Optimizing Nutrition to Support a Dancer’s Health with Kristin Koskinen, RDN

[00:11] Jennifer Milner: Welcome to Bendy Bodies. This is your guest co-host Jennifer Milner here with Dr. Linda Bluestein for another episode of this dance-specific series. Today we are so fortunate to be chatting with registered dietitian nutritionist and dancer Kristin Koskinen. Kristin pursued a career in dietetics to find the answers to her questions about nutrition and its impact on health and performance. She owns a private practice where she offers virtual nutrition counseling with a focus on performance nutrition. She incorporates the functional aspects of food in her approach to help artistic athletes of all levels, including those who've retired from dance. Her integrative approach recognizes that nutrition isn't just about the food you eat. It's important to take many factors into consideration, including individual biochemistry, environment, cultural influences, social norms, and body image, especially when working with dancers. Kristin is a founding member of DanceMed and is regularly invited to speak on topics related to dancer health and is a frequent contributor to media including Dance Magazine, Shape, Oprah, Healthline, NBC, and today.com.
[01:32] Hi, Kristin. Welcome to Bendy Bodies.

[01:37] Kristin Koskinen, RDN: Hello. Thank you so much for having me.

[01:40] Jennifer Milner: Absolutely. I can't wait to dive into our topic today. So before we start with the questions that we have lined up for you, can you give us some background on your life and just how you ended up as a nutritionist?

[01:54] Kristin Koskinen, RDN: Sure. Well, as you mentioned, I'm a dancer. I grew up dancing in a pre-professional ballet company, and there was a lot of talk about diets and weight loss, but not much about how to eat to support performance. Nutrition was essentially equated with weight loss, and in the culture then — as there unfortunately is now — thinner meant being better. It was better in ballet. And by the time I was 12 or 13, I found that I was restricting what I ate to watch the number on the scale go down. I was a normal weight and no one had ever suggested that I should lose weight, but it was clear that thinner dancers were serious dancers and I wanted to be taken seriously.
[02:38] But in spite of that, interestingly, my artistic director was the first person to introduce me to the concept of nutrient timing. That's the idea of what to eat and when to support your performance. And that, combined with watching Rocky Balboa swallow raw eggs, were really my introduction to sports nutrition.
[03:02] So then I retired from ballet and I went on to college where I switched from ballet to cheerleading and I studied biology and psychology intending to go to medical school. However, my biochem prof knew that my end goal was nutrition and recommended that I switch gears to pursue a master's in nutrition, which I actually did. After I finished school, I worked as a clinical dietitian — that means I worked in a hospital setting. And then I took some time off to be at home with our five kids, and I even homeschooled them for several years. I love teaching. I find it really rewarding. And that was an interesting part of my life that I wouldn't have forecasted.
[03:45] So then as the kids grew and went to school, I decided to go into private practice because I wanted to practice functional nutrition, and I really wanted to be who I needed when I was dancing and who a lot of people need when they're looking to take care of their own health and well-being. You know, healthcare is what we do at home. Sick care is what happens in hospitals. When I was working in a hospital, I was taking care of sick people, which is wonderful and we absolutely need that. I just wanted to be on the other end of things, giving people more control over their own health and destiny.
[04:26] So I take a holistic approach in my practice where I emphasize long-term health and wellness using food and nutrition to support the body's natural processes, including recovery, athletics, immunity — and I really try to emphasize how foods make my clients feel. Sometimes the emphasis is more physiologic and sometimes it's more emotional, but we're always mindful of where we're sourcing and how that goes.

[04:55] Jennifer Milner: There's so many things about that that I love, including the concept that healthcare is what we do at home, and hopefully if we do that, we don't end up at the hospital needing the sick care.

Kristin Koskinen, RDN: Exactly.

[05:03] Jennifer Milner: That is a great way to look at it. It's not really a luxury to be trying to eat healthy foods. It's a necessity. It's like prehab instead of rehab.

[05:16] Kristin Koskinen, RDN: Oh, exactly. I love it. You know, when I talk to our dance PT friends — and we share friends — it's the same thing. What they can do, what we can do ahead of time is so much more powerful than if we wait to fix things. Prevention really is the best cure.

[05:38] Jennifer Milner: Absolutely. One of the things we look at in the circles that the three of us travel in is that balance between dancers being the artist but also being the athlete. So many times we work on finding that perfect aesthetic, right? Trying to make ourselves look a perfect way. In my line of work, it might be that they're cheating the way their hip is used to get a beautiful line when that's just not physiologically how they're built. And in your line, it might be cheating their fueling in order to have a specific kind of aesthetic and a certain look. Going beyond that, what are some of the typical mistakes that dancers make in the way that they fuel themselves?

