46. Fueling Against Fatigue with Kristin Koskinen, RDN

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

00:16
Dr. Linda Bluestein
Our goal is to bring you up to date information to help you live your best life. Please remember to always consult with your own healthcare team before making any changes to your routine. 

00:38
Jennifer Milner
Our guest today is registered dietitian nutritionist and Bendy Body's own Kristen Koskinen. Hello, Kristen. 

00:45
Kristen Koskinen
Hello. Thank you for having me. 

00:49
Jennifer Milner
Thank you for coming back on the podcast. Always a pleasure to have you here. 

00:53
Kristen Koskinen
The pleasure is mine. 

00:55
Jennifer Milner
So fatigue is something that a large part of the population can probably relate to, and in the past, we've discussed fatigue with other experts, as fatigue is something linked to a lot of issues common in the hypermobile population. Dr. Pasinki defined fatigue for us as the inability or difficulty in accomplishing simple tasks, and we want to use that definition for the purpose of this discussion, if that works for you. Sort of separating fatigue a bit from the idea of sleepiness. So does that work? 

01:25
Kristen Koskinen
Yeah, I think that's a great way to define it, and really helpful. 

01:30
Jennifer Milner
Excellent. So with that in mind, what role can nutrition play in fatigue? 

01:34
Kristen Koskinen
Nutrition plays a huge role in fatigue, and we're all familiar with the term of food as fuel, and we are going to hit on that. But first I want to pull the lens back on our perspective of fatigue and talk about it's not just what you eat, it's what you digest and absorb. And nutrition happens at a cellular level, but to get there, we have to procure the food, prepare the food, eat the food, and hopefully those nutrients are broken down appropriately, are digested and absorbed, and get to where they need to go. Some of the things, some issues that are common in the hypermobile community include we'll start with an obvious one, which is fatigue or being tired, and we talk about the number of emotional, physical, and mental resources someone may have. Sometimes this is referred to as the number of spoons you may have in a day, which can vary. 

02:33
Kristen Koskinen
And so we want to pay attention to that, like, what are your resources generally and what are they maybe from day to day? And if you have a perspective on that'll give you an idea of what you may have available in terms of getting foods that work for you. Another thing, just like the practical issues, grocery shopping, food prep, cooking, anything like that. Another thing we want to look at is TMJ issues, which are really common. So if you have any issues with your TMJ, chewing can be a problem, and so that's something we might want to address. You need to adjust how you prepare your foods so that they're easier for you to chew and swallow. Sometimes people have chronic TMJ issues, sometimes they have flares with it. So that's something that we want to consider. The entire dental aspect matters. Do you have loose teeth? 

03:23
Kristen Koskinen
Do you have anything that you need fixed? Or mended is important. And then we also want to look at executive function. We know that ADHD and autism spectrum disorder is common among hypermobile people, and so executive function tends to be a huge issue. You only have so many decisions you're going to make during the day, and if it comes to the end of the day and it's time to decide what to eat, you may be spent. If you have a hard time focusing and you need some help planning meals or what to eat or what's appropriate for you, getting some support there can sometimes be your best choice because if you've run out of spoons in that department, then the rest of it isn't going to follow like we would like it to. So those are three kind of overriding things I look at as a dietitian that are related to the nutrition component and we really need them, even though they aren't looking at the specifics of, say, vitamins and minerals. 

04:22
Kristen Koskinen
What I want to do is start by talking about the things let's control what we can control. And here are some recommendations that very often are exceptionally helpful for my clients. They may be overlooked by a lot of people, but the results can be a big bang for zero buck, which I like a lot. They are free, they are simple, and they will do no harm. So those are wonderful places to start with any sort of health improvement program. The first is we want to look at digestion, and that actually starts with the head. There's a cephalic component that we talk about, and that's when you think about food. You see food, you smell food. It really starts from the literal top and goes down when you do this. This engages your nervous system to start acting in on your digestive system. And it readies things. 

05:10
Kristen Koskinen
It says, hey, things should be coming down the pipe here pretty soon. Let's get ready, gang. What does that mean? It means that stomach acid will start to produce. It means your salivary gland will start producing saliva, which includes enzymes that break down food. Your pancreas will get ready to pump out digestive enzymes that you need to digest your food. So the idea of starting with thinking about your food, thinking about what you're going to have to eat, this can be part of that executive process. If you know in advance what you're going to eat, you can start to hype yourself up about it. Oh, yeah, I'm so excited. I get to have this meal later. And that can be very beneficial in this process of digestion. We are very far away from the original ways of eating, which would be think of the little red hen. 

