Fueling Against Fatigue with Kristin Koskinen, RDN

[00:36] Jennifer Milner: Welcome back to Bendy Bodies with the Hypermobility MD, where we explore the intersection of health and hypermobility, focusing on dancers and other aesthetic athletes. This is co-host Jennifer Milner here with the founder of Bendy Bodies Podcast, Dr. Linda Bluestein.

[00:51] Dr. Linda Bluestein: Our goal is to bring you up-to-date information to help you live your best life. Please remember to always consult with your own healthcare team before making any changes to your routine.

[01:08] Jennifer Milner: Our guest today is registered dietitian nutritionist and Bendy Bodies own Kristin Koskinen. Hello, Kristin.

[01:19] Kristin Koskinen, RDN: Hello. Thank you for having me.

[01:22] Jennifer Milner: Thank you for coming back on the podcast. Always a pleasure to have you here.

[01:29] Kristin Koskinen, RDN: The pleasure's mine.

[01:30] Jennifer Milner: So fatigue is something that a large part of the population can probably relate to, and in the past we've discussed fatigue with other experts, as fatigue is something linked to a lot of issues common in the hypermobile population. Dr. Pacynski defined fatigue for us as the inability or difficulty in accomplishing simple tasks, and we want to use that definition for the purpose of this discussion, if that works for you, sort of separating fatigue from the idea of sleepiness. So does that work?

[02:01] Kristin Koskinen, RDN: Yeah, I think that's a great way to define it and really helpful.

[02:05] Jennifer Milner: Excellent. So with that in mind, what role can nutrition play in fatigue?