[06:24] Kristin Koskinen, RDN: Oh yeah, absolutely. They are artistic athletes. And when we look at this, we need to look at the psychology of the dancer. There's a spectrum that a dancer falls on. Some really view themselves as artists and others really embrace the athletic component of dance. Most people fall someplace in the middle, but no matter what, they are artists in this idea of line. Ballet is really my main area, and line — ballet tends toward the beauty of a thin line. And so we drive a lot of thin ideologies, which drives dancers to under-eat, which drives them toward fad diets.
[07:16] Some of the diets they pick up may actually have an appropriate role for other people. Keto is a big one. Keto can be used therapeutically for great results. It's not a place that dancers should be. So I think they get caught up in fad diets. They underfuel. They use artificial means to elevate their energy levels, which is really just robbing yourself from another day, whether it's caffeine or energy drinks or sugar. And it just drives things in the wrong direction.
[07:58] What we want to do — and the dance medicine field as a whole is really looking at longevity in dance — we're not looking at the dancer retiring at 18 or 22 or even 30. We're looking at dancers dancing well into their 50s or maybe even 80s. And what you do now impacts how long and how strong you can dance.

[08:32] Jennifer Milner: What I heard was that some of the things you commonly see are under-eating, looking at fad diets, just underfueling in general, and then artificially raising energy levels. I like that you specifically talked about that, because a lot of dancers do that — overdosing on coffee or shooting a Pixie Stick before they have to go on to do Snow, or whatever. But another common thing that I see is just not knowing what and when to eat. Do you see that as a common thing too? That they're not necessarily trying to avoid eating healthy, but they don't know when to eat a bigger meal and when to eat less, and when should I eat more fat-heavy or protein-heavy, and when should I eat healthy carbs?

[09:33] Kristin Koskinen, RDN: All the time, all the time. And that is okay. That's actually a decent place to be, because that's so common. Sports nutrition — that's specific knowledge that we want to layer into a sound diet. So if I'm working with a dancer or any athlete, but specifically dancers, we want to have a foundational diet. The trick is we need to be able to shift what they're eating depending on a lot of factors. Those factors could be where they are in their season — whether it's Nutcracker, whether it's audition season, coming off Nutcracker into a little bit of a break and then driving into the audition season during the winter, some associated issues there. Are they getting ready for summer intensives? How are they going to eat during intensives? So all these things make the particulars different, and they're going to be different for each person.
[10:36] I really try to work with dancers to build flexibility into their diets and meal plans. One of the ways I do that is with what I call the Ballet Bento. About two years ago, I was really thinking about how can we educate dancers and provide real food solutions for them, whatever their needs are, that also turn them away from disordered eating. And I got thinking about it, and the bento is a beautiful tool for this. I use the bento as a tool. If I can start a dancer at 8 years old, it's perfect. Kids at any age can do this. Dancers, dance professionals, PTs use these.

[11:21] Jennifer Milner: Oh, I do it. You got me started doing it.

[11:24] Kristin Koskinen, RDN: Right, exactly. And I did it because of this: they're portable. You can take your healthy foods on the road. My dancers have been working with shelf-stable foods for a while because you can't depend on having refrigerator space. If you're at the theater, taking a cooler may or may not be an option. If you're traveling, that may or may not be an option. So we work on these things in the beginning.
[11:49] And with the Ballet Bento, the one I use has six compartments, and that lets us build things up and prepare for the unexpected — because there's always the unexpected. What if you're more hungry? What if rehearsal runs long? What if you only have this much time to eat? What if you can only get your nutrition in in three bites? A big salad is a beautiful food, but that's not a good idea if you've got five minutes to get in what you need before you're being called back because we're going to run it three more times because we flopped it before.
[12:27] So creating flexible strategies that a dancer can go to and create on their own is really foundational to my work with this community. And as it turns out, it works really well with other people too.

[12:51] Jennifer Milner: No, you answered it — we were talking about starting out with a baseline of coming in not knowing what to eat and when to eat. Dancers might feel like that's a terrible place to start, but you were saying that's actually a great place to start because that's something you can work with. And then trying to find ways to learn how to do that in a flexible way — like you said, creating flexible strategies. And as we all know, dancers are masters at dealing with the unexpected and love being flexible and living in uncertain times. I'm saying that sarcastically. Dancers very much want rules that they can follow, and it sounds like part of what you do is teach them: here are the basic concepts, and now you have the tools to figure out how to work within this structure.

[13:48] Kristin Koskinen, RDN: Absolutely. And you're right. The bento creates that structure. We are all about structure — and that is dance. We have structure. Someone's always telling us what to do. There's a mirror. Someone says you're right, you're wrong. There are the fundamentals and technique. After that, we can flex it out.
[14:07] But even with the parameters of a bento — you know, you're going to put some protein in here — I can give general recommendations and put lists together to help people get started. If I'm working with someone specifically because they have specific needs, they really want to dial in their performance, or they have a health condition we need to address, we can still have lists of options and then just do it. It's reliable and it can take a lot of pressure off and remove a lot of anxiety when you just know you're going to be okay. It's very figureoutable.