05:58
Kristen Koskinen
She grew the wheat, she ground the wheat, she baked the bread, she did all the things before she actually ate that bread. And all of that is part of the process of preparing yourself for eating. And now it's just as simple as we live in this grab and go lifestyle that doesn't facilitate that. So we need to take the extra step to be mindful, and this is being distinctly mindful about thinking about the food you're going to eat. That also includes being quiet and sitting down and relaxing. Being stressed while you eat shuts off the digestive process. You are either in a rest and digest mode or you are in a fight or flight mode. There's really no in between. If you're trying to do both, you're going to lose. It'll impact your digestion negatively for sure. You'll notice if you're under stress, you may not feel like eating. 

06:46
Kristen Koskinen
Your appetite may be decreased. You may feel like throwing up if you eat when you're really stressed. So all of those things are indicators that we want to be restful. A tip and trick here's something you can employ today is to sit down to eat when you stand. That engages the sympathetic nervous system. The sympathetic is that fight or flight. Sitting helps with the parasympathetic, which is the rest and digest. Two, you can eliminate stressors while you're eating. Don't watch the news, don't have cantankerous company. Whatever you need to do to make sure meal times are pleasant. That can be difficult sometimes. Work on it, even if it's one meal, if it's dinner, if it's breakfast, whatever you can do for that. If it's breaking away from gossipy people at the studio to go eat a meal in peace, do that. That can be really helpful. 

07:34
Kristen Koskinen
Another thing is breathing. Breath work is really important. We're starting to talk a lot more about that in the dance community and it can definitely enhance your digestion box. Breathing is an easy way to do that. It's super simple. You breathe in for account depending on what your stress and relaxation levels are, they're going to vary. But we'll start with four. You would breathe in for account of four, hold for account of four, exhale for account of four, and hold for account of four, and repeat that until you feel rested. And the point is, the exhale is actually where the power of that breath is, which is really where things come down. So those are a couple of things you can do. The next thing you want to do is make sure that you're chewing your food well. Chewing your food to the consistency of applesauce or yogurt is what you need to do. 

08:21
Kristen Koskinen
That's going to vary depending on the food that you're eating. But that gives your body a chance to, one, break it down. Your stomach cannot handle big blocks of food. That's not its job. That's your mouth and teeth job. Chew, chew, chew. Chew. Saliva also contains enzymes that start to break down that food. And that process actually continues while it's in the stomach until those enzymes are broken down. So chewing is emphatically necessary. Generally, twelve to 15 chews will do it. It'll vary by food source. So please chew your food well and then the food gets to your stomach and in your stomach, it needs hydrochloric acid to break down. If you're under stress, hydrochloric acid levels will decrease. If you're taking certain medications, you may have lower levels of hydrochloric acid. If you are not getting enough of certain nutrients, including zinc, your body may not be able to produce enough hydrochloric acid. 

09:19
Kristen Koskinen
This does a couple of things. One, it means your body's not breaking down the food. If the food is not broken down enough, you're not going to be able to absorb it later on. All these steps are important. And if you're not producing enough hydrochloric acid, proteins aren't going to be broken down. Well, another protein that's not going to be broken down is bacteria. So bad things that you get in from the environment, whether you've inhaled them, whether you've eaten them, they've come in, get swept in from your nose and mouth and ears even. You swallow them, they end up in your stomach. And that hydrochloric acid breaks them down. Infections are not a good way to keep your energy levels up. They lead to fatigue. So this is actually a really important component that we may not think about, but it is. And one of the nutrients that we look at there is zinc. 

10:08
Kristen Koskinen
So if you're not getting enough zinc, that can impact that process. Hydrochloric acid is also necessary to extract vitamin B Twelve from protein sources. And then B Twelve connects with something called an intrinsic factor that needs to be partnered up. So later on in the intestines it can be absorbed. So if you don't have enough hydrochloric acid, if your acid levels aren't high enough, you may be eating enough vitamin B Twelve, but you may not be able to utilize it. That's really important because vitamin B Twelve is critical for energy levels. Deficiency levels of it can lead to neuropathies neurologic problems, decreased energy anemias all things that tank your energy levels and will result in the symptom of fatigue. Then we get to the intestine. Then along the way, we also have your pancreas. It should be shooting out digestive enzymes that break down all the different components of food you need. 

11:07
Kristen Koskinen
That if you're not resting and digesting or you're just shoveling things in, maybe your digestion doesn't have enough time to get there. Some people don't produce enough of these enzymes. This is something we want to be aware of too. And if you're on the hypermobile spectrum and Dysautonomia is part of your life, maybe the signaling isn't getting there appropriately for you. So these are some things to consider. Next stop on the process is your small intestine. And that is where your body absorbs the nutrients that have been digested, for the most part earlier along the track. So to simplify things, this is where things are going to be primarily absorbed. And that's important. You need to go from the digestive tract to the inside of the body. Technically speaking, your entire digestive tract counts as the outside of your body, which I think is fascinating. 

