--头皮屑、花斑癣、甲霉菌病--导致手指甲和脚趾甲变形）。这些情况很少被认真
对待，当然许多妇女有持续性或者复发性的阴道炎困扰的另当别论。
It is not widely recognized that those conditions often occur in patients
with previously weakened immune system, resulting in lowered
resistance to yeast infection. The most common and overlooked site
for yeast proliferation is the large intestine. Constipation is commonly
caused by yeast. Yeast in the colon release large amounts of allergens,
toxins and other hormonally active substances into the circulation,
without raising a suspicion of where the problems are coming from.
然而大家并没有认识到这些情况往往发生在之前免疫系统脆弱的病人身上，他们没
有足够的力量抵抗酵母菌的感染。最常见也最容易忽视的酵母菌繁殖的地方就是大
肠。便秘常常是酵母菌引起的。在结肠里面，酵母菌释放出大量的过敏原、毒素以
及其他激素活性物质进入循环，却不引起病源的怀疑。
IF THIS IS SO COMMON, WHY IS IT NOT MORE WIDELY
RECOGNIZED?
如果它如此常见，为何没有广泛为人所知？
It is common in the history of medicine that recognition of a safe and
effective therapy may not occur until an accepted scientific rationale is
found to fully explain observed benefits.(15) Highly effective therapies
have been rejected in the past, sometimes for decades, merely
because they were innovative and did not fit with currently accepted
theories.(16)
Clinical experience and observation of benefit should be the "gold
standard" on which patient care is based. Patients should not be
deprived of a safe and effective treatment only because the scientific
basis has not been fully researched and proven.(16,17) If thorough
medical evaluation shows no other plausible cause for symptoms of
CFIDS, a trial of anti-fungal therapy with dietary and environmental
avoidance of potentially offending substances will cause no harm.
There are no definitive tests to diagnose CFIDS in advance of
treatment. Response to therapy, as described in this paper, is the only
practical way to confirm a treatable condition, which would otherwise
remain untreated.
HISTORY
In the late 1970's Dr. C. Orian Truss, an allergist in Birmingham,
Alabama, first published and lectured on the wide variety of CFIDS
symptoms associated with Candida albicans.(4-6,11) Dr. Truss
successfully treated many hundreds of chronically fatigued, allergic
and depressed, seemingly neurotic patients. His patients experienced
great improvement following prolonged treatment with oral nystatin,
an anti-yeast medicine. Dr. Truss' patients suffered with a wide variety
of symptoms which had often not responded to many other treatments.
Patients of Dr. Truss' who improved with his therapy reported the
following types of medical histories:
1. Having been treated, sometime many years previously, for acne
with prolonged courses of tetracycline or other antibiotics.
2. Multiple courses of antibiotics for urinary tract infections, sore
throats, ear infections, bronchitis or sinus trouble;
3. Use of oral contraceptives;
4. Treatment with cortisone-type medicines or injections.
Dr. Truss was the first to describe this syndrome of "yeast-related
illness," characterized by the following symptoms, with varying
severity and in different combinations (I now classify these symptoms
more broadly as CFIDS):
1. Nervous symptoms, including fatigue, headache, dizzy spells,
anxiety, "nervous tension," panic attacks, depression, schizophrenia,
insomnia, irritability, impaired memory and "spaced out" feelings.
Complaints of nervousness, depression and unexplained fatigue were
the most commonly present symptoms.
2. Reproductive tract symptoms, including premenstrual syndrome
(PMS), infertility, cystic mastitis (painful breast lumps), pelvic pain,
painful intercourse, recurrent vaginitis, prostatitis, reduced sex drive
and impotence. Patients had often received repeated courses of
antibiotics for infections of the bladder or prostate.
3. Digestive tract symptoms, including unexplained and chronic
abdominal pain, canker sores in the mouth, esophagitis, indigestion,
heartburn, constipation (often alternating with diarrhea), anal itching,
gas, bloating, spastic colon, and intolerances to common foods.
