According to Dr. Manek, the broad, rapidly changing field of the microbiome can be distilled into one clinically actionable point: Anything that increases butyrate helps fight inflammation. To build butyrate, she emphasized pairing probiotic/fermented foods with prebiotic fibers—two strategies that work hand in hand. Her preference isn’t a capsule, but whole, naturally fermented foods. Whole foods, such as fruits and vegetables, are also rich in prebiotic components that help promote a healthy microbiome. In contrast, ultra-processed foods may have a detrimental effect on overall gut microbiome health.6 She recommended the International Scientific Association for Prebiotics and Probiotics as a trusted source for emerging scientific information.7
Food Avoidance Trials
Some patients may also benefit from cutting out other specific types of foods, like those containing gluten, Dr. Manek argued, because they may have an inflammatory effect. This science is not settled, with many experts claiming a lack of convincing evidence on this point, at least for patients without celiac disease or a clear gluten intolerance.8,9 For some, a gluten-free diet may entail eating fewer ultra-processed foods, which can complicate interpretation.
If patients do want to try a dietary change, such as going gluten-free, Dr. Manek recommends a 12-week trial, carefully comparing symptoms, such as joint aching, and frequency of pain reliever use (e.g., NSAIDs) before and after the change.
Supplements
Although a huge part of the commercial health industry, supplements raise concerns about drug interactions, product quality and efficacy.
Especially for complex patients on multiple medications, it’s important to assess safety and potential drug interactions. Dr. Manek noted that Natural Medicine’s Database for Healthcare Professions, a subscription-based service, is a helpful resource for clinicians in this respect.10
To address a frequently asked question of which brand of a supplement to choose, Dr. Manek recommends consumerlab.com as a subscription-based, patient resource. They perform third-party testing of popular supplement brands, assessing quality and giving price comparisons.
Vitamin D
Vitamin D plays an important role in immunomodulation, and many patients do not obtain sufficient levels through sunlight and diet alone. Multiple studies have shown associations between low levels of vitamin D and the presence and severity of rheumatic diseases.11
The optimal level of serum vitamin D is a matter of debate. Although a level greater than 30 ng/mL may prevent osteomalacia and secondary osteoporosis, higher levels might be needed for overall immune and general health.11
Dr. Manek tests her patients for vitamin D and very frequently finds levels below normal. She has found that many patients with immune diseases get better control of inflammation with vitamin D supplementation. She aims for 50 to 80 ng/mL.