11:59
Kristen Koskinen
I always have, but that's true. So now that we're in the intestine, this is a critical point and we see and there's connective tissue involved. And something that's important about the intestine is there's something called intestinal permeability or leaky gut. It's fairly common in the population at large. I find it to be more common in the hypermobile community. And this shouldn't be a big surprise because when we think of connective tissue in any sorts of risk or damage, it's vulnerable. So things that can disrupt the integrity of the intestine include stress and include toxins or any sort of insult to these very delicate one cell thick connections. And if they are damaged for any reason, they create gaps where bacteria and other proteins that shouldn't have gone through can get through. This can lead to inflammation because of any number of reasons, and food sensitivities, which can also lead to chronic inflammation. 

13:12
Kristen Koskinen
And those express themselves differently in different people. And this is one of the reasons why when we talk about anti inflammatory foods can have particular properties, they can have mechanisms of action, but how they operate in each person is going to be different. So if your body has at some point had a leak and a protein from a food that we would consider anti inflammatory got through, and your body looks at it now as faux because it came through as a protein that your body, the mediators of your body respond to and say, oh, we're going to react to that then even healthy foods we would consider healthy and anti inflammatory, including spinach. I see spinach come up quite a bit. Or other foods, you may have an inflammatory response. So we're not going to use using blind words like anti inflammatory, I don't like to do. 

14:08
Kristen Koskinen
And I feel like it's frustrating because it doesn't acknowledge the experience that so many people really have and it creates a right wrong atmosphere, which is not helpful. It's just absolutely not helpful. So if someone says, oh, just and if someone PS, if someone starts with just do something, they clearly don't have an understanding because just we can even say the term simple means simple. It means it's elegant. There aren't a lot of steps. It's clear. It doesn't mean it's easy. So just negates the challenges that people may be going through and the idea of just eat anti inflammatory foods that might drive you crazy. Citrus and tomatoes are two common foods that are healthy and would qualify as anti inflammatory. But wreck havoc with a lot of my clients. And even when people talk to me for the first time, I'll say I'll just throw some things out, like how do you do with tomatoes? 

15:11
Kristen Koskinen
Oh, I can't do tomatoes. Oh no. So we really want to be mindful of those things. And then we go to the large intestine, and that's where your microbiome largely, you have microbes all over your body, your mouth, your skin, your large intestine. And then we get there and that is where hopefully a lot of fibers you've been eating produce lovely items like neurotransmitters and other things that help us feeling well. But they're not going to be a big part of our talk today, so we can just end there. 

15:47
Jennifer Milner
So if anybody is tuning into this episode hoping to hear five Magic Foods to Fight fatigue, that is not going to be this discussion. Clearly. I feel like we just got this amazing Ted talk on nutrition and fatigue, and we haven't really even started talking about specific foods or nutritions. It's just been that general overview, like the whole thing about neurodivergency and how executive dysfunction can contribute to nutritional deficits that are not the sort of links that we usually draw. But you're absolutely right and that was I'm going to have to go back and listen to that again because that was a lot of information. And I feel like we just rode the magic school bus through our digestive system. 

16:29
Kristen Koskinen
We need special areas for that. 

16:35
Jennifer Milner
But that was incredible and a good reminder that when we're talking about things with hypermobility, there is not one size fits all. There's no, oh, you just do this or you just eat that. So people say, oh, just cut this out and you'll feel great. Just stop eating wheat, or whatever it is. There's not that one size fits all. So thank you for taking something really complex and trying to distill it down into sort of a smaller form. So we know that nutrition has a big role to play in fatigue. And we know that even how we eat, as you were talking about making choices with how we eat and when we eat and everything can contribute to it. And you were saying there are superfoods, not superfoods, I shouldn't say that. There are foods that we need. Like you were saying the mineral zinc that's going to help us have an easier time absorbing and digesting are there not to try to make blanket statements, but are there foods that we can eat that could actually contribute to that feeling of fatigue? 

17:35
Kristen Koskinen
Oh, absolutely. So there are two that come to mind right away. The first one is alcohol. Alcohol is a depressant that right away can wreck havoc with mood. Two, alcohol can deplete certain nutrients, including B vitamins. Thiamine is one of note. And if you are deficient in Thiamine, you can end up with all kinds of problems, including things that look a lot like Dysautonomia, so alcohol can be a huge one. Alcohol can also displace nutrients. People who are drinking a lot of alcohol may not pay attention to other foods that they're eating. If they're drinking, they may make different food choices while they're under the influence. I'm not trying to knock anything, but these are just some simple this is the biochemistry of stuff. So again, you'll need to apply this to your own situation, a second one. And again, this is based on the conversation of fatigue. 