Multiple surgical procedures had sometimes been performed, without
benefit until anti-yeast therapy was prescribed. A persistent coating on
the tongue was a common finding.
4. Other chronic and resistant symptoms, including unexplained
muscle and joint pain; arthritis; headaches; visual disturbance;
difficulty thinking, remembering and concentrating; recurrent sore
throats; swollen or painful glands (lymph nodes); low grade fevers of
unknown origin; sensitivity to heat or cold; hair loss; numbness or
tingling in the face or extremities; persistent nasal congestion; cough;
and respiratory allergies. Many patients were abnormally sensitive to a
variety of environmental exposures, including tobacco smoke,
perfumes, sprays, formaldehyde, petrochemical products, exhaust
fumes and other odors. They became "spacey" or felt ill breathing the
chemical odors in shopping malls, fabric stores or shoe stores. They
reacted adversely to many common and nutritious foods, especially
the grains, sugar, and milk products.
Much to their distress upon seeking medical advice, such victims of
CFIDS are often told, "Your physical examination and laboratory
studies are all normal. Your symptoms are '
"psychological." In other words, "you're imagining your illness."
Physicians and family alike would consider such patients to be
"hypochondriacs." Victims of CFIDS would go from doctor to doctor,
year after year, with no benefit.
William G. Crook, M.D., a pediatric allergist from Jackson, Tennessee,
subsequently published confirmatory reports to support Dr. Truss'
original observations.(2,3,7,8,15)
Patients included all age groups and both sexes. Children with learning
disabilities, dyslexia, hyperactivity, attention deficit disorder, food
allergies, drug abuse and a variety of delinquent and emotional
disorders, had often received repeated courses of antibiotics for
recurrent ear infections, bronchitis and other conditions―including
prolonged courses of tetracycline for acne.
Even patients who had been committed to mental hospitals have been
helped by anti-fungal therapy. Other puzzling immunologic diseases,
including multiple sclerosis, rheumatoid arthritis and lupus
erythematosus, have responded better when attention was given to
reduction of yeast and immune stress. A wide spectrum of allergic
disorders, from classical hay fever to chronic, delayed-onset type of
food allergy and petrochemical sensitivity, have improved following
anti-yeast therapy.
The use of allergy injections has been eliminated in many cases.
Injection therapy has never been of much help in food allergy.
Avoidance and anti-yeast therapy are the most effective long-term
programs. Tolerance to previously offending foods and exposures often
improved after several months of anti-fungal therapy.
DIAGNOSIS
Unfortunately, there exists no reliable laboratory test to prove or
disprove the presence of CFIDS. Yeast and fungus are normally
present in everyone. Because of the ubiquitous nature of yeast,
cultures and microscopic smears are not of much use.
A thorough examination prior to therapy is important to insure that an
otherwise treatable condition is not being overlooked. Response to a
course of therapy will then confirm or refute the diagnosis of CFIDS.
Many laboratory tests are available to assess antibodies and immunity.
In practice, however, those laboratory tests do not predict which
patients will respond to this therapy. Because testing is expensive (and
often too new for routine reimbursement by medical insurance) a trial
of therapy may be the most reliable and also the most cost-effective
way to diagnose and manage CFIDS.
The most reliable predictor of response is the typical past medical
history and symptoms. Several case histories will demonstrate this.
In addition to factors described above, a diet high in sugars, including
natural sugars such as fruits, fruit juice and honey, etc., is common.
Yeast grow more rapidly in the presence of sugars and simple
carbohydrates. Symptoms often worsen following sugar intake. Socalled "hypoglycemia" frequently has an element of CFIDS and will
improve following anti-yeast treatment.
Adverse and allergic reactions to prescription and non-prescription
medications, chemical fumes, solvents, perfumes, shopping-mall odors,
and even nutritional supplements are a common complaint. Presence
of those symptoms increases the likelihood of benefit from this therapy.
