Optimizing Immunity with Kristin Koskinen, RDN

[02:05] Jennifer Milner: Welcome back to the Bendy Bodies Podcast, where we strive to improve well-being, enhance performance, and optimize career longevity for every bendy body. This is co-host Jennifer Milner here with the Hypermobility MD, Linda Bluestein.

[02:20] Dr. Linda Bluestein: We are so glad that you are here to learn tips for living your best bendy life. This information is for educational purposes only and is not a substitute for medical advice.

[02:30] Jennifer Milner: Our guest today is Kristin Koskinen, registered dietitian nutritionist, Bendy Bodies resident nutritionist and specialist in nutrition for performance and hypermobility. Kristin, hello and welcome back to Bendy Bodies.

[02:39] Kristin Koskinen, RDN: Hello. Thank you for having me.

[02:44] Jennifer Milner: We're so thrilled that you're here. Yes, we are. Any excuse to be able to chat with Kristin. So Kristin, for our listeners who may not know who you are, may not be familiar with the work that you've done or heard the other podcasts we've done with you, could you tell us a little bit about yourself?

[03:02] Kristin Koskinen, RDN: Sure. As you said, my name's Kristin Koskinen. I'm a registered dietitian nutritionist, and I work with dancers and hypermobile people to help them optimize their health and performance, help them to reach their goals with really translatable skills using food and nutrition.

[03:19] Jennifer Milner: Excellent. So part of us knows that everybody needs to eat healthy, everybody needs to eat good nutrition, and we also know that all the athletes and artists need to work really hard to take care of their instrument, especially because their body is their instrument. We're asking it to do really difficult things. But as we tie into our audience, why should bendy artists specifically care about the immune system and nutrition in general?

[03:45] Kristin Koskinen, RDN: Sure. Well, the immune system is critical for everybody. It protects us from foreign organisms and substances. It's critical for our survival, and it's made up of a number of cells and organisms that require the nutrients that we get ideally from food. Sometimes we need to bring in some supplementation for structure and function. And what we find is even mild nutrient deficiencies can set you up for illness.
[04:07] What we find for artistic athletes specifically is they are under a lot of stress. They have high physical demands and they often have high psychosocial and emotional demands too. And that all plays a role in what your needs are. So the body is complex and dynamic. There's not one set of "this is what you need all the time." It's really a moving target with regard to nutrients and your requirements.
[04:43] So we can set some general goals, and we see general goals all over the place. Governments set goals — here's the RDA, for example. And those can be starting points, but they may not be the ending points, because what we know is there are a number of things that impact your needs. And if you are not meeting your physiologic needs, your body's going to be compromised, including your immunology.
[05:07] An example that I use somewhat frequently is that of a fishbowl. So if you imagine a fishbowl and you've got a fish inside the fishbowl, if the water's dirty, throwing a lot of supplements at the fish may help it to deal with the dirty water, but it's really not going to solve things. Things that can dirty the water include stress, pollution, mold toxicity, disease states, Lyme, anything underlying you may have, including some of the sidekicks that we have with hypermobility. All those things can impact things. Sleep. Have I mentioned stress? Lack of sleep. What you're eating, what you're not eating — all those things impact that milieu.
[05:54] So what we really need to do is keep in mind that nutrition is a component, and it's an exceptionally important component, but it's not the only thing. It's really important to give a 360-degree look to your life, your lifestyle, and all the inputs you have with regard to how this impacts your health and your immunity. And when we look at what that entire package is for you, it may help to direct us in what your specific nutrient needs are.

[06:22] Jennifer Milner: I'm just going to follow up on that because there's a lot of greatness in that, and I think I'm going to carry that goldfish image with me for a while. That's a really great image. But if someone is a bendy artist — I have lots of hypermobile dancers — they seem to feel the impact of their nutrition more on their bodies. They're like, how come that person gets to eat whatever they want and I don't? So is there something about being hypermobile or having a connective tissue disorder that means you have to be mindful of your nutrition in ways that other people don't?