18:33
Kristen Koskinen
And really we're looking at more at biochemistry and physiology and sugar. And I am not opposed to sugar. But sugar can contribute to fatigue. And the way that it can do that is sugar. If people have heard me in other venues, they know I use sugar as a tool. I'm not opposed to sugar. I think sugar can be great. I like sugar and celebratory things, all that stuff. However, it can also lead to fatigue. And the way that it does that is sugar. Straight, sweeteners that aren't attached to a food source. So if you're taking sugar away, sugar just doesn't magically appear. We get it from other food sources, whether it's beets or cane sugar or whatever. Sugar also comes. We know natural sources of sugar and fruits and sweet potatoes and grains and stuff like that. When we take the sugar away from those food sources, it stands alone as a two molecule carbohydrate. 

19:33
Kristen Koskinen
And it's great because it can give you quick energy. However, that's all it is the quick energy. And it does not have with it any of the B vitamins that are required to metabolize it. So if you're eating a lot of sugar, what can happen is you may deplete whatever B vitamins you have in your body because they're being used to metabolize that sugar. If you're fatigued or tired or don't have mental if your mental emotional bucket is low, a lot of times you'll crave sugar. Your brain knows it's going to get a good hit. Your brain, it thrives on glucose. That is the preferred currency of fuel for your body. And you get glucose from primarily carbohydrates. They are strands of glucose and some other stuff. But you can break that down into glucose very efficiently. The body likes that a lot. You can get it from protein through a process called gluconeogenesis. 

20:34
Kristen Koskinen
It's complicated. Usually it comes at a great cost, including breaking down your own muscle protein, which we don't want to do. And so the body really likes glucose. And people will notice if they are tired, if they're fatigued, they may crave sugar. And that's the brain's way of saying I need something. But what the brain may really need too, is it also needs those B vitamins that come along with it to metabolize it. In nature, we don't go along and just see, we don't just pull up some sugar. Our bodies would have we see sugar in terms of berries and fruit and other things. If we get it in that form, then we're getting the nutrients to ride along to make sure that the metabolism happens. That actually can lead to fatigue. If you are getting amounts that exceed what is appropriate for you and what is appropriate for you in a particular situation or condition, this is something that's really interesting too. 

21:38
Kristen Koskinen
There are neurotransmitters in your brain that actually pick up on the levels of circulating blood glucose. And these neurotransmitters are responsible for wakefulness and arousal and even appetite. And if your blood sugars are too high, they actually tune down, which is really interesting because some of the instances when your blood sugars may be really high are during chronic inflammation. So if you're chronically inflamed, those blood sugars may be high, your insulin sensitivity to your cells may be diminished. And that's part of why those blood glucose levels are high. So what that does is it shuts down the responsiveness of these neurotransmitters that are involved in wakefulness and arousal and things like that. So that can lead to fatigue. That can make sense too, when they look at inflammation. And being hyperglycemic can be a reflection of being in a state of chronic inflammation. And chronic inflammation does a few things. 

22:45
Kristen Koskinen
One, it's a sign that things aren't right, things aren't going well, and it also requires a lot of energy. So being chronically inflamed those inflammatory processes require energy. So to support the inflammation, you may be burning through energy, which can lead to fatigue. And inflammation can also suggest that you're sick. And so it makes sense for the body if you're not well. It doesn't want you out running around and taking class and doing training and things like that. It needs to conserve resources to attend to infection in particular or whatever it needs to do. And so this process of, oh, sugars are too high, shut you down. Makes sense, hey, we need to rest the body so we can recover someplace else. And so that can be something you might notice too. So if your blood sugars aren't managed for any particular reason, that may be part of your fatigue. 

23:46
Dr. Linda Bluestein
Wow. I'm listening to all of this, and I'm thinking about a lot of the patients that I have and how they, I think, are kind of defeating their own selves in some ways. Because if you start to have some digestive issues, oftentimes you start to restrict foods more, you start to get more stressed. You probably get more stressed before you even put the first bite of food in your mouth. And you anticipate that you're going to have bloating or abdominal pain or whatever, which becomes a self fulfilling prophecy. Right. Restrictive food plans or fad diets seem like they can really be such a huge problem and really contribute to a person's level of fatigue. So what do you think about some of those restrictive diets? 