[02:07] Kristin Koskinen, RDN: Nutrition plays a huge role in fatigue. We're all familiar with the term food as fuel, and we are going to hit on that. But first I want to pull the lens back on our perspective of fatigue and talk about it's not just what you eat, it's what you digest and absorb. Nutrition happens at a cellular level. But to get there, we have to procure the food, prepare the food, eat the food, and hopefully those nutrients are broken down appropriately, are digested and absorbed, and get to where they need to go.
[02:48] Some of the issues that are common in the hypermobile community — we'll start with an obvious one, which is fatigue or being tired. We talk about the number of emotional, physical, and mental resources someone may have. Sometimes this is referred to as the number of spoons you may have in a day, which can vary. And so we want to pay attention to that. What are your resources generally, and what are they maybe from day to day? And if you have a sense of that, it'll give you an idea of what you may have available in terms of getting foods that work for you.
[03:27] Another thing — just the practical issues: grocery shopping, food prep, cooking, anything like that. We also want to look at TMJ issues, which are really common. So if you have any issues with your TMJ, chewing can be a problem. Do you need to adjust how you prepare your foods so that they're easier for you to chew and swallow? Sometimes people have chronic TMJ issues, sometimes they have flares with it. The entire dental aspect matters too. Do you have loose teeth? Do you have anything that needs to be fixed or mended? That's important.
[04:04] And then we also want to look at executive function. We know that ADHD and autism spectrum disorder are common among hypermobile people, and so executive function tends to be a huge issue. You only have so many decisions you're going to make during the day, and if it comes to the end of the day and it's time to decide what to eat, you may be spent. If you have a hard time focusing and you need some help planning meals or deciding what's appropriate for you, getting some support there can sometimes be your best choice. Because if you've run out of spoons in that department, then the rest of it isn't going to follow like we would like it to.
So those are three overriding things I look at as a dietitian that are related to the nutrition component. And we really need them even though they aren't looking at the specifics of, say, vitamins and minerals. What I want to do is start by talking about things where we can control what we can control. Here are some recommendations that very often are exceptionally helpful for my clients. They may be overlooked by a lot of people, but the results can be a big bang for zero bucks, which I like a lot. They are free, they are simple, and they will do no harm. So those are wonderful places to start with any sort of health improvement program.
[05:25] The first is we want to look at digestion, and that actually starts with the head. There's a cephalic component that we talk about — that's when you think about food, you see food, you smell food. It really starts from the literal top and goes down. When you do this, it engages your nervous system to start acting on your digestive system and readies things. It says, hey, things should be coming down the pipe here pretty soon, let's get ready. What does that mean? It means that stomach acid will start to produce. It means your salivary glands will start producing saliva, which includes enzymes that break down food. Your pancreas will get ready to pump out digestive enzymes that you need to digest your food.
[06:08] So the idea of starting with thinking about your food, thinking about what you're going to have to eat — this can be part of that executive process. If you know in advance what you're going to eat, you can start to hype yourself up about it. "Oh yeah, I'm so excited I get to have this meal later," and that can be very beneficial in this process of digestion. We are very far away from the original ways of eating. I think of the Little Red Hen — she grew the wheat, she ground the wheat, she baked the bread, she did all the things before she actually ate that bread. And all of that is part of the process of preparing yourself for eating. Now it's just as simple as, we live in this grab-and-go lifestyle that doesn't facilitate that. So we need to take the extra step to be mindful.
[06:55] This is being distinctly mindful about thinking about the food you're going to eat. That also includes being quiet and sitting down and relaxing. Being stressed while you eat shuts off the digestive process. You are either in a rest-and-digest mode or you are in a fight-or-flight mode. There's really no in-between. If you're trying to do both, you're going to lose. It'll impact your digestion negatively for sure. You'll notice if you're under stress, you may not feel like eating, your appetite may be decreased. You may feel like throwing up if you eat when you're really stressed. All of those things are indicators that we want to be restful.
[07:30] A tip and trick you can employ today: sit down to eat. When you stand, that engages the sympathetic nervous system — the sympathetic is that fight-or-flight. Sitting helps with the parasympathetic, which is the rest-and-digest. Two, you can eliminate stressors while you're eating. Don't watch the news, don't have cantankerous company — whatever you need to do to make sure mealtimes are pleasant. That can be difficult sometimes. Work on it, even if it's one meal — if it's dinner, if it's breakfast, whatever you can do for that. If it's breaking away from gossipy people at the studio to go eat a meal in peace, do that. That can be really helpful.
[08:10] Another thing is breathing. Breathwork is really important. We're starting to talk a lot more about that in the dance community and it can definitely enhance your digestion. Box breathing is an easy way to do that. It's super simple. You breathe in for a count — depending on what your stress and relaxation levels are, they're going to vary, but we'll start with four. You would breathe in for a count of four, hold for a count of four, exhale for a count of four, and hold for a count of four, and repeat that until you feel rested. The exhale is actually where the power of that breath is, which is really where things come down.
[08:48] The next thing you want to do is make sure that you're chewing your food well. Chewing your food to the consistency of applesauce or yogurt is what you need to do. That's going to vary depending on the food that you're eating, but that gives your body a chance to break it down. Your stomach cannot handle big blocks of food — that's not its job. That's your mouth and teeth's job. Chew, chew, chew, chew, chew. Saliva also contains enzymes that start to break down that food, and that process actually continues while the food is in the stomach until those enzymes are broken down. So chewing is emphatically necessary. Generally, 12 to 15 chews will do it. It'll vary by food source, so please chew your food well.
[09:31] And then the food gets to your stomach, and in your stomach it needs hydrochloric acid to break down. If you're under stress, hydrochloric acid levels will decrease. If you're taking certain medications, you may have lower levels of hydrochloric acid. If you are not getting enough of certain nutrients, including zinc, your body may not be able to produce enough hydrochloric acid. This does a couple of things. One, it means your body's not breaking down the food. If the food is not broken down enough, you're not going to be able to absorb it later on. Every step — all these steps — are important.
[10:06] And if you're not producing enough hydrochloric acid, proteins aren't going to be broken down well. Another protein that's not going to be broken down is bacteria. So bad things that you get in from the environment — whether you've inhaled them, whether you've eaten them — they get swept in from your nose and mouth and ears even. You swallow them, they end up in your stomach, and that hydrochloric acid breaks them down. Infections are not a good way to keep your energy levels up. They lead to fatigue. So this is actually a really important component that we may not think about, but it is. And one of the nutrients we look at there is zinc. So if you're not getting enough zinc, that can impact that process.
[10:48] Hydrochloric acid is necessary to extract vitamin B12 from protein sources. And then B12 connects with something called intrinsic factor that it needs to be partnered with, so that later on in the intestines it can be absorbed. So if you don't have enough hydrochloric acid, if your acid levels aren't high enough, you may be eating enough vitamin B12 but not be able to utilize it. That's really important. Because vitamin B12 is critical for energy levels. Deficiency can lead to neuropathies, neurologic problems, decreased energy, anemias — all things that tank your energy levels and will result in the symptom of fatigue.
[11:33] Then along the way we also have your pancreas. It should be shooting out digestive enzymes that break down all the different components of food. You need that. If you're not resting and digesting, or you're just shoveling things in, maybe your digestion doesn't have enough time to get there. Some people don't produce enough of these enzymes. This is something we want to be aware of too. And if you're on the hypermobile spectrum and dysautonomia is part of your life, maybe the signaling isn't getting there appropriately for you. So these are some things to consider.
Next up in the process is your small intestine, and that is where your body absorbs the nutrients that have been digested earlier along the track, for the most part. So to simplify things, this is where things are going to be primarily absorbed, and that's important. You need to go from the digestive tract to the inside of the body. Technically speaking, your entire digestive tract counts as the outside of your body, which I think is fascinating. I always have.
Now that we're talking about the intestine, this is a critical point. There's connective tissue involved. And something that's important about the intestine is there's something called intestinal permeability, or leaky gut. It's fairly common in the population at large. I find it to be more common in the hypermobile community. This shouldn't be a big surprise because when we think of connective tissue and any sorts of risk or damage, it's vulnerable. So things that can disrupt the integrity of the intestine include stress and toxins, or any sort of insult to these very delicate one-cell-thick connections. And if they are damaged for any reason, they create gaps where bacteria and other proteins that shouldn't have gone through can get through. This can lead to inflammation for any number of reasons, and food sensitivities, which can also lead to chronic inflammation. And those express themselves differently in different people.
[13:50] This is one of the reasons why when we talk about anti-inflammatory foods, foods can have particular properties, they can have mechanisms of action, but how they operate in each person is going to be different. So if your body has at some point had a leak and a protein from a food that we would consider anti-inflammatory got through, and your body looks at it now as foe because the mediators of your body respond and say, "Oh, that's what we're going to react to," then even healthy foods — including spinach, I see spinach come up quite a bit — you may have an inflammatory response. We're not going to use blind words like anti-inflammatory. I don't like to do that, and I feel like it's frustrating because it doesn't acknowledge the experience that so many people really have, and it creates a right-wrong atmosphere, which is not helpful. It's just absolutely not helpful.
[14:54] And if someone says, "Oh, just do something," they clearly don't have an understanding, because "just" — we can even say the term "simple." Simple means simple. It means it's elegant. There aren't a lot of steps. It's clear. It doesn't mean it's easy. So "just" negates the challenges that people may be going through. And the idea of "just eat anti-inflammatory foods" — that might drive you crazy. Citrus and tomatoes are two common foods that are healthy and would qualify as anti-inflammatory, but wreak havoc with a lot of my clients. Even when people talk to me for the first time, I'll just throw some things out like, "How do you do with tomatoes?" "Oh, I can't do tomatoes. Oh, no, no, no." So we really want to be mindful of those things.
[15:56] And then we go to the large intestine, and that's where your microbiome largely lives. You have microbes all over your body — your mouth, your skin, your large intestine. And that is where hopefully a lot of the fibers you've been eating produce lovely items like neurotransmitters and other things that help us feel well. But they're not going to be a big part of our talk today, so we can just end there.