Response to treatment remains the most reliable way to confirm or
disprove a suspected diagnosis of CFIDS. Diagnosis can only be
suspected from the medical history, after other types of illness have
been excluded by a thorough medical evaluation and by lack of
response to other therapies.
COEXISTING VIRAL INFECTION
Persistent and chronic viral syndromes have been well-documented in
patients with CFIDS. Those include Epstein-Barr virus (EBV),
cytomegalovirus (CMV), human herpesvirus 6 (HHV-6), Coxsackie-B,
and other viruses. Laboratory tests are available for many viruses, and
both alpha interferon and interleukin-2 (IL-2) tend to be elevated in
the presence of viral replication. It is postulated that some symptoms
of CFIDS may be caused by increased alpha interferon and IL-2.(18-21)
If immunity is impaired, increased susceptibility to viral infection is
expected. Many viruses normally lie dormant throughout life. They
only become active if the body's defenses are weakened. For the most
part, the only good defense against viral infections is a healthy
immune system. The treatment program described below can benefit
CFIDS by removing immune stress, allowing immunity to become
stronger. Although chronic viral syndromes and CFIDS may co-exist,
not all patients with CFIDS have viral problems.
The presence or absence of a diagnosable viral syndrome does not
seem to alter potential benefit from this therapy. Viral testing is also
expensive and is therefore not routinely performed prior to therapy.
Both viruses and fungal organisms create stress to the immune system.
It is therefore quite probable that one can predispose to the other. Any
treatment which strengthens natural immunity can improve either
condition. In that way anti-fungal therapy may hasten recovery from a
chronic viral syndrome.
TREATMENT
1. DIET
During the first three months or more of treatment a so-called "Cave
Man Diet" or rare food diet is recommended. Bear in mind, however,
that after two months of elimination combined with triple anti-yeast
medicines, many foods that would have previously caused symptoms
will be better tolerated.
Simple carbohydrates are restricted. Even natural sugars, fruits and
fruit juices are reduced, since they promote the growth of yeast. Many
nutritious foods that are more stressful to the immune system are
eliminated. Equally nutritious but rarely eaten foods are substituted.
Foods eliminated for several months include milk products (all dairy
and everything containing dairy products) and all grains (including
wheat, corn, rye, rice, barley, etc.) and most other frequently eaten
foods. Of the so-called "junk foods," chocolate, cola, candy, pastries
and other sweets are eliminated. Food intolerances can be quite
individual but these eliminated foods have been the most common
food allergens in clinical practice. Regardless of the reason, this
program works in practice.
The following foods should be minimized:
1. Refined and simple sugars, including table sugar, honey, syrup,
molasses, fruit juices and dried fruit. Small servings of unsweetened
fresh fruit may be consumed in limited amounts--up to three moderate
servings per day.
2. Breads and bakery products, which contain wheat, rye, corn and
yeast, are eliminated. Rice, oats and barley are somewhat better
tolerated, but most patients respond better if they avoid all grains for
several months. Potatoes are better tolerated as a substitute for grains.
Sweet potatoes and yams are highly nutritious and are the best grain
substitutes that are least likely to cause problems.
3. Other foods stressful to the immune system that might will slow
recovery include mushrooms, chocolate, cola (even diet cola drinks),
chemical flavorings, colorings and sweeteners, and alcoholic beverages.
An occasional patient must temporarily restrict all carbohydrates to as
little as 25 to 50 grams per day before improvement begins. As
improvement progresses, intake of unrefined, complex carbohydrate
may be increased to a more desirable level.
The most frequently eaten foods are those which are most likely to
cause or aggravate symptoms. The immune system becomes
sensitized by prolonged and repeated exposures. Symptoms may be
triggered by either protein and carbohydrate foods. Fats are less likely
to be bothersome. Sensitivity should be suspected to favorite foods,
especially if they are craved and eaten frequently. Sensitivities to
foods can best be diagnosed by testing for provoked symptoms after
strict dietary elimination until symptoms improve.