24:36
Kristen Koskinen
That are out a, I have a lot to say about them. And Linda, your experience is mine too. I see that all the time. And one of the things that we work on is that idea of the mental game know, what can you do? Like, how can we do this? And people will restrict down sometimes out of fear. They have fear foods and they have safe foods. And sometimes those safe foods can get down to eight, which creates its own set of problems. When we look at restrictive diets, that's another thing. So sometimes people will recommend go gluten free, go keto, go low carb, any number of things. And my recommendation is they not be taken lightly. Because if you, for example, going gluten free can be very helpful for a lot of people. I'm not discounting it at all. A lot of people benefit from getting rid of gluten. 

25:32
Kristen Koskinen
However, when you pull the gluten, foods that contain gluten also contain a lot of B vitamins and fiber. So now we need to make sure, what are you doing on this end that ensures you are getting those nutrients and coming in and just replacing the whole grains that you may have been eating that were sources of gluten with gluten free options. You may not be getting it, and you may also be getting foods that drive inflammation in you. Because if it's a gluten free replacement. 

26:03
Jennifer Milner
Product. 

26:06
Kristen Koskinen
It'S going to have a lot of stuff in it to make it feel comparable to those gluten foods. And we want to eat foods that taste normal and feel normal. It's just something to be aware of. And if you're struggling from fatigue, that's something. Another thing to look at is, particularly when we're looking at grain type products, is folic acid on the label? I notice a lot of clients when they pull gluten, something they also remove from their diet is folic acid. Because folic acid in the United States is required to be in particular food products. If you have like, refined flour, they're not required to put folic acid in foods that are organic, but they are in conventional foods. So here's the deal. Regular foods like wheat and these grains have folate. Originally, during the processing, the folate pulls out and manufacturers replace it with folic acid, which has a distinct purpose. 

27:05
Kristen Koskinen
In large part, it's required in the US. To prevent spina bifida and other neurologic disorders in developing babies. The problem with that can be is not everyone has the genetic makeup to metabolize folic acid. The metabolic wheel where folic acid comes in is kind of slow, and it gets bottlenecked as it is. But if you don't have the equipment to metabolize that folic acid, your levels may increase, and that can cause brain fog and fatigue. So sometimes when people pull the gluten, they are also inadvertently pulling the folic acid, which actually may be the problem more than the gluten. So I like to let's recognize that and keep it in mind. If it's gluten, whatever. If you feel better off gluten, stay off gluten. There are lots of other options. You just need to make sure that you're eating other whole foods that give you a similar nutrient profile so that you're not behind. 

28:03
Kristen Koskinen
Another kind of trendy diet that I hear all the time is the keto diet. Keto has a role and it is a therapeutic one. If you have had a traumatic brain injury, if you have seizure disorders, a ketogenic diet may be appropriate for you. You shouldn't pursue this without professional help to make sure you're getting the nourishment you need. If you are doing keto for any other reason, we need to talk about the reason. It's often promoted as a great way to lose weight. Well, if you're trying to lose weight, chances are you may suffer fatigue. Earlier I mentioned that carbohydrate is the body's preferred fuel source. And a keto diet has very limited carbohydrate, 25 to 50 grams a day, which is abysmal. And if you're an athlete, that ain't going to work for you. And it's primarily fat. And the intention is your body will become keto adapted. 

29:05
Kristen Koskinen
Eventually it'll use that fat for fuel and the fatty acids it converts to ketone bodies for your body to use. That can be fatiguing, particularly for athletes. So if you are an artistic athlete and you're trying to go keto, what we know from the research is your perceived level of exertion will be high. You'll feel like you're performing at a twelve out of ten, which on another day would have felt like a seven out of ten. So that is not a good way to go. Another problem with keto is because you're so limited with your carbohydrates trying to get in b vitamins and fiber becomes limited. So now you're limiting your fiber constipation is very common. You may not be getting a host of other nutrients you're not getting I keep mentioning the B vitamins, but they're super important. You may not be getting the B vitamins you need. 

29:57
Kristen Koskinen
And these B vitamins are necessary for metabolizing energy. They're necessary for making red blood cells, they are necessary for central nervous system operation. So all kinds of things that relate to nutrition. So if you're going with keto and you pull these nutrients out, you may feel fatigued. The whole 30 is another one. Effectively, the whole 30 is an elimination diet and a lot of people feel really great when they finish. The problem is it's very limited. And any of these things can also lead to eating disorders. And eating disorders are more common in the hypermobile community than the other community. And if you're a bendy buddy, if you're an artistic athlete, you're at increased risk. If you are a bendy body, you're at increased risk. So we do not want to bring these things in unnecessarily. If. You want to do an elimination diet, you should do it with someone who can help make sure you're doing it in a way that suits you and. 