[16:19] Jennifer Milner: So if anybody is tuning into this episode hoping to hear five magic foods to fight fatigue, that is not going to be this discussion, clearly. I feel like we just got this amazing TED Talk on nutrition and fatigue, and we haven't really even started talking about specific foods or nutrition. It's just been that general overview — like the whole thing about neurodivergency and how executive dysfunction can contribute to nutritional deficits that are not the sort of links that we usually draw. But you're absolutely right, and I'm going to have to go back and listen to that again, because that was a lot of information. I feel like we just rode the Magic School Bus through our digestive system.

[17:04] Kristin Koskinen, RDN: You need special earrings for that.

[17:06] Jennifer Milner: That was incredible. And a good reminder that when we're talking about things with hypermobility, there is not one size fits all. There's no "oh, you just do this" or "you just eat that." People say, "Oh, just cut this out and you'll feel great, just stop eating wheat," or whatever it is. There's not that one-size-fits-all. So thank you for taking something really complex and trying to distill it down into a smaller form.
[17:37] So we know that nutrition has a big role to play in fatigue. And we know that even how we eat — as you were talking about — making choices about how we eat and when we eat and everything can contribute to it. And you were saying there are foods that we need, like you mentioned the mineral zinc, that's going to help us have an easier time absorbing and digesting. Not to try to make blanket statements, but are there foods that we can eat that could actually contribute to that feeling of fatigue?