[14:50] Jennifer Milner: That sounds completely doable, and it sounds like it gives dancers the flexibility they need. You already have me doing it.

[14:59] Kristin Koskinen, RDN: Yay! I love it.

[15:02] Jennifer Milner: Every time I make one up, I look at it and think, oh, this makes me so happy.

[15:06] Kristin Koskinen, RDN: Awesome. I love hearing that. That really makes my day.

[15:11] Jennifer Milner: So it's great to have that flexibility and that knowledge of knowing you can have that structure and then have stuff to put in it. One of the things dancers deal with regularly is that we push ourselves too much and we're running on fumes. And sometimes we need to think beyond what do I need to eat in the next four hours. Sometimes we need to think: my body is running completely on empty. What are some changes that I need to make to help keep my immune system strong? Especially in today's world, it's even more important than ever. Are there specific nutrients that dancers can focus on to help keep their immune system elevated?

[15:57] Kristin Koskinen, RDN: Absolutely. Generally speaking, I'm always going to go back to: we want a foundationally strong diet. We want the fuel you're putting in your body on a regular basis — if that's the tank, we don't want to run our tanks down to zero. We want to have these nutrients accessible on the regular. We don't want to just fill the tank, top it off, and then spray the entire car with things thinking that's going to solve the problem. So let's start foundationally, and if we're not there, that's okay. We're going to start where we are.
[16:33] We do know there are certain nutrients that are imperative for immunity. Part of the way we know about the role of specific nutrients and immunity is by looking at undernutrition — we understand that well when we look at areas impacted by food shortages or famines, or explore nutrition status in developing countries. However, we can impose the same nutrient deficiencies on ourselves by dieting, underfueling, not paying attention, not practicing the self-care of eating the foods our bodies actually need.
[17:17] I think immunity really gets pushed to the side with dancers because they tend to operate in the here and now — this performance, this season — versus the long term. Some of the nutrients of focus we would look at straight away would include vitamins A, C, D, and E, selenium, zinc, and then there are a host of plant chemicals that can support immunity as well. They conveniently tend to come packaged in fruits and vegetables. Some of them we may need to supplement or layer in. Some of them may be more reliably available to the body in an animal product, and we would talk about that with dancers too.
[18:15] I know a lot of dancers come to me wanting a vegan diet, and I'd like to clarify what plant-based means, because it's really important — especially with a lot of documentaries we're seeing come out these days. Plant-based doesn't necessarily mean vegan. It means the basis, the foundation of your diet is plants, and you can build other things into it. So it may include some animal products, and for most people, I do recommend that, because it can be challenging to have a diet that meets all your needs that's simply plant-based.
[18:54] For example, zinc. We can find zinc in plant foods like legumes and whole grains, but those kinds of foods also come with a lot of fiber, which is awesome — but the fiber tends to hold on to the zinc a bit more, making it less easy for the body to actually access.
[19:17] Other foods we want to think about for the immune system include fermented foods. About 80% of your immune system is stationed in your gut, and how we feed the gut, how we treat the gut, influences what we call the microbiota — all the microorganisms from parasites and viruses and bacteria that live in your gut. So we want to feed those well and also take care of the gut tissue. Fermented foods can be very supportive for the general population. For specific populations, we might not want to use fermented foods.
[19:59] Fiber is generally a good one to support the gut. Vitamin A is found in a lot of plant foods, including yellow and orange foods like carrots and squash and cantaloupe. It can also be in dark leafy greens where the chlorophyll covers the vitamin A — this is a precursor to vitamin A, not active vitamin A, but dark leafy greens are another good source. Mango as well. You can get vitamin A in its pre-formed version, which is going to be easier for the body to absorb, in liver or egg yolks.
[20:39] Vitamin C, we know, is found in citrus fruits, Brussels sprouts, berries of all kinds. It's really pretty easy to get in whole food form. Vitamin E, pretty much the same — we find it in seeds and nuts and more fat-based plant foods.
[20:54] And vitamin D is a little bit of an outlier. Our best source tends to be the sun. However, most dancers aren't getting enough sun. It's not readily available in food sources. You can get it in fortified dairy, fortified orange juice. It is present in egg yolk, grass-fed and finished meats will have some, as well as mushrooms that have been exposed to UV light. But a lot of people just aren't eating enough of those foods to meet their immune and function needs.
[21:36] When we talk about how much is enough — is it the RDA? The RDA is a starting point. That's what's going to prevent a blatant deficiency. A blatant deficiency of vitamin D is rickets. A blatant deficiency of vitamin C is scurvy. But when our bodies are under a lot of stress — whether it's emotional stress like what a lot of people are experiencing now, whether it's physical stress from intense dance and training schedules, or both — the body draws on a lot of these nutrients. So you may need more. Some people may even need some additional support from supplements.
[22:24] Stress is a big one, and what people may not understand is your body doesn't differentiate between physical stress and emotional stress. It reads stress as stress, and fight or flight comes into play. Your adrenal glands control a lot of the hormonal processes that drive these responses, and your adrenal glands also house most of your vitamin C — which is a good indicator of how important it is for the stress response, because the location makes it very rapidly accessible for producing the hormones you need.
[23:06] So if you've been under a lot of stress, your vitamin C demand may actually escalate. What people find is: I was so busy, it was Nutcracker, and then I just crashed and got sick. Or they find they're under a lot of pressure and then they crash and get sick. It may be in part because they're burning through their stores and not refueling their vitamin C stores to the degree they need to on the regular to keep them healthy. That may be part of the crash.
Vitamin D is another concern. Dancers don't go outside. They don't expose their skin. Even when they can go outside in the summer, if it's summer break, they're at intensives. So we've got to address that and make sure they're covered.