[06:55] Kristin Koskinen, RDN: Yes. So let's just be really simplistic and basic about hypermobility. You have connective tissue throughout your body, including your intestines. And so for some people with hypermobility, they may have difficulty with digestion and absorption. That means they may need to be more conscientious about getting more nutrients because they need to effectively hit the system harder with certain nutrients, simply because their digestion and absorption is impacted by the structure and how things are able to operate.
[07:36] Another thing that we see in hypermobile people is they may struggle with dysautonomia, or their digestion may be slower than other people's. They may struggle with getting enough food because they may notice fullness, or they may not have peristalsis that moves things along so that they get appropriate digestion and absorption. And you can eat food — that's definitely an important step one — but you also have to digest the food so that your body can absorb the nutrients. And that happens in a stepwise order.
[08:05] So if we're missing a step — if your TMJ is sore and you're not able to masticate the food, meaning chew it properly, incorporate the digestive enzymes from saliva, swallow it appropriately — next step is the stomach where we have hydrochloric acid. If you have a nutrient deficiency because days before you weren't able to get enough nutrients so that your body's producing adequate hydrochloric acid, you're not going to have that breakdown, and then things aren't going to move along. That can move to other issues that we see in the hypermobile community, which can include things like SIBO overgrowth, which — as we will talk about the microbiome and immunity — can be really significant.
[08:53] So all these things roll in, and there are a lot of complications. You may see, if you have a histamine intolerance or mast cell activation syndrome, your selection of foods may be different than what other people can eat, because your body may tolerate them differently — in different amounts, not at all, not right now — depending on what your stress level is. So those are all things we really have to take into consideration that might make things different for you than for another dancer.
[09:24] I love what you were saying about the gastric acid, because I find in my patients and my clients that gastroesophageal reflux is much more common. And so sometimes people get put on proton pump inhibitors and then they never get taken off. That's something that can also affect micronutrient levels. And I feel like we have this kind of black-and-white thinking: gastric acid is bad because we've had an issue with reflux.
[09:58] We do see proton pump inhibitors a lot — whether it's part of an approach to address histamines, whether it's simply because there was some reflux and we're going to hit it with a PPI, or if it's someone who's coming off an eating disorder and has some reflux from that. I see those dancers, so they can be young, put on a proton pump inhibitor. And that all impacts that hydrochloric acid. If you do not have enough hydrochloric acid — bringing it back to immunity — you also aren't going to be killing organisms that hit your stomach that have been swept from the nasoesophageal pathways into the stomach. That hydrochloric acid is there to kill bad stuff as well as optimize digestion.
[10:48] Something else that I see people do in terms of medication: if dancers decide they want to get more calcium and they take something like Tums for a calcium source, that also increases the pH of your stomach. Now we may, by bringing in this supplement, compromise a whole lot of other things downstream from the stomach, and you may not have even needed that calcium.

[11:16] Jennifer Milner: Wow. So it's really so complex. And as you always say, n equals 1, right? So each person is definitely unique in terms of what — if you're working one-on-one with someone, you're going to give them very specific recommendations. But in general, we know that foods impact immunity a lot. So can you give us some general guidelines or general information about how the foods we eat impact immunity?

[11:42] Kristin Koskinen, RDN: Sure. So, as a dietitian, I work with a lot of lenses. My lenses include the microscopic — what's going on at a biochemical level — all the way out to satellite or telescopic level when we're looking at where you live on the planet, and then everything in between. All of these things matter. So sometimes we need to pull back the lens. There's a great tendency to want to narrow in and dial into individual nutrients, and we want to look at one-offs and find the magic bullet and what we can control. Pills are controllable — we'll hit it with a pill, we've signed off, we get the numbers where we want them. Great. Maybe. Often not so great.
[12:29] So we're going to pull the lens out and look at the diet overall and what it does for the body. The first thing I look at — and it may be surprising — is protein. That's where we start because all your cells require protein. The organs that produce the immune cells require protein, and sometimes we forget about that. We get caught up in the white blood cells and antibodies and things, but where are those things coming from? Are you making sure that your thymus is well supported as an organ? Is your bone marrow well supported? How about your spleen? All these things require protein.
[13:09] When we look at protein, one: you need to make sure you have enough to support the structures that produce the cells and the production of the cells themselves. Two: when you eat protein, it's not just about the protein, it's about the nutrients that come along with it. So if you're eating an adequate amount of protein and getting it from good sources, you're also going to be getting things like zinc and iron, which we need for the immune system. The marrow of your bone cells is important and it requires iron. We know that when we see even a slight zinc deficit, we will see immune deficiencies. So we want to start with protein.
[13:53] Looking at dancers, we start with a range of somewhere between 1.2 to maybe up to 2.5 grams per kilogram. That's going to depend on a lot of things, and we might get back to that fishbowl. So if a dancer is injured or coming in with any sort of other physiologic compromise, you're going to be toward the higher end of that goal. If you're eating a vegan diet or very limited amounts of animal foods — and by plant-based, I'm going to limit that to say a vegan diet, though there's no definition for plant-based — you're going to lean toward the 2.2 to 2.5 grams of protein simply because the protein and minerals that come from plant foods are less bioavailable than those from animal sources. So if that's a dietary choice you make, okay, but I don't want dancers to be confused and think that eating a lot of plants and a variety of plants is good while converting to eating only plants is best. It's not necessarily the case.
[15:04] So we start with protein. I'm going to stop there and see if there are some questions before I move on to anything else.

[15:10] Jennifer Milner: I do want to clarify — when you're talking about 1.2 to 2.5, that's grams per kilogram, correct?