[18:10] Kristin Koskinen, RDN: Oh, absolutely. So there are two that come to mind right away. The first one is alcohol. Alcohol is a depressant that right away can wreak havoc with mood. Two, alcohol can deplete certain nutrients, including B vitamins. Thiamine is one of note, and if you are deficient in thiamine, you can end up with all kinds of problems, including things that look a lot like dysautonomia. So alcohol can be a huge one. Alcohol can also displace nutrients. People who are drinking a lot of alcohol may not pay attention to the other foods that they're eating, and they may make different food choices while they're under the influence. I'm not trying to knock anything — these are just the biochemistry of things. So you'll need to apply this to your own situation.
[19:05] A second one — and again, this is based on the conversation of fatigue and we're really looking at biochemistry and physiology — is sugar. And I am not opposed to sugar. If people have heard me in other venues, they know I use sugar as a tool. I'm not opposed to sugar. I think sugar can be great — in celebratory things, all that stuff. However, it can also lead to fatigue.
[19:35] The way that it does that: sugar — straight sweeteners that aren't attached to a food source — just doesn't magically appear. We get it from other food sources, whether it's beets or cane sugar or whatever. Sugar also comes from natural sources in fruits and sweet potatoes and grains and things like that. When we take the sugar away from those food sources, it stands alone as a two-molecule carbohydrate. And it's great because it can give you quick energy. However, that's all it is — just the quick energy. And it does not have with it any of the B vitamins that are required to metabolize it. So if you're eating a lot of sugar, what can happen is you may deplete whatever B vitamins you have in your body, because they're being used to metabolize that sugar.
[20:32] If you're fatigued or tired or your mental-emotional bucket is low, a lot of times you'll crave sugar. Your brain knows it's going to get a good hit. Your brain thrives on glucose. That is the preferred currency of fuel for your body. You get glucose primarily from carbohydrates — they are strands of glucose and some other components, but you can break that down into glucose very efficiently. The body likes that a lot. You can get it from protein through a process called gluconeogenesis, but that's complicated and usually comes at a great cost, including breaking down your own muscle protein, which we don't want to do.
[21:19] So the body really likes glucose. And people will notice that if they are tired or fatigued, they may crave sugar. That's the brain's way of saying, "I need something." But what the brain may really need too are those B vitamins that come along with it to metabolize it. In nature, we don't just pull up some sugar — our bodies would get sugar in terms of berries and fruit and other things. If we get it in that form, then we're getting the nutrients to ride along to make sure that the metabolism happens.
[21:56] So that actually can lead to fatigue if you are getting amounts that exceed what is appropriate for you in a particular situation or condition. This is something that's really interesting too. There are neurotransmitters in your brain that actually pick up on the levels of circulating blood glucose, and these neurotransmitters are responsible for wakefulness and arousal and even appetite. And if your blood sugars are too high, they actually tune down. Which is really interesting, because some of the instances when your blood sugars may be really high are during chronic inflammation. So if you're chronically inflamed, those blood sugars may be high. Your insulin sensitivity to your cells may be diminished, and that's part of why those blood glucose levels are high. So what that does is it shuts down the responsiveness of these neurotransmitters that are involved in wakefulness and arousal. That can lead to fatigue.
[23:08] And being hypoglycemic or hyperglycemic can be a reflection of being in a state of chronic inflammation. Chronic inflammation does a few things. One, it's a sign that things aren't right, things aren't going well. And two, it requires a lot of energy. So being chronically inflamed — those inflammatory processes require energy. You may be burning through energy to support the inflammation, which can lead to fatigue. And inflammation can also suggest that you're sick. It makes sense for the body — if you're not well, it doesn't want you out running around and taking class and doing training. It needs to conserve resources to attend to infection or whatever it needs to do. And so this process of "sugars are too high, shut you down" makes sense. It's saying, "We need to rest the body so we can recover." So if your blood sugars aren't managed for any particular reason, that may be part of your fatigue.

[24:22] Jennifer Milner: I'm listening to all of this and thinking about a lot of the patients that I see and how they — I think — are kind of defeating themselves in some ways. Because if you start to have some digestive issues, oftentimes you start to restrict foods more. You start to get more stressed. You probably get stressed before you even put the first bite of food in your mouth. You anticipate that you're going to have bloating or abdominal pain or whatever, which becomes a self-fulfilling prophecy.

[24:55] Kristin Koskinen, RDN: Right.

[24:56] Jennifer Milner: And so restrictive food plans or fad diets seem like they can really be such a huge problem and really contribute to a person's level of fatigue. So what do you think about some of those restrictive diets that are out there?