30:57
Jennifer Milner
Is appropriate, that makes sense. I also appreciate what you were saying about how people might not have enough zinc. Like you mentioned earlier, people might not have high enough levels of B vitamins, but they also could be getting too much of something like folic acids. We always think about, oh, we're not getting enough of some nutrients. So it's interesting to think about. It really is the balance and making sure what's appropriate for our body types. So if someone suspects that their fueling patterns might be contributing to their fatigues, are there simple steps they can take to find out what might be the culprit? Are there blood tests that they could do to sort of assess fatigue? What could they do? 

31:36
Kristen Koskinen
Sure, there are a lot of things. The first thing, the cheap, effective thing to do is use a food journal to keep track of what you're eating, what you're drinking, your circumstances, like, your environment, what's going on in your life. All these things matter. All of it matters. And then you can track symptoms too. And if you keep track of that, whether you're able to discern what's going on or you use that as data to share with your healthcare team, either way, it can be really helpful sometimes. And that's simple but not easy. For my clients, what I do is I have a photo food journal they can use. So all they have to do is take a picture of it, then they can make notes about what's going on with them. But then I get the data and I can help translate that to what's going to work best for them. 

32:25
Kristen Koskinen
So I have an app that works. Most apps on the market that have to do with food are looking at weight loss. I mean, that's the end goal. So they give calorie counts, macro counts, all these numbers that can be distracting and really misleading. And so I'm not a fan of those. I have one that people can use that gets rid of that, but they can just look at foods and also track their symptoms, including GI symptoms, poop patterns, all kinds of things. So that can be helpful. Testing is another option. So there are several things that you may want to test. One thing may be making sure having a complete thyroid panel. So if your thyroid is out of whack, that can be nutrition related. And if your thyroid is out of whack, if your thyroid is particular, you're suffering from hypothyroid, it can slow your digestion. 

33:23
Kristen Koskinen
So now you may end up with the cramping, bloating, constipation, maldigestion, malabsorption things because your thyroid is diminished. So, checking your thyroid, one of the things that we know about thyroid is we want to know if your thyroid is converting from T four to the active form of T three. And that requires minerals, zinc and selenium. So if you're deficient in those nutrients, you're missing a step in the process, and then everything downstream from there is going to go caput. So this is where someone who may look not a lot of people are thinking about selenium, so that's important. And we might look at food sources where you can get those. So having a thyroid panel is a good one. Looking at markers of inflammation can be good. CRP is one you can look at with regard to specifically with food and nutrition. There's a test called the MRT test. 

34:18
Kristen Koskinen
That's something you need to go. Typically not every practitioner will offer that because not every practitioner knows how to help you with the results once they get them. So that is a mediator release test. And effectively that's a fast track to see what foods you're very likely sensitive to. So rather than going through a traditional elimination diet is complicated. It's hard, it's not easy, it's not simple, but this really kind of shoots you ahead so you can start and get a better idea of what may be impacting you specifically. That's a test. What are other tests? And tests for different anemias are really important. So an iron panel and what are your hemoglobin and hematocrite? If you're deficient in iron, you will feel low on energy. People who are anemic feel fatigued, and there are different kinds of anemias. So you may have an iron anemia, a B, twelve, anemia, A, Folate anemia. 

35:12
Kristen Koskinen
So those are things we want to test. You need B, Twelve, and Folate to create those blood cells. So if you're deficient in them because you're not absorbing them, you're not eating enough of them, whatever it is. If your demands are just higher, and you may be eating what may look like a lot, but it's not enough for you could have a relative deficiency. So checking to see if you have any sort of anemias can be important. Checking vitamin D levels can be a good one. Getting a micronutrient panel can be another one to see where you're at. And those are good first stops. A hemoglobin, a one C, where's your blood glucose writing most of the time. Your physician or primary care provider should be able to provide most of those for you. You may want to ask specifically, like a complete thyroid test isn't just a TSH, it involves other components. 

36:09
Kristen Koskinen
So you may want to check with someone who runs those regularly just to make sure you get everything you actually want to see to get a complete picture. 

36:18
Dr. Linda Bluestein
And what do you think about continuous glucose monitoring and or glucose tolerance tests? 

36:25
Kristen Koskinen
Yeah, the continuous glucose monitoring, I know some people who are doing it. I think it could be a good tool. And I also think sometimes we get so much information it can be overwhelming. Or we start to dial in one area to the neglect of others. So I think it depends. That would be really individualized, and I think it would be like, several steps down. Like, you've got a lot of other things rolling before you start there. What was the other one glucose tolerance test. 

37:00
Dr. Linda Bluestein
I'm thinking of, like, fasting insulin versus a one C versus glucose tolerance test. Like, some of those not just looking at the fasting glucose, but looking at some of those other tests. And in terms of those options, like, what you think is the most valuable. 