[15:16] Kristin Koskinen, RDN: Grams per kilogram. And if you want to convert your weight from pounds to kilograms, you need to divide by 2.2. So anyone who's listening and thinking, "well, what?" — that's how you do it.
[15:30] That's a range, and it depends on a lot of things. Even within the same person, we may shift that range depending on what you have going on. Where are you at in your season? Where are you at in your life stage? Are you male or female? There are a lot of things that go into calculating that and getting some estimates, but that's where I like to start.
I really do often recommend animal products because they are more bioavailable. And when we're looking at dancers, a lot of times the limitations we look at for artistic athletes are time, convenience, and affordability. And if we blend that over into the hypermobile world where we talk about spoons — the resources you have — we really need to marry: what are your resources? How much time do you have to prepare things? How much time do you have to eat things? How much time do you have to digest things?
[16:28] So if you're going vegan or strictly plant-based, it takes a lot of food to get to those goal levels. Do you have the time to eat it? Do you have the time to prepare it? Do you have the time to chew it? That's important. And sometimes when I'm working with dancers, I'm working with how many bites do we have between here and here? It's not ideal. We are working in completely unideal circumstances and we're going to make it work, but they're not ideal circumstances to support health, so we have to be incredibly intentional.

[17:02] Jennifer Milner: So what you're describing is the basic steps that you take with every new client and start working through for designing healthy eating patterns. And as we speak specifically about the immune system, could you connect the dots for people who are listening between how you're eating and how you don't get a cold during Nutcracker season? Because there are people out there — hopefully not our listeners — who think a calorie is a calorie, and as long as I'm fueling my energy levels, I'm good. I know there was a doctor who famously, like 20 years ago, lived off of gas station food only for a month just to prove that a calorie is a calorie, and he was alive and all that. But as he did that, I was thinking his body is now made of beef jerky and Ho Hos and Cool Ranch Doritos. What does his immune system look like? So can you connect the dots for us between eating a healthy diet and being able to fight off that cold, not having a sprained ankle turn into a lingering tendinopathy? Help us with that.

[18:12] Kristin Koskinen, RDN: Yeah. So the basics are: you need to have a foundationally sound diet. And that sounds kind of boring, and maybe you've heard it, but this well-balanced diet idea is true. I think what too many dancers want to do is skate by and then deal with it later — oh, I'll come in with echinacea, elderberry, zinc lozenges and all this stuff. Those may be helpful and they may be curative to a point or help with symptoms. But your best bet is to start strong and stay strong. We want to be really consistent.
[18:46] In some ways, I kind of feel like it's similar to if you look at someone who is struggling on pointe, like they can't get over their box, and it's because they are weak and they need to strengthen a certain set of muscles, Jen — that would be something you'd address. But they're dialed into their elastic. It's like, your elastic's important, but that's not the driver of this problem.
[19:08] So what we want to start with is a well-balanced diet. And as boring as that sounds, let's unpack what that looks like. One: we've got to make sure you're getting adequate protein — we covered that. Two: I actually want people to eat a lot of plant foods. Plant foods include things that grow — legumes, vegetables, fruits, grains, herbs — these are all plants. I'm also going to throw in mushrooms. They're not really a plant, but we think of them as a non-animal source, so I'll put them in that world too. They all provide different nutrients, including polyphenols and different chemicals that support your health and well-being.
[20:02] So the RDA doesn't have lists of requirements for things like quercetin, luteolin, or resveratrol, but we know that they're important and getting them from whole foods matters. When I'm recommending a diet, I want you to have a lot of variety. There's the thought of "eat the rainbow" — eat lots of different colors. That's a good guideline. I suggest that dancers and anyone eat at least 10 different plant foods per day. And that may sound like a lot, but it's really not. When you do this, you're going to get different fibers, different nutrient profiles from each plant, and different allotments of these plant chemicals that we're really just learning about.
Here are some examples. Take an orange. People see orange and think vitamin C. There is vitamin C and it's a great source of it. However, it's got a lot more going for it than just the vitamin C. When you eat that orange, you get vitamin C, you get fiber, you get folate, which is helpful for mood and DNA — which you need to make sure you're producing all these immune cells. And if you look at eating the rind or the pith of the orange, that inside lining contains a phytochemical called rutin, which is anti-inflammatory. So a whole food diet means eating whole foods and eating as much of the food as possible.
[21:38] When we shift that over to animal products: if you're going to eat an egg, I want you to eat the whole egg, including the yolk. The yolk will provide things like vitamin A, which we know is necessary for immune health. It can be a source of omega-3 fatty acids. It has choline, which helps with neurologic health. So that's a whole food. When you're eating animal products, eating a variety of different animal products will provide different nutrient profiles. So protein isn't just protein — getting it from a wide variety of sources helps to ensure you're meeting the wide needs you have and keeps us from narrowing into, "Oh, I'm just going to pop a zinc pill."
[22:19] When you eat a whole foods diet, you've got to eat food anyway. You're going to get energy, and it supplies your nutrient needs. When we look at a lot of studies, they may isolate nutrients, which is fine as a way of studying, but our bodies are intended to eat food, not to hit supplements. Supplements are awesome and can play a great role, but when you get your vitamin C from oranges, bell peppers, cauliflower, and berries, you're eating them in a balance of other nutrients. The chance that you are going to create a nutrient deficit by overdoing one nutrient because you've created a competitive environment for absorption is effectively nil. The chance that you're going to end up with an overdose — which can be dangerous — it's hard to do. It's possible, but it's a real challenge.
[23:18] So if you're looking at a plate, typically I want to start with that protein requirement we talked about, and then we're going to fill in with colorful fruits and vegetables, which provide the vitamins, minerals, and phytonutrients that help support the immune system, as well as complex carbohydrates that come from starches and legumes, which provide energy as well as minerals and B vitamins that are important for supporting your performance as well as driving those immune functions.