[25:15] Kristin Koskinen, RDN: I have a lot to say about them. And I see that all the time. One of the things that we work on is that idea of the mental game — like, what can you do? How can we do this? People will restrict down sometimes out of fear. They have fear foods and they have safe foods. And sometimes those safe foods can get down to eight, which creates its own set of problems.
[25:40] When we look at restrictive diets, sometimes people will recommend: go gluten-free, go keto, go low carb — any number of things. And my recommendation is they not be taken lightly. Going gluten-free, for example, can be very helpful for a lot of people. I'm not discounting it at all. A lot of people benefit from getting rid of gluten. However, when you pull the gluten, foods that contain gluten also contain a lot of B vitamins and fiber. So now we need to make sure: what are you doing to ensure you are getting those nutrients? Just coming in and replacing the whole grains that you may have been eating — that were sources of gluten — with gluten-free options, you may not be getting them. And you may also be getting foods that drive inflammation in you, because if it's a gluten-free replacement product, it's going to have a lot of stuff in it to make it feel comparable to those gluten foods. We want to eat foods that taste normal and feel normal, but it's something to be aware of. And if you're struggling from fatigue, that matters.
[26:53] Another thing to look at — particularly when looking at grain-type products — is folic acid on the label. I notice a lot of clients when they pull gluten also remove folic acid from their diet, because folic acid in the United States is required to be in particular food products — specifically refined flour. They're not required to put folic acid in foods that are organic, but they are in conventional foods. So here's the deal. Regular foods like wheat and these grains have folate originally. During the processing, the folate is pulled out and manufacturers replace it with folic acid, which has a distinct purpose. In large part, it's required in the US to prevent spina bifida, epilepsy, and other neurologic disorders in developing babies.
[27:42] The problem can be that not everyone has the genetic makeup to metabolize folic acid. So if you get into the metabolic wheel where folic acid comes in, it's kind of slow and it gets bottlenecked as it is. But if you don't have the equipment to metabolize that folic acid, your levels may increase, and that can cause brain fog and fatigue. So sometimes when people pull the gluten, they are also inadvertently pulling the folic acid, which actually may be the problem more than the gluten. So I like to say, let's recognize that and keep it in mind. If it's gluten, it's gluten — whatever. If you feel better off gluten, stay off gluten. There are lots of other options. You just need to make sure that you're eating other whole foods that give you a similar nutrient profile so that you're not behind.
[28:37] Another trendy diet that I hear about all the time is the keto diet. Keto has a role and it is a therapeutic one. If you have had a traumatic brain injury, if you have seizure disorders, a ketogenic diet may be appropriate for you. It should be — I wouldn't pursue this without professional help to make sure you're getting the nourishment you need. If you are doing keto for any other reason, we need to talk about the reason. It's often promoted as a great way to lose weight. Well, if you're trying to lose weight, chances are you may suffer fatigue.
[29:20] Earlier I mentioned that carbohydrate is the body's preferred fuel source, and a keto diet has very limited carbohydrate — 25 to 50 grams a day, which is very low. And if you're an athlete, that ain't gonna work for you. It's primarily fat, and the intention is that your body will become keto-adapted. Eventually it'll use that fat for fuel, and it converts fatty acids to ketone bodies for your body to use. That can be fatiguing, particularly for athletes. So if you are an artistic athlete and you're trying to go keto, what we know from the research is your perceived level of exertion will be high. You'll feel like you're performing at a 12 out of 10, which on another day would have felt like a 7 out of 10. So that is not a good way to go.
[30:11] Another problem with keto is because you're so limited with your carbohydrates, trying to get in B vitamins and fiber becomes limited. Constipation is very common. You may not be getting a host of other nutrients. I keep mentioning the B vitamins, but they're super important. They're necessary for metabolizing energy. They're necessary for making red blood cells. They are necessary for central nervous system operations. So if you're going with keto and you pull these nutrients out, you may feel fatigued.
[30:53] The Whole30 is another one. Effectively, the Whole30 is an elimination diet, and a lot of people feel really great when they finish. The problem is it's very limiting, and any of these things can also lead to eating disorders. And eating disorders are more common in the hypermobile community. And if you're a bendy body, if you're an artistic athlete, you're at increased risk. So we do not want to bring these things in unnecessarily. If you want to do an elimination diet, you should do it with someone who can help make sure you're doing it in a way that suits you and is appropriate.

[31:31] Jennifer Milner: That makes sense. I also appreciate what you were saying about how people might not have enough zinc, as you mentioned earlier. People might not have high enough levels of B vitamins, but they also could be getting too much of something like folic acid. We always think about, "Oh, we're not getting enough" of some nutrients. So it's interesting to think about the balance and making sure what's appropriate for our body types. So if someone suspects that their fueling patterns might be contributing to their fatigue, are there simple steps they can take to find out what might be the culprit? Are there blood tests that they could do to sort of assess fatigue? What could they do?

[32:12] Kristin Koskinen, RDN: Sure. There are a lot of things. The cheap, effective thing to do is use a food journal to keep track of what you're eating, what you're drinking, your circumstances — your environment, what's going on in your life. All of these things matter. And then you can track symptoms too. If you keep track of that, whether you're able to discern what's going on yourself or you use that data to share with your healthcare team, either way it can be really helpful. That's simple but not easy.
[32:46] For my clients, what I do is I have a photo food journal they can use. So all they have to do is take a picture of what they eat, then they can make notes about what's going on with them. I get the data and I can help translate that into what's going to work best for them. Most apps on the market that have to do with food are looking at weight loss — that's the goal. So they give calorie counts, macro counts, all these numbers that can be distracting and really misleading. I'm not a fan of those. I have one that people can use that gets rid of that, but they can just look at foods and then also track their symptoms, including GI symptoms, poop patterns, all kinds of things. So that can be helpful.
[33:38] Testing is another option. One thing may be having a complete thyroid panel. If your thyroid's out of whack, that can be nutrition-related. And if your thyroid is particularly — if you're suffering from hypothyroid, it can slow your digestion. So now you may end up with cramping, bloating, constipation, maldigestion, malabsorption because your thyroid is diminished. One of the things that we know about thyroid is that we want to know if your thyroid's converting from T4 to the active form T3, and that requires minerals zinc and selenium. So if you're deficient in those nutrients, you're missing a step in the process, and everything downstream from there is going to go kaput. Not a lot of people are thinking about selenium, so that's important. Having a thyroid panel is a good one.
[34:43] Looking at markers of inflammation can be good — CRP is one. With regard to specifically food and nutrition, there's a test called the MRT test. That's something you need to go to a specific practitioner for, because not every practitioner knows how to help you with the results once they get them. It's a mediator release test, and effectively that's a fast track to see what foods you're very likely sensitive to. So rather than going through a traditional elimination diet — which is complicated, it's hard, it's not easy, it's not simple — this really kind of shoots you ahead so you can start and get a better idea of what may be impacting you specifically.
[35:27] Tests for different anemias are really important too. An iron panel — your hemoglobin and hematocrit. If you're deficient in iron, you will feel low on energy. People who are anemic can feel fatigued, and there are different kinds of anemia. You may have an iron anemia, a B12 anemia, a folate anemia. So those are things we want to test. You need B12 and folate to create those blood cells. So if you're deficient in them because you're not absorbing them, you're not eating enough of them, or whatever it is — if your demands are just higher and you may be eating what looks like a lot but it's not enough for you — you could have a relative deficiency. Checking to see if you have any sort of anemias can be important.
[36:11] Checking vitamin D levels can be a good one. Getting a micronutrient panel can be another one to see where you're at. A hemoglobin A1C — where's your blood glucose riding most of the time? Your primary care provider should be able to provide most of those for you. You may want to ask specifically, like a complete thyroid test isn't just a TSH — it involves other components. So you may want to check with someone who runs those regularly just to make sure you get everything you actually want to see to get a complete picture.

