Three expert speakers from the EULAR Congress 2026 share their top tips for where to start when supporting patients with rheumatic and musculoskeletal diseases to enhance their gut microbiome and help to reduce inflammation and other symptoms.
The gut microbiome is a subject well and truly in vogue and the associated wellness industry is thriving – and for good reason. Where some health and wellness trends are seemingly grounded in myth and legend, the evidence base around optimising the gut microbiome is wide-reaching and increasing, including for the benefit of rheumatic and musculoskeletal diseases (RMDs).
As such, a session at the recent European Alliance of Associations for Rheumatology (EULAR) 2026 Congress entitled ‘The microbiome: a primer for health professionals in rheumatology’ considered how the microbiome may influence the onset, progression and treatment response in RMDs and its potential implications for clinical practice and the work of the multidisciplinary team.
For example, Borja Martinez Tellez, researcher at the University of Almería in Spain, noted the role of Roseburia inulinivorans in preventing age-related muscle strength depletion. This bacterium is known to be depleted in conditions such as fibromyalgia and is an interesting therapeutic target for rheumatoid arthritis, he said, as approximately 24-30% of these patients have sarcopenia.
Evidence and caution
Yet Chris Martey, MSK transformation clinical lead physiotherapist across primary care, urgent primary care and the minor injuries unit at the Aneurin Bevan University Health Board in Gwent, Wales, said that uncertainty remains among the rheumatology workforce about the best course of action for optimising the microbiome in RMDs.
‘There are so many unanswered questions,’ he said. ‘Which bacteria might start inflammation, and which good bacteria might reduce inflammation? And, crucially, how do we get this messaging across to patients? There’s a real mixture of people’s understanding of their condition and their health literacy, so how do we actually relay that information to make it understandable for our patients.’
He also alluded to the different factors contributing to gut dysbiosis, such as genetics, diet, the environment and atmosphere – whether that be rural or urban – and medications that patients might be taking.
But while there is certainly an interplay between these factors, caution is required. Chris added: ‘The clinical significance should not be overestimated and it’s potentially too early to make far-reaching conclusions’.
Anecdotal evidence from patients is emerging for things like diet reducing joint inflammation and fatigue, alongside more formal evidence in the literature, and it’s very much a case of trial and error to see what works for individual patients.
Top tips for optimising the gut microbiome in RMDs
Session co-chair Dr Khadija El Aoufy, nurse and research fellow at Careggi University Hospital and the University of Florence, Italy, noted that this focus on the microbiome is already having a positive effect in the clinic. But she asked the panel for their top tips on where the rheumatology multidisciplinary team should start when it comes to optimising the gut microbiome.
With reducing systemic inflammation and increasing beneficial bacterial populations being the goal, what is the most important, simple strategy recommended for clinical practice?
- Recommend a high fibre diet
For Professor Jose Scher, Steere Abramson professor of medicine and rheumatology at the New York University School of Medicine, New York, US, there are two simple answers, the first being a high fibre diet.
‘I don’t understand when I look around and see how many people do not incorporate fibre into their diet – it’s astonishing,’ he said. ‘Ask ChatGPT what a high fibre diet looks like – that truly is what I tell my patients.’
- Encourage weight loss, where appropriate
This, Jose said, is ‘all encompassing’.
‘You do everything you do for cardiovascular disease, you do everything you do for lowering cholesterol, all to improve survival, but what about joint pain? If you are overweight or obese, I promise you that your knees and your ankles are not happy,’ he said. ‘And so, if you say those two things – high fibre diet and lose weight – you will make significant progress with the treatment of your patients.’
- Ensure a unified message
For Chris, the importance of multidisciplinary collaboration in optimising the microbiome cannot be overstated.
‘I would hope that when you leave here, taking this into your department, into your teams, and say “hey, I want to raise this as a topic for debate and a topic for discussion”, and see where everyone else is,’ he said. ‘Practically, that’s something that we’ve done here in the UK, and it starts that conversation going, and, crucially, it allows us to see who those key partners are in this conversation and align that shared approach to medicine. Patients will see different individuals within the team, and we want to ensure that unified message.’
- Promote movement
‘For me, one of the most important is to move,’ said Borja. ‘We need to ask our RMD patients what type of exercise, or what kind of physical activity, they really like and build on that, even if it’s just walking.
‘This is reducing hypoxia in the gut and restoring the gut barrier integrity and also maintaining the gut microbiome. So, just move – the little bit that you can do everyday, and that will help your gut microbiome a lot.’
Chris echoed this and said: ‘We need to get better at prescribing exercise, period. I often see patients who are doing lots of cardiovascular exercise and then missing out on the strength training. Or people who are doing good flexibility exercise might actually be missing out on other aspects. And so, I think at this stage, my stance would be that we just need to prescribe holistic exercise.’
He added that when it comes to exercise and the gut microbiome, ‘it’s a really exciting prospect that there's an opportunity to hone in on more research’ and that from a clinical, practical stance, it’s important to take that message forwards’.