[23:51] Jennifer Milner: What I'm hearing from you — and I liked what you mentioned at the beginning about how a lot of dancers will say, "I'm just going to skate by right now and I'll deal with it later" — is that it's very similar to dancers with injuries, or any artist with injuries. When it's something small, we don't pay attention to it, and then when it gets bigger, we deal with it. So dancers always have their arnica gel or their body wraps or their Salonpas or whatever to deal with it when it gets to be a problem.
[24:24] For everybody who's listening: we need to deal with our nutrition like our conditioning class, like our performance enhancement. Not just "I'm going to have chicken soup when I'm sick because it'll make me feel better." Let's do that beforehand. Trying to plan nutrition is hard, I get that, but skating by on the Skittles and the Red Bull is not going to be ideal. And maybe just that little bit of planning, as Kristin was discussing and as we've talked about before, will help us not need the echinacea and the chicken soup and all of that. So I love that thought about letting nutrition be part of our maintenance even though it seems invisible and we think we're fine without it.

[25:03] Kristin Koskinen, RDN: And it's important to note that you can operate at a low-level deficiency and still be operational. You don't know what's going to be too low. And we can test for certain things. There's not necessarily — to the best of my knowledge, though there could be by now — a specific immune panel that says you are in perfect shape. We have panels we can take and we can extrapolate information, but most people aren't having a broad sweep of blood work done — blood work and other work testing metabolites, GI health, that kind of thing, which includes stool samples, urine samples, blood work — regularly. I mean, they feel like they're getting a great workup if they get a Chem 20 and a CBC. And maybe, if we're really lucky, we've tacked a vitamin D on it. But I know a lot of people — dancers — who have to fight to get a vitamin D level.
[25:59] So we also don't want you to be lulled into a sense of "oh, I'm fine." Those lab levels oftentimes don't refer to you. They refer to the general public, not high-performing athletes or hypermobile people. They're not specific to these populations. So the interpretation of those labs should be made in context of your entire fishbowl, not just in isolation.
[26:25] So we're pretty sure we know the answer to this question, but are there any categorical absolute nos for a healthy diet — like no fat, no sugar? We see a lot of things that people are trying to oversimplify. What do you think about that?

[26:40] Jennifer Milner: Okay.

[26:41] Kristin Koskinen, RDN: I'm literally going to come out and say: I don't have hacks. Do not try to hack your system. Do not allow food manufacturers or influencers to hack your system. The things that I really want to say hard no to — and you may have to temper this because the world is the world — are: sugar replacements, protein replacements, fat replacements. Don't do it, without exception. Almost all the time they are calorie-cutting and diet-related, not health-related. So don't kid yourself.
I was just listening to a lecture about someone trying to push a fiber supplement because it could decrease calories and decrease sugar. Don't listen to this stuff. Without exception, every time these things come in, there is a risk.
[27:36] For example, let's talk about stevia. But it's a natural product, right? Well, stevia is known to decrease the MMC — the migrating motor complex of your intestines. So if you've slowed down the pace of your intestinal tract, that GI motility, what you've done is set yourself up for infection, something called SIBO. The bacteria — even the good bacteria in your gut — have the opportunity, if things aren't moving at the pace they're supposed to go and in the direction they're supposed to go, to move up into the small intestine where they do not belong. And this can cause a lifelong problem.
[28:16] Fat substitutes were bad from the get-go. They can cause nutrient deficiencies, they can cause anal leakage. I'll let you paint your own picture on that visual problem. And protein replacements too — all the fake chicken nuggets, the fake burgers, they're touted as being a plant-based, healthy, environmentally sound thing. A lot of that is up for debate, and I will tell you in terms of health, they're heavily processed. They do not come with the same nutrient profiles as the originals they're mimicking. You may feel really good about it, but you may not be getting the benefits that you think you are from these halo foods.
[29:06] So I'm not a fan of fake food. And I'm not a fan of food that'll make you sick. If you go to a cast party or a holiday event and there's a buffet, and you're concerned about the safety of that food — has it been kept hot at the temperatures it's supposed to be kept at? Has it been kept cold consistently? — don't eat it. Foodborne illness can wreck your gastrointestinal system. You do not want food poisoning because it's nasty, but it can also cause long-term damage to the gut. Same thing at the theater: if you can't keep hot food hot or cold food cold, if your Chipotle had to sit for a few hours, don't eat it.
[30:00] In these instances — and this is where we need to talk about performance-specific foods — processed food is really helpful. It's shelf-stable. It can give you energy when you are away from home. You may need that stuff. I use it and recommend it all the time because it's a practical consideration that we need to look at. We don't have a chef there to prepare our meals while we're rehearsing who can give us the number of bites we can digest in the amounts we need right here, right now. So processed foods can be an absolute boon when you need them.
[30:40] When you're eating at home, I recommend you eat whole foods as often as possible — even simple foods. Food cooking doesn't have to be hard, but foods that you can make or prepare easily that are nourishing and as minimally processed as possible. And we know that we are going to lean on processed foods and food products and sports drinks sometimes because they're necessary or they're performance enhancers, or they allow us to perform and keep up a pace because our demands exceed what we can do trying to eat whole foods.