[36:54] Jennifer Milner: And what do you think about continuous glucose monitoring and/or glucose tolerance tests?

[37:00] Kristin Koskinen, RDN: Oh yeah. The continuous glucose monitoring — I know some people who are doing it. I think it could be a good tool. And I also think sometimes we get so much information that it can be overwhelming, or we start to dial in on one area to the neglect of others. So I think it depends. It would be really individualized. And I think it would be a several-steps-down thing — like, you've got a lot of other things rolling before you start there.

Jennifer Milner: What about glucose tolerance tests? I'm thinking of like fasting insulin versus A1C versus glucose tolerance test — some of those options beyond just looking at fasting glucose. In terms of those options, what do you think is the most valuable?

[37:49] Kristin Koskinen, RDN: I'd look at insulin. I'd actually look at an insulin test. Fasting glucose is so limited. The glucose tolerance test — Glucola — it can make people sick. And I am a sympathetic dietitian. If something's going to make someone sick, can we do anything else? If people are afraid of needles, what are the workarounds? Are there ways to piggyback tests? What can we do to make this as comfortable as possible? Which is so important. Going back to that — what are your emotional resources? Creating stress or distress, we don't want to do that as providers. We're here to take care of you. So yeah, I'd be testing insulin and insulin reactivity.

[38:42] Jennifer Milner: Awesome. Great, that's great to know. In terms of vitamins and supplements, we know that this is totally the wild west, right?

[38:53] Kristin Koskinen, RDN: I love that. Yes. A tumbleweed just blew by.

[38:59] Jennifer Milner: Exactly. It is crazy what people are doing, and going into stores and just — you've got a ten- or twelve-dollar-an-hour employee telling you, "Oh, here, take these things." What are some of the vitamins and supplements that you see playing the most significant role in fatigue, and what should people be looking for, be aware of, be cautious about?