In order to consistently relieve and then provoke food-related
symptoms, elimination should be preceded by a few weeks of daily
consumption. Sensitivity tends to fade with avoidance.
Sensitivity most often occurs to a number of different foods
simultaneously, making diagnosis difficult. All of the reactive foods and
environmental exposures must be avoided for long enough for
symptoms to fade before provocative testing can be done.
Impaired immunity predisposes to food and chemical sensitivity. Socalled food allergy might be best considered a symptom of CFIDS and
not the primary problem. All potentially reactive foods should be
avoided during the initial period of treatment with anti-fungal
medicines to remove as much stress as possible from a disordered
immune system. Continued intake of just one reactive food can mask
reactions to another food when it is added back. Only after most if not
all symptoms have improved is it possible to do provocative testing for
food allergy. The so-called "Rare Food Diet," also known as the "Cave
Man Diet," has clinically been most successful in relieving symptoms.
Various blood and skin tests are promoted for food allergies, but falsepositive and false-negative results are common. Blood testing can be
accurate for the rapid onset type of allergy accompanied by hives that
can occur with shell fish or grass pollen. Most food allergies come on
slowly, they often require repeated exposures and tend to fade with
elimination from the diet. Blood testing for that type of allergy has
proven to be very unreliable, with a high percentage of both false
positive and false negative results. The only reliable test for sensitivity
to a specific food or chemical is consistent improvement following
elimination and reoccurrence of symptoms following a challenge. Onset
of symptoms after exposure to a food allergen may not occur until
hours or even days later, and often requires multiple exposures.
Food allergies tend to change as diet is changed. They are often not
"fixed" allergies. The foods, which are eaten most, are most likely to
cause symptoms. Sensitivity to those foods slowly fades after
elimination. Allergic foods may again be tolerated after several months
of avoidance while previously "safe" foods may begin to cause
symptoms, as their frequency of consumption is increased.
Rotation of dietary foods, avoiding repeated consumption of
botanically related foods more often than every fourth day, is
sometimes helpful for severely allergic patients. After a course of antifungal therapy, especially the triple therapy as recommended here,
reactive foods are often better tolerated.
Small traces of bakers' yeast or other types of yeast which occur in
food may be tolerated, while the foods themselves, such as dairy or
grain products, may cause symptoms. It is a common misconception
that the yeast in bread and not the wheat is causing the problem.
Patients usually discover that they feel better and have fewer allergic
symptoms if they limit consumption of milk products, wheat and corn
throughout life. If eaten infrequently, they may not cause problems.
2. MEDICATION
Yeast and fungi can develop resistance to anti-fungal medicines, and a
significant percentage of yeast and fungi in the body at any given time
will be resistant to any one anti-fungal medicine. In clinical practice, it
has been found more effective to combine more than one anti-fungal
medicine simultaneously. Two or three of the following medicines are
given together for one to two months. These medicines require a
physician's prescription:
A. Nystatin: Brand names include Nilstat®, and Mycostatin® (available
in powder, tablet, suspension, suppository and capsule forms). Generic
forms of nystatin are also available but some sources can be bitter
tasting and impure. Only the pure powder, available from
compounding pharmacists, is free of chemical colorings, additives,
and allergens. Beware of receiving nystatin a foot powder instead of
the pure pharmacologic grade for internal use.
When the powder is taken directly into the mouth it is more effective
and eliminates yeast in the mouth which can seed the intestine. The
usual dose of nystatin powder is 1/4 teaspoon four times daily (which
is equivalent to 4 tablets containing 500,000 units each four times per
day). This is twice the dose customarily prescribed by most physicians.
Nystatin is not absorbed from the digestive tract in any significant
amount and is an extremely safe medication, even at higher doses.
This dosage is what works best in practice.