[23:57] Jennifer Milner: Absolutely. I love that — it sounds to me like you're not saying, "Eat almonds and you'll be fine." I think we as a society love to find that next big thing. I know for a while it was goji berries. People think, "I'm just going to eat a bunch of these and I don't have to do anything else." And we're realizing there's no magic bullet. There are lots of great superfoods, but there's not one superfood. We have to get a wide variety — which we all hear but don't like to believe, because we love shortcuts.

[24:35] Kristin Koskinen, RDN: Right. Well, I'm going to tell on myself a little bit here. When I was dancing, I saw Total cereal — and it was like, "Total, it's got 100% of all these things you need." And my logic was if I just eat Total cereal three times a day, boom, I've done it and I don't have to think about it anymore. Yeah, that's not the way it works, sweetheart.
[24:58] When we're getting our nutrition from food, we're getting what I call the speck of dust theory. Science is always emerging, we're always learning more, and when you get your nutrition from the whole food source — like potatoes or carrots or grapes or whatever — you're also getting phytochemicals, which the federal government doesn't regulate or monitor, but they're super important. Resveratrol, quercetin, rutin — these are all plant compounds that come in your food that support immunity, that are anti-inflammatory, and that are best taken in food form.
[25:49] So when we eat the food, we're hitting those bases. And there is no one food. A broad swath of foods is our best bet. If we need to limit foods for certain reasons — right now, you get what you can get, you go to the store and may not be able to find things — we can work with that. But in normal circumstances, definitely go for a broad variety of plant-based foods and layer in well-sourced animal products.

[26:23] Jennifer Milner: I do want to get into supplements, and I know Linda has several questions for you on that. But first, I wanted to circle back to something — you mentioned fermented foods and how important they were for the gut. Do you see a place for probiotics as well, since I know that's a supplement? Do you see probiotics being as effective or helpful as the fermented foods?

[27:01] Kristin Koskinen, RDN: Yeah, I think probiotics definitely have a place. And the interesting thing is when we talk about probiotics, there's not just one — we can look at what strains of bacteria offer different benefits, and the answer is always going to be: it depends.
[27:26] In the general community, yes, probiotics can typically be beneficial. If we want to get really specific and we have specific health concerns, we might want to look at what formulation we're using. For example, someone with allergies may benefit from using a particular strain of probiotic. If someone has what we call small intestinal bacterial overgrowth — SIBO — we may not want to do that, because there's already a problem where bacteria are where they're not supposed to be. We need to resolve the underlying problem and we don't want to fuel the fire by throwing more on. That's going to be a specific case-by-case measure.
[28:13] Even with the fermented foods — if we're looking at dancers specifically with hypermobility who may have mast cell activation concerns, histamines can be a problem. We don't want to do fermented foods there because that can drive other issues for those dancers.
[28:42] So it starts to become a bit of a dance with the specifics. Generally speaking, yes. But when we're looking at the human body, N always equals 1. What works for me will not necessarily work for someone else. What works for me today may not work for me in 10 years, and may need to be shifted depending even on the day of the week, where a woman is in her cycle, where we are in the calendar year, where we are in our work year, where we are in the seasons. So we're always mindful of these things and how we may need to shift and adjust.

[29:19] Jennifer Milner: Excellent, thank you.

[29:19] Dr. Linda Bluestein: And I'm really glad that you brought up SIBO, small intestinal bacterial overgrowth, because that is something that people with hypermobility disorders are definitely at increased risk of having. They can have a lot of those vague symptoms — bloating, discomfort after meals, things like that — that can take quite a bit of time before they actually get that diagnosis. So I'm really glad that you brought that up, that while probiotics might be really great for one group of people, they're not going to be great for another group of people.
[29:56] That's so important. And what are your thoughts about supplements in general, and are there certain circumstances under which you do encourage supplements?