[31:15] Jennifer Milner: Well, there were a lot of really great things in there. The discussion about food substitutes is an important one to have because a lot of us do like our hacks. You mentioned fat substitutions — I remember very much a certain fat substitute, Olestra, that was supposed to bind fat so you couldn't absorb it. People were eating entire bags of potato chips because they were like, "I won't get fat because I won't absorb the fat." And then they were having intestinal distress because of it, number one. And number two — sorry, no pun intended — number two, one of the consequences that a lot of people didn't expect was that people lost a lot of nutritional support in their body because there are fat-soluble vitamins, right? A, D, E, and K are the fat-soluble vitamins. So if you're eating that bag of fat-free potato chips, all of a sudden those vitamins aren't being absorbed. Unintended consequences.
[32:24] At the same time, if people want to eat vegetarian and they want to have a veggie burger, I would encourage them to go to a really great local restaurant and get a really great portobello or black bean or some sort of amazing vegetarian-style burger. And I think what you're referring to when you're talking about the protein substitute is like the frozen chicken nuggets or the fast food meat substitutes for burgers and things like that.

[32:52] Kristin Koskinen, RDN: Yes.

[32:52] Jennifer Milner: So it's about going and finding those whole foods still, right? It's saying, hey, sure, it says that it's plant-based, but what does the ingredient list look like? What does the cholesterol look like? All of that. So that's an important distinction.

[33:05] Kristin Koskinen, RDN: Yeah, totally. And it doesn't mean — it's how it's represented. If you look at the list of ingredients, it's massively processed, and the processing of that consumes environmental resources. So go in eyes wide open. There are a lot of great options — and depending on where you live, some people may not have access to a restaurant, and that's okay. I have recipes that I give my plant-based clients all the time. Soups and chilies and stews and patties that they can make relatively quickly with affordable ingredients that they can freeze in advance, and then they can take them and have them and enjoy them when they want. Even if you can't have that at the theater or the studio, you can have it ready when you get home because you have these really late come-home times. If you need to pop it in the microwave, great. If it's something you can put in a pan, great. But there are definitely options. They may take a little bit of time and preparation, but they really don't have to be difficult or complex, and they should be delicious.

[34:18] Jennifer Milner: When I was a dancer, I was very focused on my weight and avoiding things. But what I like about this conversation is it's really focused on what you need to include. I think when you're talking about packaged and processed foods and performance nutrition, maybe if people pay more attention — to the degree that they're able — to what's on the label and what is this food providing for me? Like, you can see a massive section of fruit roll-up type things in the store, and I guess not all packaged foods are created equal. Some of those things are going to provide calories but not a whole lot else, whereas others will actually provide more benefits. So are there any particular guidelines for what people should be looking at when it comes to those kinds of things?

[35:12] Kristin Koskinen, RDN: Okay, let's start with the mindset — abundance versus scarcity. Weight loss is a scarcity mindset: can't, don't, bad. We're going to start with abundance. What's going to fuel me? What looks good?
[35:25] If you're looking at labels on packaged or processed foods, it's going to vary based on your needs. There are sometimes when, for example, I recommend sports drinks to dancers — not as a beverage to drink at home all the time, but we may use those strategically. I am not a fan of Red Dye No. 40. I really don't like it. It has some bad effects and it can really negatively impact a lot of people. However, if a sports drink is what you can have and you don't get migraines from Red Dye No. 40 and it's going to get you through, and you're not going to be underhydrated and lacking electrolytes and missing sugar you need to perform — we're going to take that as an exception. So planning out what you're going to do in advance can be really helpful.
[36:17] Sodium is one that I look at a lot, and people poo-poo sodium, and I think we all know the value of sodium. Avoid products that say "low" on them. We don't want low. We don't want low sugar because low sugar usually means there's a sugar substitute in there, even if it's natural. If it's a sugar substitute — whether it's an artificial sweetener or something that's natural but highly processed — avoid it.
[36:44] If it says high fiber, we want to look at that too because they may have added something like chicory or inulin, which may be okay, but it could give you massive intestinal distress. Fiber is good, but inulin is coming in and be cautious with that. We don't know if it's absolutely safe. Manufacturers are putting it in because then they can pull back on sugar and other things when they add this food additive. So if you see "high fiber" being advertised on the nutrient label, be cautious — inulin and chicory may mess with you.
Anything with acesulfame K, saccharin, or stevia can mess with you. If it says high protein, look at where the protein's coming from. Are they adding it in, and is it a source that is good for you or not? Sometimes it is, and sometimes it's great in these specific situations, like I need a packaged food — but be aware.