37:14
Kristen Koskinen
Oh, yeah, I'd look at insulin. Okay. I'd look at an insulin test. Fasting glucose is so hard. Oh, my gosh. I have glu cola. The problem is it can make people sick. I am a sympathetic dietitian. I really am. If something's going to make someone sick, can we do anything else but that? If people are afraid of needles, what are ways are there some goal rounds? And a lot of times there are, can we piggyback? What can we do to make this as comfortable as possible, which is so important? Again, going back to that, what are your emotional resources and creating stress or distress? We don't want to do that as providers, man, we're here to love you up and take care of you. No looking at I'd say doing it. I'd be testing insulin, and insulin reactivity. 

38:06
Dr. Linda Bluestein
Awesome. 

38:07
Kristen Koskinen
Great. 

38:08
Dr. Linda Bluestein
That's great to know. In terms of vitamins and supplements, we know that it is totally the Wild West, right? I mean, people are love it. 

38:20
Kristen Koskinen
Yes. A tumbleweed just blew by. 

38:23
Dr. Linda Bluestein
Yeah, exactly. It is crazy what people are doing and going into I shouldn't mention any specific names, but, like, going into stores and just you've got a $12 an hour, $10 an hour employee that's telling you, oh, here, blah, blah. 

38:40
Kristen Koskinen
Take these things. 

38:42
Dr. Linda Bluestein
What are some of the vitamins and supplements that you see playing the most significant role in fatigue? And what should people be looking for, aware of, cautious about. 

38:52
Kristen Koskinen
Yeah, okay. So we're going to go back to those B vitamins because okay, so here's something I see. I'm going to give you a clinical example because they're really interesting. So sometimes the symptoms we see aren't what you expect. So I had a client come to me, and she had unremitting vomiting. That was one of her primary complaints. She was vomiting daily. And so if you're vomiting daily, you can imagine that your digestion and absorption isn't hot. And what we did is we did a few things. So one of the things we did is we increased her B vitamins. So we started with just kind of a well balanced multivitamin vitamin mineral. And by well balanced, that means that the manufacturer has an understanding of how much of things to put in so that competing nutrients, like too much zinc will knock out your copper. 

39:50
Kristen Koskinen
We don't want that. We don't want to have too much magnesium. And calcium in one, they compete with each other. We don't want that. So a well balanced supplement has nutrients in ways that your body will best utilize them. So we started with that and then we layered in another B complex to bring up her B vitamins and the vomiting stopped. And then now she's able to eat. Now her stress levels are down. Now we're able to work on the disordered eating. And it all starts to come together. And usually if we can get a hold one thing that starts the momentum. And momentum isn't a mental game, it's physics. Whatever direction you start going, you'll start going that. And if we can, sometimes it's fixing one simple thing, one easy thing. That's why I started with, hey, let's start with chewing. Can you do that? 

40:40
Kristen Koskinen
Could you get rid of something that's distracting you while you're eating? Because sometimes that one simple thing is the gateway to everything else. Turning the corner. Okay, so there's that. Other supplements. Sometimes we want to look at your meds. Are you taking meds that may deplete vitamin, your different nutrients? So if you're on birth control pill, that can do it, that can be B vitamins, magnesium. So we want to look at that. Are you taking things that definitely are required for your management of your symptoms? Like if you're on H One or H Two blockers, that may have another sequelic. Does it mean we want to take yothos? Not necessarily, but we may want to look at is there a supplement that may help your overall picture and how you're digesting? So we may want to bring in something like hydrochloric acid or betane HCL to help support your body. 

41:39
Kristen Koskinen
And sometimes these are just they're not long term. It's like, while we're here, let's do this or we're going to fix a problem. We're going to create a bridge with supplements until we can get the food up to speed and this is a bridge. And then we're going to do something else. We're going to get you fixed up to the point where if you're only eating eight foods, we want to supplement and support your body so you feel well enough, and then we're going to start expanding things. It may be part of a process. It depends. Maybe we have all kinds of different strategies. It depends. So those are some looking at nutrients. A lot of people need vitamin D. That's not uncommon. It's one you can definitely test and get a level. If you are hypermobile, you may need what seems like a ridiculous off the charts amount. 

42:26
Kristen Koskinen
And so like thousands and thousands of units every day where someone else may max out at 2000 and someone say, oh, no, that's ridiculous, you can't do that. But if you're working with a practitioner who's monitoring your blood levels of this stuff, you may find you need 10,000 a day compared to someone else who just takes some vitamin D 2000 that I recommend pairing with vitamin. K Two to optimize the use of the vitamin D in your body and make sure that the minerals that you need for hard surfaces like bone and teeth are deposited where they need to go and not in soft tissues. What else? Sometimes it's digestive enzymes. Digestive enzymes. That's a supplement that can be supportive for some people if they find that they have a hard time eating that food just sits in their stomach. Sometimes it can be an enzyme problem. 