Nothing should be taken by mouth for 20 to 30 minutes after taking
the nystatin powder. This allows a coating to remain in the mouth and
upper digestive tract for long enough to eliminate yeast in those
locations. Prolonged administration is usually necessary―several
months (occasionally a year or more) before full benefit is achieved.
The "rare-food diet" is maintained throughout the time of anti-fungal
therapy and for several weeks thereafter. Gradual improvement is
usually observed during the second and third month of
therapy―although sometimes sooner. This program requires patience.
After improvement plateaus out, and symptoms are much improved,
medicines are discontinued. The greatest improvement may not occur
until after the anti-fungal medicines are stopped.
If symptoms return, anti-fungal medicines may again be prescribed for
a month at at a time and the more allergenic foods again eliminated
until improvement can persist without medication. Lasting benefit has
been seen much more frequently after two or three anti-fungal
medicines are given together. When improvement is maintained for at
least a month without medication, a more normal diet may gradually
be resumed, doing provocative testing for each added food for
sensitivity as described above. Eliminated foods are added back one at
a time to test for continued sensitivity.
If antibiotic therapy should become necessary for treatment of a
serious bacterial infection, which would not otherwise resolve
spontaneously, it is advisable to subsequently resume the anti-yeast
program for a month or more, but only after antibiotics are
discontinued. Administration of anti-fungal medication simultaneously
with antibiotics could theoretically promote the growth of resistant
fungal organisms against which no therapy would be effective.
Broad-spectrum antibiotics such as ampicillin, tetracyclines, and the
cephalosporins are more likely to cause yeast overgrowth. Treatment
with topical antibiotics on the skin or the use of less potent antibiotics,
such as penicillin-VK, sulfisoxazole, and nitrofurantoin, are not as likely
to reactivate yeast overgrowth.
Nystatin powder should be stored in a refrigerator if kept for a
prolonged period, although a few weeks at room temperature will not
cause a problem. Nystatin slowly takes on a bitter taste at room
temperature. Nystatin should not be exposed to high temperatures or
left in a parked automobile on a hot, sunny day. Taste and bitterness
normally vary somewhat from batch to batch. Nystatin is one of the
least toxic of prescription drugs. It is safer to use than most nonprescription products. Nystatin merely coats the interior of the mouth,
throat, esophagus, stomach and intestine, preventing yeast from
multiplying.
Mild side effects may occasionally occur during anti-yeast therapy,
including nausea and skin rashes. Most such symptoms are the result
of yeast die-off and not from the nystatin itself. Some patients may
experience a temporary increase in the symptoms, such as fatigue and
depression during the first few weeks of treatment with anti-fungal
medicines. This phenomenon has been attributed to a yeast "die-off"
effect or Herxheimer's-like reaction and long-term benefits are not
reduced. If the medicine is stopped too soon, yeast can easily
recolonize.
Nystatin powder is preferred over tablets, capsules and suspensions
because the pure powder contains no chemically derived coloring
agents, binders, flowing agents, sugar or other potential allergens. The
powder begins its work in the mouth and coats the upper digestive
tract. Tablets and capsules do not dissolve until they reach the
stomach or lower and are therefore less effective. Commercially
available nystatin suspensions marketed as prescriptions for the
treatment of thrush in the mouth contain very little medication and it
suspended in a solution of sugar. The pure powder is thus much more
effective.
Nystatin powder is best placed on the tongue dry by inverting a halfteaspoon measuring spoon in the mouth and tapping the spoon
against the upper teeth, then allowing the powder to mix with saliva.
Rub it into the tongue and swish it around for several minutes in
contact with the tissues in the mouth and throat, before swallowing.
Nystatin powder possesses two advantages over tablets and capsules.
It is less expensive and it is effective against yeast in the mouth,
throat and esophagus where the tablets and capsules have no effect.
Patients with symptoms of sore tongue, canker sores, indigestion and
heart burn (hiatal hernia or esophagitis) improve more quickly
following treatment with nystatin powder―providing evidence that
yeast overgrowth is at least partly responsible for those symptoms.