[37:47] Jennifer Milner: So basically eat whole foods, basically, right? And as you said, you're not a big fan of hacks — beware of them. Hacks can be great for diabetics, people on very specific medical diets, totally get that. But if it seems too good to be true — eat this whole package without eating any sugar but it tastes like sugar — then that could be an issue.
[38:10] Speaking of sugar, with the holidays there's a big emotional component to food. There are all those treats that we have emotional ties to that should probably be worked out with a therapist, and how we deal with food sometimes, right? But if we feel like this is the time to enjoy those special foods, what roles do sugar and alcohol have with the immune system? And how do we deal with that? It's okay to eat it, it's okay to indulge in something if you want — but then we have to worry about using the words "indulge" or "withhold." So how do we walk that fine line about eating healthy, allowing ourselves to have it, not feeling like we're walking some mental tightrope emotionally with our relationship with food — and of course the immune part too? Ready, set, go.

[39:03] Kristin Koskinen, RDN: Okay, so again, we're going to pull the lens back — and ideally we're going to pull back in time — and we're going to go from: what's your mindset? Is it scarcity or is it abundance? I work with dancers a lot. I use bentos as one of my tools, and one of the reasons I use bentos is they drive variety, which can be difficult for dancers because they tend to get very narrow and specific and limited. Bentos drive variety, they're neat and tidy, they're structured — they check many dancer boxes.
[39:43] One of the things I have with my bentos and that I prescribe is "hold space." Well before the holidays arrive, my dancers are accustomed to this idea of hold space. Hold space is reserved just for you. There's no judgment, there's no commentary. It's what do you want? This is the stuff that nourishes your soul, that makes you feel good, and it is designated. It's important. We're setting it aside just for you, and you choose what it is. For some people, hold space is chocolate, M&M's, Skittles, a token to have a glass of wine after class if you're 21 or older. It could be a note, it could be Play-Doh, a toy — it can be anything, but it's designated and it can be reserved for foods.
[40:33] And I will say that the dance dietitians I work with and respect — I know Rachel Fine — enjoy a sweet every day. I don't think there's a day that goes by that I don't have something sweet. It's just part of life. It feeds us in different ways, and sometimes it fuels us in great physiologic ways too. When you come in with that attitude, it's normal, it's something we've normalized as a community. And for you, your parents, your studio, your instructors — because you do this and they see you doing it all the time, there's no big deal.
[41:13] So when we take that concept of hold space and translate it to the holidays, there's not a big difference, except now the hold space may be more emotionally tied. Like, "This family recipe means so much to me. I have enjoyed this recipe since I was a child." Or, "This is something in my culture. We do this, and I feel a connection to this, and it is important." For some people, it's just knowing it's there. For some people, just making the food and following through with "this is how my grandmother's hands have kneaded this dough or twisted this knot" — that's adequate.
[41:55] If you're gluten intolerant or you just don't feel well or you've got a performance and you know that hit of sugar at that particular moment isn't going to serve you, that's okay. You may want to save it for later, or take it to have when you can enjoy it. Or maybe you can't enjoy it right now because of the way your health is working, but you can be there and be with it, or create other ways to still enjoy it.
[42:20] Caveat: just being around the food or saying "I just like to look at the food, or touch it, or make it for the other people" can also be a sign of disordered eating. So take what I said, and if that resonates with you, that may be something to unpack. But there should be no pressure, and it really should be something that brings you joy. Joy is important. The artistic community seems to think you have to be in pain and somewhat crazy to be a good artist, and I'd like to dispel that.
[42:53] And joy is a perfect lead-in to alcohol too. Could you just touch on that briefly? So we know alcohol is a depressant. It's definitely something to take in moderation, if at all. Alcohol is a toxin, and it disinfects — not to the degree that we can use it on surgical instruments, it's not concentrated enough — but it can sterilize things in your microbiome. Be aware of that, and you really need to limit how much you have.
[43:35] There's been a lot of talk — and as we watch science unfold — in the '90s about the benefits of alcohol and all these things in the Mediterranean diet, drinking wine. But was it the wine or was it the resveratrol that came with the wine? Was it that people needed to manage their stress, and maybe going for a walk after dinner was a better idea than three glasses of wine with dinner? We know there are definite negative consequences with alcohol.
[44:07] I want to touch back on sugar because this is important with regard to where we're at. Sugar timing matters. If you notice that you are grabbing sugary sweets throughout the day, I want you to ask yourself why. Very often, if you are eating sweets throughout the day — and this isn't vilification, this is curiosity — we want to ask why. Are you using it for an energy bump? Are you not eating enough? Are you not getting enough protein? If this is a behavior you have, we want to know why.
[44:47] Eating a lot of sugar consistently in the form of refined sweets can demonstrate that you're not eating enough overall and your brain needs glucose, so it's saying, let's get it. You may not be getting enough protein. You may have a dysbiosis such as a Candida overgrowth, which can drive sugar cravings. So we want to see if that's a problem.
[45:15] When I suggest sugar in that hold space, it is for a time to sit and be enjoyed, not to nosh on over the course of the day. The reason for that is we know that simple sugars can tamp down the impact and health of white blood cells for a period of up to maybe 5 hours. So if you're noshing on sugar throughout the day, you're really hitting your immune system in a big way. Just like with alcohol, you've got a period of time where it's in your system before you've metabolized it. The same with sugar. It's there for a period of time. And that's okay — the body's resilient and it's going to be fine. Have the brownie, have the cookie, have the cake, and then be done and move on with everything else.
[46:00] You really need a lot of nutrients, and if you're eating a lot of simple sugars, you're also setting yourself up for a B vitamin deficiency, because metabolizing that sugar requires B vitamins. If you've consumed all those B vitamins and you're not getting more in with whole foods like fruits, vegetables, whole grains, and meats, now you may find you're fatigued again, and it creates a cycle of demanding more of those. And if you're low on those B vitamins, your immune system isn't just depressed because we've hit the neutrophils and slowed them down — now we're at a B vitamin deficiency that may be subclinical, meaning you're not presenting with it in ways that your physician is going to notice. It can just be right under the radar.