[30:07] Kristin Koskinen, RDN: My idea on supplements in general is we want to start with the diet, and then we use supplements to do just that — to supplement, to build in where we may have gaps. And a lot of people have gaps because of what food is available, increased demand, and their physiologic needs. Our food supply is not what it was. The nutrient density of our food supply has declined. Our bodies have to fight a host of toxins constantly — from pesticides, what your neighbor sprays in their yard, fumes from materials, Wi-Fi, it's a lot for our bodies to deal with.
So generally speaking, yes, I definitely use supplements in my practice. But I don't lead with a lot of supplements at any one time — particularly with a dancer — because it can give a false sense of security, like, "Oh, I'm taking this, so I don't need to pay attention to the diet." But your supplements aren't going to provide the curcuminoids that you get from eating turmeric that you put into an Indian dish you're enjoying. So I'm really particular about how and when we bring these into the program, and how psychologically the client takes it.
That said, vitamin D — honestly, almost across the board, people just aren't getting enough. They spend too much time inside. If people have any issues with liver or kidney function, or absorbing certain nutrients that support those organs, they can fall short. I always pair vitamin D with vitamin K2 to make sure that the vitamin D goes where we want it and doesn't settle in soft tissues like arteries and blood vessels.
Now — let's talk about high quality, because that's important. When we're looking at supplements, it's really important to take a high-quality supplement. That means you're getting what you think you're getting, it's not been doctored up with things you don't want or that can hurt you, it's free of contaminants, it's been stored properly so that the active ingredients are still active when you get them, and it's efficacious — it's going to do what it's supposed to do because it's been processed properly. High-quality supplements typically aren't going to come off the shelf at Target. Your best bet is to consult with your healthcare provider, who will have access to a dispensary, or to get them from a pharmacy.
[33:14] I recently wrote a blog on supplements — Supplements 101 — if listeners want to check that out. And we want to know what's coming in our supplements. I saw a supplement come out with colloidal silver. Now, colloidal silver is antibacterial and antimicrobial topically, but it can also lead you to having permanently discolored skin. Some of these really cute supplements being advertised on social media have things in there with side effects you might not anticipate — like having your skin or eyes discolored for life. Unless you are under the specific care of a healthcare provider who practices functional and integrative medicine, who understands how to apply that specifically to your case for a limited duration and when to pull it out, don't go there.
This is why we want to be really thoughtful about supplements — they're almost pharmaceutical when you look at it, because the interplay matters. If people say, "Oh, I heard zinc's great for your immunity, I'm going to start sloshing down the zinc" — well, that's fine, but if you overdo it, you can end up with a copper deficiency because copper and zinc compete for absorption. If you end up with a copper deficiency, you're going to have a host of problems including being immunocompromised. So you've circled around and caused a new problem.

[36:00] Jennifer Milner: So you mentioned you want to be under the guidance of a healthcare professional. Let me ask you: licensed nutritionist, registered dietitian, health coach — there's so much out there on the internet and through social media and people with these titles. How do we differentiate and how do we know who is really qualified to hand out this kind of information?

[36:26] Kristin Koskinen, RDN: Right, so what you say matters. For example, the term "doctor" — you can go to a doctor who's a doctor of philosophy, who you probably don't want managing your healthcare. They can be brilliant but not in the ways you need them to be brilliant.
[36:46] A registered dietitian is a specific designation. "Registered dietitian" or "registered dietitian nutritionist" is the same thing — it's just a moniker choice. But that's a legal designation, just like MD for a medical doctor, DO for a doctor of osteopathy, ND for a naturopathic doctor, a chiropractor, a doctor of physical therapy, DMD, DDS — all these healthcare providers have regulations based on a process they have gone through that is outlined and consistent.
[37:28] For a dietitian, that means they have a minimum of a four-year degree with coursework that includes, but is not limited to, biochemistry, microbiology, physiology, and nutrition sciences. They have also passed rigorous board exams — and you hear the same for physicians, dentists, all of us — and then they have continuing education requirements to stay abreast in the field. My continuing education: I am every day reading medical journals, nutrition research, all the things about what I do.
[38:29] Even within the field, what Linda does as a functional and integrative practitioner gives her a knowledge base about a lot of these things that others won't have. Her knowledge about hypermobility and pain management is going to give her a unique perspective that even if you went to another doctor, they may not be able to dial in. So one, you want to make sure you have a licensed, credentialed practitioner. Then you want to make sure that practitioner meets the specific needs you're looking for.
[39:14] After you have a registered dietetics degree and those qualifications, there are certain programs where you can pick up additional certifications — as a diabetes educator, as a sports nutritionist, and so on. But there is no broadly accepted, nationally or internationally accepted "certified nutritionist" — I'm saying that in air quotes — or even "health coach." A health coach can offer you some great support, but they cannot offer you the kind of background and knowledge and understanding that a dietitian is going to have because of what they bring and the understanding they have about the body.
What sounds like a simple question — if you ask me something, I'm running that through a layer of filters to decide where we want to go next. There is no formulary, no "we do this, then we do this, we prescribe this." You can do that, but that's not the way it actually works.