[39:28] Kristin Koskinen, RDN: Okay. We're going to go back to those B vitamins, because — okay, here's something. I'm going to give you a clinical example because it's really interesting. So sometimes the symptoms we see aren't what you expect. I had a client come to me and she had unremitting vomiting. That was one of her primary complaints. She was vomiting daily. And so if you're vomiting daily, you can imagine that your digestion and absorption isn't high. What we did is we did a few things. One of the things we did is we increased her B vitamins. So we started with a well-balanced multivitamin and mineral. And by well-balanced, I mean that the manufacturer has an understanding of how much of things to put in so that competing nutrients — like too much zinc will knock out your copper, we don't want that; too much magnesium and calcium together — they compete with each other, we don't want that. So a well-balanced supplement has nutrients in proportions that your body will best utilize. We started with that, and then we layered in another B complex to bring up her B vitamins, and the vomiting stopped. Now she's able to eat. Now her stress levels are down. Now we're able to work on the disordered eating, and it all starts to come together.
[40:55] Usually if we can get a hold on one thing, that starts the momentum. And momentum isn't a mental game — it's physics. Whatever direction you start going, you'll start going that way. And sometimes it's fixing one simple thing, one easy thing. That's why I started with "let's start with chewing." Can you do that? Can you get rid of something that's distracting you while you're eating? Because sometimes that one simple thing is the gateway to everything else turning the corner.
[41:28] Other supplements — sometimes we want to look at your medications. Are you taking meds that may deplete your different nutrients? If you're on the birth control pill, that can deplete B vitamins, magnesium. So we want to look at that. Are you taking things that are required for your management of symptoms, like if you're on H1 or H2 blockers? That may have another sequela. Does it mean we want to take you off those? Not necessarily, but we may want to look at whether there's a supplement that may help your overall picture and how you're digesting. We may want to bring in something like hydrochloric acid or betaine HCl to help support your body.
[42:15] And sometimes these are just not long-term. It's like, while we're here, let's do this. We're going to create a bridge with supplements until we can get the food up to speed. If you're only eating eight foods, we want to supplement and support your body so you feel well enough. And then we're going to start expanding things. It may be part of a process. It depends, and we have all kinds of different strategies.
[42:48] A lot of people need vitamin D. That's not uncommon. It's one you can definitely test and get a level. If you are hypermobile, you may need what seems like a ridiculous off-the-charts amount. Thousands and thousands of units every day, where someone else may max out at 2,000. And someone may say, "Oh, that's ridiculous, you can't do that." But if you're working with a practitioner who's monitoring your blood levels, you may find you need 10,000 a day compared to someone else who just takes 2,000. I recommend pairing vitamin D with vitamin K2 to optimize its use in your body and make sure that the minerals you need for hard surfaces like bone and teeth are deposited where they need to go and not in soft tissues.
[43:41] What else? Sometimes it's digestive enzymes. Digestive enzymes are a supplement that can be supportive for some people who find they have a hard time eating, that food just sits in their stomach. Sometimes it can be an enzyme problem. Sometimes it's an overgrowth of bacteria. Maybe that slowed digestion has led to the proliferation of bacteria in places they're not supposed to be. It's not that they're bad bacteria — they were supposed to stay down in your large intestine, but they moved up to your small intestine, or they came in through your mouth and you didn't have enough hydrochloric acid to kill them. So then we can look at some different supplements to help with motility if necessary. That can provide a bridge from where we are to where we want to go and provide relief too.
[44:35] Magnesium — a lot of people are deficient in magnesium. The form you take will depend on what you've got going on. There are lots of forms of magnesium. Magnesium citrate is available and it's cheap, but it could give you diarrhea. So it's not necessarily the best absorbed. If you're constipated, that may be one that we start with. If you're struggling with mood disorders, we may look at a formulation that binds the magnesium with the amino acid glycine so that it helps cross the blood-brain barrier. Magnesium bisglycinate is generally well tolerated and generally well absorbed. People who struggle with sleep or rest or relaxation — which may be part of your fatigue issue — may benefit from getting some magnesium too.
[45:17] It depends, but we want to start with your diet. We always want to start with your food source. What we bring in as a supplement — I like to think of it like a stone wall, and the foods you eat are the stones in that wall, and the supplements just come in as the mortar to fill in the blanks. We don't want to have a mortar wall that we just punctuate with stones. It's cheaper — a lot cheaper to eat food than to eat fistfuls of supplements. When you get things in food, that balance is already there. And we get other things from food that we may not even be aware of. There are nutrients we probably don't know about yet. There are over 50,000 phytonutrients that come from plants that are real — they're new to the scientific community. We keep discovering things. And if you're just leaning on supplements and you're not working on your diet, you're going to miss out on those things. And they can be distinctly helpful when we're looking at inflammation — and again, inflammation, fatigue, all the things.
[46:28] So things like resveratrol, quercetin, curcumin all come from food sources, and you can use them strategically or therapeutically in supplement form. But if you're getting them consistently from your food sources, you're also getting the other nutrients that come along with them. You're getting the fuel you need — carbohydrate, protein, and fat — and other nutrients that you don't need to think about all the time if you're eating well.

[46:57] Jennifer Milner: So what you're saying is that there's no one simple answer to nutrition and fatigue — whether you're a bendy body or even if you're not. We often walk into these conversations saying, "Please just give me the three bullet points that I can walk away with and feel like I'm doing something better about my nutrition." And I love that you've given us concrete things that we can do here, but you're also reminding us once again that so much of this is not something that we should be doing under the advice and guidance of Facebook or whatever social media platform we are on.
[47:42] So as we remember, everybody, that it is not a one-size-fits-all issue here — if we are really having an issue, we should be trying to find someone to help us manage our nutrition if we can. And so if someone is going, "Oh my gosh, this is overwhelming, I did not realize I need to make some changes," fortunately we have the worldwide web, and you can find someone who is experienced in your area who may not literally live in your area. And that's one of the benefits of being out there.
Kristin, I could pick your brain all day because you have such a wealth of information on this topic. Is there anything that we did not cover that you wanted to make sure we touched on before we leave?

[48:26] Kristin Koskinen, RDN: One thing. I think one thing that is probably going to come up — this is a popular one with dancers — are quick fixes and the idea of energy drinks and caffeine. How about that for fatigue?
And I want to actually direct this back to Dr. Linda, because these are stimulants. They're not energy, they're not fuel. They're going to have a short-term effect. They can be used strategically and can be an important part of your overall plan. Caffeine and energy drinks are a different ball of wax, but they're not something you want to lean on. Fatigue is a symptom, and if you're using caffeine or caffeinated beverages, that is a Band-Aid over a symptom. You're not getting at the cause of the fatigue, and that's what we want to do. Why are you fatigued? It's a symptom, not a disease state. We want to dig deeper and figure out what's going on to make that happen. Trying to cover it up with caffeine is typically going to work against you. It's also going to interfere with your sleep, which is going to create momentum in a downward spiral. I know — and I'm not opposed to caffeine. Anyone who's hung out with me for more than two hours knows that.