If saliva is not adequate, a small sip of water or juice may be used to
swish the powder into the mouth, making a paste to coat the gums
and tissues. Small children may object to the taste unless a small
amount of fruit juice or applesauce is used to mask the taste of
medicine. The more concentrated the nystatin, the more effective it
will be.
Female patients may improve more rapidly with the simultaneous use
of small doses of an anti-yeast vaginal cream, one-half applicator or
less once daily at bedtime, when symptoms of vaginitis are present.
Some yeast are normally present on vaginal tissues and even small
numbers may increase symptoms in a highly sensitized patient.
Keeping yeast colonization to a minimum throughout the entire body
for several months lowers stress on the immune system and allows
gradual recovery.
Vaginal creams and suppositories all contain a chemical preservative,
which is potentially allergic. The creams themselves may cause allergic
symptoms which mimic yeast. If either Sporanox® or Diflucan® is used
together with nystatin, as described below, vaginal therapy is usually
not necessary.
B. Sporanox® (generic name itraconazole): Is taken by mouth in
capsule form and is fully absorbed in the upper digestive tract.
Because it is absorbed, Sporanox is not as effective for reducing yeast
inside the intestinal cavity and colon where there is no blood
circulation. The usual dose is one 100-mg capsules daily with the
largest meal of the day. Absorption is better with food in the stomach.
Sporanox® is indicated in preference to Diflucan (described below)
when skin or nails are affected by yeast or fungus. Sporanox is
concentrated to a greater extent in skin and nails.
C. Diflucan® (generic name fluconazole)is very similar to Sporanox®.
Diflucan® seems to work somewhat better when vaginal yeast is a
symptom. Concentrations of Diflucan® in body fluids are somewhat
higher than Sporanox® but Diflucan® is not concentrated as much in
skin and nails. Otherwise, in practice there does not seem to be much
difference between Diflucan® and Sporanox®. It probably does not
make much difference which one of the two medicines is used.
Either Sporanox® or Diflucan® is used as one of the three anti-fungal
medicines administered in combination. But Sporanox® and Diflucan®
are never prescribed together. (Nizoral® is no longer preferred because of
greater potential for liver toxicity.)
D. Amphotericin-B is an anti-fungal drug which, like nystatin, is very
safe and not absorbed systemically when taken by mouth. (An
injectable form of amphotericin-B is quite toxic, however, and its use
is restricted to treatment of life-threatening systemic fungal infections.)
The oral form of amphotericin-B is very safe and non-toxic.
Amphotericin-B is a more potent anti-yeast medicine than nystatin.
Oral forms of pure amphotericin-B are presently available at only a few
specialized compounding pharmacies in the United States. It has been
approved by the FDA for use by mouth and was marketed in the
United States for many years in combination with tetracycline. That
FDA approved product was named Mysteclin-F®. To treat yeast
problems, you do not want the form that is combined with tetracycline.
Amphotericin-B in pure form for oral administration is can also be
obtained at pharmacies in many other countries (often without a
prescription). It is sold in France, on prescription only, under the brand
name Fungizone®, in 250 mg capsules. In Germany and Switzerland
the prescription form is called Ampho-Moronal®, as 100 mg tablets.
Patients recover more quickly and often remain well without further
medication when amphotericin-B is combined with nystatin and
Sporanox therapy. The best form of amphotericin-B is a powder inside
250 mg capsules (Fungizone® is formulated in this manner). The
capsules can be opened and emptied into the mouth four times daily,
along with the nystatin, and mixed with the nystatin powder in the
mouth.
Several US sources of Amphotericin-B and nystatin powder are listed
on our webpage entitled "How to get Amphotericin-B".
E. "Triple therapy", the simultaneous daily administration of nystatin
powder, amphotericin-B and either Sporanox® or Diflucan®, for one to
two two months, has led to lasting improvement in a large percentage
of patients who had previously been resistant to therapy. Patients
should continue all three medicines for a month or two and then
continue with the dietary restrictions for another month or longer, for
as long as progressive improvement continues to occur.