[40:37] Dr. Linda Bluestein: I think this is such an important point, and I'm so glad, Jen, that you asked this question. Because I think as you're explaining this, Kristin, it's making me realize that when people are getting a simple answer or something that sounds too good to be true, that's how a lot of people end up being convinced to try things that maybe are not in their best interest. Like you're saying, you're thinking through all of these different scientific things, and the body is so incredibly complicated. That's why you don't have one single answer for everyone that is going to work in every single person every single time — there are just so many variables.

[41:25] Kristin Koskinen, RDN: Absolutely. And another thing that a dietitian — not all dietitians, but a dietitian who works in concert with other health professionals — will have access to is different levels of testing. So we can test and not guess. A lot of times we can use a clinical approach based on physical signs and symptoms, what you're eating, and a number of inputs, and we can choose a right direction. But we also have access to high-level testing and supplements that other people — like a multi-level marketing coach — aren't going to have available to them. And we're going to be able to test to see how it's all working and what parameters we have.
A dietitian is also going to work in concert with your other healthcare providers when it's appropriate to make sure we're getting great results. And when we're looking at communities or populations with high-level or specific needs, we might need to get to that level of complexity. What I would start with for a dancer who has hypermobility, who is someplace on the hypermobility spectrum, is going to be at a much different place than I'd start with a dancer who doesn't — including maybe pulling out some testing right away to start addressing gut issues, SIBO, or inflammatory concerns to mitigate the process.

[43:03] Dr. Linda Bluestein: And what test results would you want to see in a perfect world? Let's say it is somebody with hypermobility. When you're first starting to see them, what test results would you like to have?

[43:14] Kristin Koskinen, RDN: In an ideal world, I'll take all the tests. I want all the data. Give them to me — I'll sort through it. I love it. I want everything. But that's not really reasonable.
Even with thyroid, for example — and I know we're not really talking about that, but it's a good illustration — I see adult clients come to me and say, "Oh, everything's fine. My primary care provider did a thyroid test." And they took one parameter out of at least four that we want to look at to actually gauge where you're at. That one TSH is not the end of the story.
[43:49] So I want to see depth of testing too. If I had to choose, my top picks would be a micronutrient panel and an MRT test. An MRT test essentially looks at what foods a person specifically has adverse reactions to — and they can even be healthy foods. I have a client who is very reactive to quinoa, basil, chicken, bananas — things people think are healthy. When we took those out of her diet and gave her other healthy options, her eczema went away, her brain fog cleared. We can get some really good results.
[44:52] Everyone's going to respond differently, but when we're looking at connective tissue concerns — and we are connective tissue, our gut especially — when we're looking at the fragility of that, I want to see what we can do. Celiac disease is a big concern with Ehlers-Danlos, and sometimes the ensuing mood issues we might see from things leaking through the gut and hitting the rest of the body can impact mental status. So those would be the ones I would go with first — with those two, I get a lot of information.

[45:29] Dr. Linda Bluestein: Absolutely. And when it comes to the hypermobile population — whether they have Ehlers-Danlos or hypermobility spectrum disorder or a different hypermobility condition — that population, which we know does affect dancers more than the general population, how do you approach their diet differently than a non-hypermobile person's?

[45:53] Kristin Koskinen, RDN: Someone with hypermobility is going to come in with a lot. We're looking at them differently because they're going to come with different health concerns. Like we talked about — SIBO, GI distress, all these things that we want to approach first. My first approach is going to be: look at the gut. We're going to talk about nutrient timing and sports nutrition performance items a little later, because if we put that ahead of tending to the gut, we're going to miss a lot. I want to make sure that GI system is in the best form we can get it. It may not be perfect or ideal, but we want it at its best, whatever that is.
A gut-friendly diet may involve removing offending foods — foods that are pro-inflammatory. We know there are some known pro-inflammatory food choices: gluten, soy, corn, dairy, sugar. A dancer who comes to me with the hypermobility spectrum, we're going to start off by getting rid of gluten. Why? Because gluten is known to drive zonulin, which drives gaps in the intestine, which can lead to subsequent inflammatory issues with other food sources. So we're going to pull gluten right away. I don't necessarily do that with every dancer, but I'm going to do that with my hypermobile dancers because it's a no-brainer to me.
[47:35] We're going to look at the kinds of fiber that work to support that gut. If they're coming with known issues — do we need to rule out SIBO? Do we need to do specific testing for that? A lot of that I'll have them do with their primary care provider because it tends to be cheaper and easier. Do they need to go on a low-histamine diet temporarily or long term based on their concerns? Do they respond differently to different kinds of foods?
[48:10] We talk about apples and onions and grapes as being wonderful foods, high in fiber, offering quercetin and resveratrol and some of these other phytonutrients we've discussed. But if a dancer's GI is such that those give them gas, distension, and bloating, we might want to try what's called a FODMAP diet — it's a temporary therapeutic approach to pulling some foods out, seeing how the body responds, and then bringing things back in slowly so we can maximize the diversity in their diet.
I'm also probably going to be really quick to bring in hydrolyzed collagen for someone with a bendier body. Why? Because with elemental nutrients — meaning we break them down to their smallest form — they are more readily available to the body. Hydrolyzed collagen has been broken down to smaller peptides that are readily absorbed, and there's some research that even suggests those peptides, after they're absorbed, signal the body that it needs to actually produce more collagen. We need collagen to heal the gut and for all the connective tissue. We need it for bone, which is also connective tissue. So I'm going to bring that in whether we have all the answers or not. It's a low-to-no risk option.