[47:09] Jennifer Milner: Those are such fabulous points. And I'm also thinking about how many people who are hypermobile have issues with their teeth and their gums. So if you're eating sugar throughout the day, you're also really helping that bacteria to grow on your teeth and increasing your risk of gum disease, which increases your inflammation throughout your whole body. And that can increase your risk for chronic pain.
[47:31] What I love about what you're saying is all of these things are so beneficial if you're making better choices — they're also so beneficial for the whole body. It's like you're dealing with the root cause rather than just, taking a pill or a supplement for this or that and then having to deal with the side effects. Anytime you can address the root cause, you're going to be so much better off than if you're just trying to fix something after the fact.
[47:58] One of the things that you've brought up a couple of times, and as our final topic, I wanted to have you dive into a little bit is the microbiome. I know lots of people are like, "Oh, but I take probiotics" or "I take prebiotic pills," and there are all kinds of products on the market now. We know that the microbiome is super important for immunity. Can you give us a little microbiome, pre- and probiotic 101 — what we should know about those and the immune system?

[48:25] Kristin Koskinen, RDN: Sure. So the microbiome plays a really big role, and it includes — Linda, you just mentioned the mouth — so mouth, gut, skin, anywhere there's mucous, we're going to find it. It's colonized by a lot of microorganisms, not just bacteria but fungi and viruses and parasites. Usually when we talk about the microbiome, we're talking about the gut. And there's an interface and a conversation that goes on between these microscopic organisms and our own immune system. It's a two-way dialogue. And it impacts our immune system and all kinds of things — metabolism, neurologic health, any number of things. For the most part, what we're talking about is in the intestines.
[49:17] So we want to make sure that we are feeding that. We have something that we call commensal bacteria — those are the good guys. What we know, and there's a lot of information, is that the more diverse that population is, the better. We want to have a wide variety. People who eat a wide variety of foods tend to have a broader variety of microbiota. That's because the foodstuffs for the microbiome for the most part come from fibers and plants and things that we don't digest. So eating a broad swath of plant foods — different herbs, different spices, different vegetables, different legumes — everything you eat that's different helps to support that diversity and feeds the good guys.
[50:07] It's a game of balance. There are going to be some things in there that can be damaging to us, but in simplistic terms, if the good guys outnumber the bad guys, we're in good shape. And we do know that specific strains do specific things. So before you take a probiotic, you want to know if that's a strain that's appropriate for you. If you struggle with IBS, bloating, any kind of GI symptoms, or SIBO, you may want to resolve some other things before you go there — it may or may not be a good idea. And that really goes with all supplements.
[50:50] So eating a broad variety of plant foods is important, and I recommend it highly. If you can eat 100 different plant foods in a month, that could be a goal. And it doesn't have to be full serving sizes. It can be, "I had a parsley plant growing and I had 2 parsley leaves." It doesn't have to be over the top. It can be, "Oh, I made chili, and I added celery and peppers, and not just kidney beans but black beans and white beans, and tomatoes" — and you're there. You're going to hit it in one dish. When I make chili, I add canned pumpkin and it's surprisingly good. You don't even taste it, and you get this food that otherwise seems to be relegated to pie twice a year in households unless you're making pumpkin bread.
[51:43] There are different things you can do. There are culinary ways that we can help bolster your diet to support that microbiome that taste good. You can also — obvious things are probiotic foods, so foods that are fermented. And if they're fermented, they need to be in the refrigerator section for them to work. If you're getting your sauerkraut off a shelf in the middle of the grocery store, it's not going to be the same as the stuff you get from the refrigerator section. Sauerkraut, kimchi, kefir, yogurt, miso, any kind of fermented vegetable — these are all examples of ways to ingest organisms that work with us in a symbiotic relationship to help us with our health. They are preferred and typically do a better job than the supplements.
[52:34] If we can't get to that level, then a supplement can be important and helpful. And sometimes you may want to bring in specific strains of things to get specific outcomes. And that's the case with supplements overall — you want to be specific, you want to be intentional. Just don't try things because you read about it in an article or your friend's taking it or your favorite influencer mentioned all the benefits.