INJECTION THERAPY
Skin testing with allergens and injection therapy with extracts
containing reactive pollens, molds and dust is sometimes helpful, but
allergies often resolve following this anti-yeast program without the
need for injections. Injections have not been found to be of benefit in
food allergy. The use of triple anti-yeast therapy, and the complete
program described in this paper, have eliminated the use of skin
testing and injection therapy. The same is true of other types of
neutralization therapy or sublingual therapy. If this treatment plan
restores more normal immunity, the allergies are no longer such a
problem and other types of therapy become irrelevant.
Stresses to the immune system are additive. Once a threshold for
tolerance is exceeded, adverse reactions tend to occur to many
different substances. When the immune system becomes stronger, the
threshold for tolerance increases and so-called allergies are less likely.
Think of the immune system as a tired pack horse, which has been
forced to carry an excessive load for many miles. When it finally
collapses it is greatly weakened. It will not be able to tolerate a normal
load until all of the load is removed and the horse is nursed back to
health. The same principle applies to the immune system. By
eliminating yeast, fungus, potentially allergic foods, chemical
exposures, perfumes, insecticide residues, etc., from the body, the
load is greatly reduced. After a period of rest, often requiring several
months, immunity recovers to the point that a more normal diet and
life-style can once more be enjoyed.
OTHER TREATMENT MEASURES
Non-specific supportive measures include:
A. A healthy, active life-style, a nutritious diet with avoidance of
refined and processed foods, avoidance of tobacco and avoidance of
excessive alcohol are important. A good attitude also speeds recovery.
B. Nutritional supplementation with a balance of high-potency,
hypoallergenic, yeast-free multiple vitamins, minerals, trace-elements,
and anti-oxidants will insure optimal intakes of essential
micronutrients and support immunity. Many nutrients essential for
immunity (B-complex, selenium, zinc, vitamin C, vitamin E, and many
others) are marginal to deficient in the diets of many Americans. DHEA
25-50 mg/day has been shown to help boost immunity.
C. Avoidance of exposure to petrochemicals, fumes, perfumes, hairsprays, insecticides, exhausts, and other potentially reactive
substances, which stress immunity, will speed recovery. Careful
avoidance of insecticide fumes and residues, which are quite toxic, and
avoidance of musty, moldy areas in the environment, both at home
and at work, will assist recovery.
DISCUSSION
CFIDS does not have a single cause such as Candida albicans or
Epstein-Barr virus. Disordered immunity is the underlying common
denominator, with many contributing factors, all adding together until
a threshold of tolerance is exceeded. All people normally have Candida
albicans in their bodies. A positive skin test for allergy to Candida is a
medical test for a competent immune system. Every healthy person is
sensitized.
Everyone also harbors a variety of inactive viruses. Healthy immunity
keeps them inactive. Only when immunity is impaired do Epstein-Barr
and other viruses leave dormancy and multiply. Yeast and viruses are
also kept in their proper place without symptoms if immunity is
adequate.
For those reasons cultures for yeast, blood tests for yeast antibodies,
skin tests and viral studies have thus far not been very useful in the
diagnosis or treatment of CFIDS. If symptoms are typical, a trial of
therapy is the easiest and most cost-effective way to determine if
benefit will result. The form of treatment described in this paper has
helped hundreds of patients who previously did not benefit from other
types of treatment.
The most common pitfall of this therapy is loss of patience, lack of
persistence and stopping therapy before full improvement is realized.
Initial benefits often take two to three months to begin. The so-called
yeast "kill-off" effect and "withdrawal" from favorite and addictive
foods may initially make symptoms worse. Patients become
discouraged.
Patients who have been sick for a long time and who have failed to
find benefit elsewhere are the ones who will be motivated to follow this
program for the months required to achieve lasting benefit.
Case Histories
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