[49:55] Dr. Linda Bluestein: That all sounds great. And when it comes to mast cell activation syndrome — which we touched on briefly earlier — and also chronic inflammation, can you talk a little more about both of those? You mentioned foods that can potentially increase inflammation. Are there certain foods that, in terms of mast cell activation syndrome and/or inflammation, can actually improve those things?

[52:35] Kristin Koskinen, RDN: Yeah. With mast cell activation, and really with inflammation in general, our first approach is removing offenders. Things that drive histamine, or that actually deliver histamine, we want to pull out. Specific foods would be fermented foods, aged foods like salamis and cheeses, and even leftovers. So we want to be really cautious with those in the diet.
Foods that are known to be anti-inflammatory and that have a wealth of historic and scientific evidence include ginger, cinnamon, garlic — though we'd want to be a little careful with garlic for certain clients, as it can drive them in the wrong direction — and green tea. Resveratrol that comes from grapes and similar foods is another good one.
Ideally we eat them in whole food form, but if we can't because other components of the food may drive inflammation, we can get them in supplement form and actually get a high load of, say, cinnamon or ginger or turmeric, which can be really helpful. There are some fairly new studies that show that dosing with around 2,400 milligrams of cinnamon divided over the course of the day can help with menstrual pain. Was it a specific study? Yes. Can we extrapolate that broadly? Somewhat. Would I add some cinnamon to the food I'm eating, particularly Ceylon cinnamon as opposed to Saigon cinnamon — which is what you buy in the grocery store mostly; the Saigon's less expensive, but look for Ceylon, you probably have to order it — could it offer some benefits? Absolutely. I would totally pull those kinds of things in.
I don't have a lot of experience with mast cell activation specifically, and I would probably be looking at a colleague to help me out with that, but these are some starting points that we would lead with.

[52:50] Dr. Linda Bluestein: I love the tip about the cinnamon. I honestly have never heard that one before, and amongst my patients, menstrual pain is really, really significant — it's super, super common. So I'm very curious to do a little more research on that myself, because that sounds really intriguing.

[53:12] Kristin Koskinen, RDN: And low risk.

[53:13] Dr. Linda Bluestein: Interesting. Sure.

[53:15] Kristin Koskinen, RDN: You know, ginger the same thing. And here's the thing too, when we look at a lot of these foods — this is again why working with a healthcare practitioner can be so helpful. If someone says, "I tried the cinnamon," we also know it can help with blood sugar control. So in a particular patient, I may not want to give them that if they tend toward hypoglycemia. So we talk about this, but if someone else says, "Oh yeah, I'm going to do all the cinnamon," it could drive them in the wrong direction. And we might want to time the cinnamon to make sure they don't crash in the middle of class or a performance.
[53:53] These are the things we layer in. And they're not a one-and-done. Just like a lot of pharmacologic products take up to six weeks to hit a threshold and actually be effective, it can be the same with food, nutrition, or even supplements — sometimes you'll see results almost immediately, and sometimes it may take time to actually reveal its beautiful self.

[54:30] Dr. Linda Bluestein: And you really are explaining so well the nuances to this and why it's so important to work with a nutritionist if you possibly can, rather than doing your own research, which is always going to be geared toward the general public. This is such great information. How would you recommend that people find a nutritionist who can specifically address their needs as a dancer, or as somebody with hypermobility, or any other specific population like that?

[55:06] Kristin Koskinen, RDN: I would recommend dancers head over to the International Association of Dance Medicine and Science, which we affectionately call IADMS — I-A-D-M-S. If you search iadms.com, you'll go to the website where there is a directory of dance medicine specialists who work with dancers. And a lot of them work virtually — one of the things that has come out of COVID is that many of us are now working more virtually. You can contact any number of people, and if someone doesn't have the answer or can't help you — perhaps because their state licensure doesn't cover your state — they can refer you to someone else.
[55:56] This network is incredibly valuable. I refer people all the time to physical therapists, or to Linda — hey, check out Linda's site. There's a wealth of information and a wealth of skill and knowledge that these people are passionate about. This is how we stay connected to the dance world, whether we're still dancing or not.

[56:26] Dr. Linda Bluestein: Yes, and it's such a collaborative group, and I really just love that about it — all three of us being members and very actively involved.