[49:55] Jennifer Milner: But we can end up in a cycle. Once things start to go in a certain direction — I love what you were saying about momentum, I think it's so true — we can end up using... I mean, I get requests all the time for prescriptions for stimulants, and I do prescribe them sometimes because there are cases where it's appropriate. But you can end up using caffeine during the day to stay awake and then alcohol at night to help you go to sleep. And we know that does not lead to good quality sleep. So then you're getting up the next day just as fatigued, if not more so. And the alcohol depletes the B vitamins. They both contribute in negative ways — the caffeine stimulating your sympathetic nervous system. So you end up in this vicious cycle, and like you said, you need to start doing things that change the momentum in the other direction.

[50:45] Kristin Koskinen, RDN: Absolutely. And how are we using the caffeine? Are you using it to stay awake? Are you, by using caffeine, blunting your appetite and therefore not eating what you need to eat? All of these things are interrelated. And do we really get to the intention of the caffeine? Why are you really using it? We have to ask some tough questions. If the answer is that caffeine, the stimulant, helps you to focus — "I've got ADHD, and if I can have some caffeine, I focus" — then that's different than "I'm trying to not fall asleep" or "I'm trying to suppress my appetite." So all these things — that's why there is no one answer. Is caffeine bad? Depends. A lot of times it's great. What's the context? Who's the person? N equals 1. And even within the same person — what's your situation now? It can even be situational.

[51:44] Jennifer Milner: So just reminding us once again that there are no easy answers. N equals 1 always makes me think of you. And just keeping in mind, as you said, caffeine might be great in one situation and not great in another. Folic acid might be great in one situation and working against you in another. Which just reminds us again that it's always great to reach out to an expert if you're really trying to get to the bottom of it and not try to figure out your own quick fixes or Band-Aids.
[52:13] So speaking of reaching out, where could people find you?

[52:17] Kristin Koskinen, RDN: Sure. You can reach me on Instagram at Kristin — K-R-I-S-T-I-N — underscore Koskinen — K-O-S-K-I-N-E-N — underscore RDN, those magical letters. You can find me on my website at www.eatwellpros.com. Or you can send me an email at [email protected]. Or with Bendy Bodies, because we love having you on Team Bendy Bodies.

[52:56] Jennifer Milner: And I will say — and I know Dr. Bluestein feels the same way — we love your Instagram posts. I'm constantly using whatever recipes you put up there so I can make them myself, but you give such great information in really small, easy-to-understand ways. And so if people don't follow you, they should follow you because it's great information.

[53:18] Kristin Koskinen, RDN: And hopefully people will take away from this, although there's no one single fix, an understanding that if you are having problems, having an RDN as part of your team is essential and can really make the difference between success and lack of success.

[53:36] Jennifer Milner: It is. It's that idea of — you're going to have eyes to come in and maybe pinpoint something that seems off the wall, but you've seen it before and it's like, "Oh, let's start here. You want to start over there? How about we start here?" And that may be the turning point.

[53:55] Kristin Koskinen, RDN: That's all it takes is that one pivot point.

[53:57] Jennifer Milner: That's what we like.

[53:59] Kristin Koskinen, RDN: Yep.

[54:00] Jennifer Milner: Well, you have been listening to Bendy Bodies with the Hypermobility MD, and today we have been speaking with Kristin Koskinen, RDN. Kristin, thank you so much for sharing your expertise with us again today and for being such a big part of Team Bendy Bodies.

[54:14] Kristin Koskinen, RDN: Thank you, ladies. It is always my pleasure. Great chatting with you.

[54:19] Jennifer Milner: Thank you for joining us for this episode of Bendy Bodies with the Hypermobility MD, where we explore the intersection of health and hypermobility for dancers and other aesthetic athletes. If you found this information valuable, please share it with a colleague or friend and leave us a review on your favorite podcast player. Remember to subscribe so you won't miss future episodes.
[54:40] If you want to follow us on Instagram, it's @bendy_bodies, and our website is www.bendybodies.org. If you want to follow Bendy Bodies founder and co-host Dr. Bluestein on Instagram, it's @hypermobilitymd, all one word, and her website is www.hypermobilitymd.com. If you want to follow co-host Jennifer Milner on Instagram, it's @jennifer_milner, and her website is www.jennifer-milner.com.
[55:18] Thank you for helping us spread the word about hypermobility and associated conditions. We want to hear from you. Please email us at [email protected] to share feedback. The thoughts and opinions expressed on this podcast are solely of the co-hosts and their guests and do not necessarily represent the views and opinions of any organization. The thoughts and opinions do not constitute medical advice and should not be used in any legal capacity whatsoever. This information is not intended to diagnose, treat, cure, or prevent any disease, as this information is for educational purposes only and is not a substitute for medical advice, diagnosis, or treatment. Please refer to your local qualified health practitioner for all medical concerns. We'll catch you next time on the Bendy Bodies Podcast.