[53:02] Jennifer Milner: We really want to be specific, which goes back to the whole "be careful where you get your information." This is a fantastic time to say everybody should follow you, because you want to get your information from a dietitian, from somebody who has some sort of certification, and not from the mom next door who started working for a pyramid group and now does coaching, who may not have the qualifications for handing out nutritional advice. So that's a really important caveat.

[53:37] Kristin Koskinen, RDN: Yeah, it really is, because there are some things that people don't know. You can have a coaching certification and that's fantastic, and there's definitely a role. But when we start looking at supplementation, you need to look at it like medicating. It's important because there can be distinct consequences.
[53:52] For example, a lot of dancers will start — and we saw this during the pandemic — people started hitting a lot of things really hard. Vitamin D, zinc, vitamin C were three big ones. It's great if you want to take vitamin D, but first get a baseline level. Let's see how much we need to give you. If you're going to take it, let's make sure you're getting enough, and let's find food and lifestyle changes that can help support you in other ways before we just start dosing vitamin D. And if you're going to take it, we want to make sure you're getting that with vitamin K2, because we can end up with some other problems if you don't.
[54:29] Do you need zinc? Let's look at it from a dietary source first so we make sure you don't overdo it. Because if you get too much zinc and you aren't balancing it with the right amount of copper, now you might not get enough copper. And the problem with that is copper deficiencies — guess what — they lead to immune compromise, and they lead to collagen production compromise too. So when we get hyped on zinc, we've created a deficit of copper. And if you already struggle with collagen production, you certainly don't want to throw another kink in the works with a nutrition deficit that you've created with nutrient competition in the intestine.

[55:10] Jennifer Milner: Yeah, that makes a lot of sense. And I know the doctor that I work with tests me regularly for my D levels, and she had said last year that she had, I think, 5 patients with vitamin D levels over 100, which is really high. She was seeing it through the pandemic — people were like, "Oh, we need to do something," and they were just taking these doses and if they didn't have someone doing regular blood work, they wouldn't see that. So it is really important not to just say, "Oh, it's getting to that season, let's take a bunch of zinc and I'm sure I will stay healthy."
This has been so much information that you've given us here — not just on the immune system, but on nutrition in general. Was there anything that you wanted to cover that we didn't? And where can people find you?

[55:57] Kristin Koskinen, RDN: I think we need to have a part 2 because the answer is oh, so very much.

[56:00] Jennifer Milner: So much more, right?

[56:00] Kristin Koskinen, RDN: So much. And people can find me on my website, which is www.eatwellpros.com. Or Instagram, which is my name, Kristin — K-R-I-S-T-I-N — underscore Koskinen — K-O-S-K-I-N-E-N — underscore RDN. Those are where you find me the most, unless I'm hanging out with you guys.

[56:31] Jennifer Milner: Yes, which is also true. Kristin is a team member of Bendy Bodies, so you will find her posting. And if enough people ask for it, maybe she will post her chili recipe with the pumpkin in it, because that sounds delicious. Maybe we can get something like that from her.

[56:54] Kristin Koskinen, RDN: It's a great idea. Yeah, we'll take a poll.

[56:58] Jennifer Milner: I think all you need to know are our opinions, and we say yes, please.

[57:03] Kristin Koskinen, RDN: If Jen wants it, we give it to her.

[57:04] Jennifer Milner: That's exactly right. I think I speak for all of the bendy bodies out there — we want this chili recipe.
[57:09] Well, you have been listening to Bendy Bodies with the Hypermobility MD, and our guest today was Kristin Koskinen, RDN. Thank you so much for being here, Kristin, and for sharing your knowledge with us once again on our podcast.

[57:24] Kristin Koskinen, RDN: Thank you. We got so much fabulous information. I know people are just going to love this episode, and we really appreciate you taking the time to share your vast expertise with us.

[57:36] Jennifer Milner: Oh, thank you. It is always my pleasure.

[57:44] Kristin Koskinen, RDN: Well, if you love what you learned, follow the Bendy Bodies Podcast to avoid missing future episodes. Screenshot this episode, tagging us in your story so we can connect. Our website is www.bendybodies.org. You can follow us on Instagram at Bendy Bodies. Leaving a review, following the Bendy Bodies Podcast, and sharing the podcast helps spread the word about hypermobility and associated conditions. This information is not intended to diagnose, treat, cure, or prevent any disease. The information shared 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 will catch you next time on the Bendy Bodies Podcast.