[56:34] Kristin Koskinen, RDN: Yeah, absolutely, for sure.

[56:40] Dr. Linda Bluestein: Okay, great. And then are there areas of nutrition that you hope to see more research on in the future?

[56:51] Kristin Koskinen, RDN: Oh, so many. And things are moving ahead so quickly. Some of the things we're seeing now — like collagen and dance, collagen and soft tissue — sometimes it just takes time for things to reveal themselves. But it's exciting.
[57:11] I think what I'd really like to see on the nutrition front is getting the information we already have to dancers now. And sometimes our best gateway to the dancers are the people who love them and teach them and look after them — dance parents, choreographers, artistic directors, teachers, the people who coordinate organizations like the Regional Dance America, the Ballet Alliance, the people who take care of dancers and bring them together and provide education for them. If we can give them the tools and the knowledge so they can make good decisions — if we can get that to dancers at any stage of the game, not just at premier companies like New York City Ballet or Miami or any of these, but if we could get this to dancers early on, we would give them such a leg up in their careers and in their lives. These are skills that will last with them, just like the skills we learn in dance that shape us. These things can shape people to have better lives.

[58:21] Dr. Linda Bluestein: Absolutely.

[58:23] Jennifer Milner: Me too.

[58:23] Dr. Linda Bluestein: Me too. And is there anything else that we didn't ask you about that you'd like to add? And if you can make sure to let people know where to find you.

[58:34] Kristin Koskinen, RDN: Gosh, I think we covered pretty much everything. Maybe we can do a part deux and keep this encapsulated. I'm glad to have people reach out to me. They can find me on my website, which is www.eatwellpros.com. You can find me on Instagram at my name, which is Kristin — K-R-I-S-T-I-N — Koskinen — K-O-S-K-I-N-E-N — underscore R-D-N. You can find me on Facebook as well, though I'm not there quite so much. Or you can email me directly at [email protected].

[59:32] Dr. Linda Bluestein: Wonderful. Well, it's been such a pleasure speaking with you today, and it's been so great to have Jennifer Milner, my guest co-host, on this show again today as well. This has been so informative and is going to benefit so many people. It's so empowering for people to realize that there are things they really can do to improve their health while they're dancing, in their life post-dance, and they can really just improve their quality of life so much from all this information. So thank you so much, Kristin, for —

[1:00:09] Jennifer Milner: Yes, thank you so much.

[1:00:09] Dr. Linda Bluestein: For coming on.

[1:00:12] Kristin Koskinen, RDN: Before I leave, I will leave with this — some quick resources available to dancers. At the time of our recording, when we're in the midst of COVID-19, some things that I have — and this could change depending on when you're listening — but as of March 28th, I have an article in Dance Magazine that talks about the way dancers can use shelf-stable foods to create meals and address nutrients, some of which we spoke about today — zinc, vitamin A, vitamin C, that kind of thing. I would direct them to Dance Magazine to read that.
[1:00:47] On my Instagram account, I have links to a couple of dance-specific handouts that I make available to dancers. One includes shelf-stable recipes that help support the dancer through this — and I think all of them are gluten-free, so for the populations who are looking for that, they can have that — as well as some grab-and-go snacks for once we're through all of this and we're back in the studio. Things that dancers can put together and start to put in their bentos. So I encourage them to go check out those resources.

[1:01:23] Jennifer Milner: That's awesome.

[1:01:24] Dr. Linda Bluestein: Yes, that's all fabulous. I'm so glad that you mentioned those because people are definitely going to want to look at those resources as well.

Kristin Koskinen, RDN: Great.

[1:01:34] Dr. Linda Bluestein: Well, you've been such a great guest today, Kristin, and thank you again, Jennifer, and you all have been listening to Bendy Bodies with the Hypermobility MD. Today our guest has been Kristin Koskinen, registered dietitian nutritionist, and my guest co-host has been Jennifer Milner. It's been so fabulous having both of you here.

[1:01:59] Kristin Koskinen, RDN: Thank you so much for having me. It's been a great time. Thank you.

[1:02:03] Dr. Linda Bluestein: Absolutely. Please go to bendybodies.org for links to all the episodes and to access the show notes. If you enjoyed this podcast, please share, leave a review, and consider rating us five stars. Don't forget to subscribe so you will be notified of all new episodes. Feedback is greatly appreciated and can be emailed to [email protected]. Go to hypermobilitymd.com to sign up for my newsletter. My guest co-host Jennifer Milner can be reached at [email protected] — that's M-I-L-N-E-R.
[1:02:35] Thank you to Rhett Gill for production and sound editing, to Andrew Savino for composing our original music, and to Jennifer Arsenault for designing the Bendy Bodies website and cover artwork. This podcast is for informational purposes only and is not a substitute for medical advice. Please see your own medical team prior to making any changes to your healthcare. Thanks for tuning in, and we'll see you next time on Bendy Bodies with the Hypermobility MD.