43:18
Kristen Koskinen
Sometimes it's you have an overgrowth of bacteria. Maybe that slowed digestion has led to the proliferation of bacteria in places that they're not supposed to be. It's not that they're bad. It's just they were supposed to stay down in your large intestine and they moved up to your small intestine, or they came in through your mouth and you didn't have enough hydrochloric acid to kill them. And so they ended up where they weren't supposed to be. So then we can look at their different supplements to help with motility if necessary. That can provide, again, a bridge from where we are here to where we want to go and provide relief too. Magnesium can be a lot of people are deficient in magnesium. That may be something. The form you take will depend on what you've got going on. There are lots of forms of magnesium. 

44:08
Kristen Koskinen
Magnesium citrate is available, and it's cheap, but it could give you diarrhea, so it's not necessarily the best absorbed. So if you're constipated, that may be one that we start with. If you're struggling with mood disorders, we may look at a formulation that binds the magnesium with the amino acid three in eight so that it helps cross the blood brain barrier. Magnesium bisclycinate is generally well tolerated and generally well absorbed. People who struggle with sleep or rest or relaxation, which may be part of your fatigue issue, may benefit from getting some magnesium too. It depends. But we want to start with your diet. We always want to start with your food source and what we bring in as a supplement. I like to think of it as like a stone wall. And the foods you eat are the stones in that wall, and the supplements just come in as the mortar and fill in the blanks. 

44:58
Kristen Koskinen
We don't want to have a mortar wall that we just punctuate with stones that's for many reasons, it's cheaper. If that makes you feel better, it's a lot cheaper to eat food than eat fistfuls of supplements. When you get things in food that balance, that well balanced formula is there. And we get other things from food that we may or may not even be aware of. There are nutrients that we don't think about. There are nutrients that we don't know about yet. There are over 50,000 phytonutrients that come from plants. They're new to the scientific community. I mean, we keep discovering things and if you're just leaning on supplements and you're not working on your diet to make sure you're eating properly, you're going to miss out on those things. And they can help and they can be distinctly helpful when we're looking at inflammation. 

45:49
Kristen Koskinen
Again, inflammation, fatigue, all the things. So things like resveratol, querceinase, curcumin, all come from food sources, and you can use them strategically or therapeutically in a supplement form. But if you're getting them consistently from your food sources, you're also getting the other nutrients that come along with them. You're getting the fuel you need that's carbohydrate, protein and fat and other nutrients that just may not be that you don't think about all the time that you don't need to think about all the time if you're eating. 

46:22
Jennifer Milner
So what you're saying is that there's no one simple answer to nutrition and fatigue if you're a bendy body, or even if you're not a bendy body. And we often walk into these conversations saying, please just give me the three bullet points that I can walk away and feel like I'm doing something better about my nutrition when I do those three things. And I love that you've given us concrete things that we can do here, but you're also reminding us once again that so much of this is not something that we should be doing under the advice and guidance of Facebook or whatever social media platform we are existing on. So as we remember, everybody, that it is not a one size fits all opportunity or issue here. If we are really having an issue, we should be trying to find someone to help us manage our nutrition if we can. 

47:19
Jennifer Milner
Right? And so if someone is going, oh, my gosh, this is overwhelming, I do not realize I need to make some changes. Fortunately, now we have the World Wide Web, and so you can find someone who is experienced in your area who may not literally live in your area. And that's one of the benefits of being out there. Kristen, I could pick your brain all day because you have such a wealth of information on this topic. Is there anything that we did not cover that you wanted to make sure we touched on real quick before we leave? 

47:52
Kristen Koskinen
Okay, so I think one thing that is probably going to come up this is a popular one with dancers are quick fixes and the idea of what about energy drinks and know how about that for want to this one I would direct at Dr. Linda. These are stimulants. They're not energy, they're not fuel. And so they are going to have a short term effect. They can be used strategically. They can be an important part of your overall plan. I'm particularly caffeine energy drinks are a different ball of wax, but they're not something you want to lean on and fatigue is a symptom. And if you're using caffeine or caffeinated beverages, that is a band aid over a symptom. You're not getting at the cause of the fatigue and that's what we want to do. Why are you fatigued? It's a symptom, it's not a disease state. 

48:49
Kristen Koskinen
So we want to look, dig deeper, what's going on with you to make that happen? So trying to cover it up with caffeine is typically going to work against you. It's also going to interfere with your sleep, which is going to create momentum in a downward spiral. That isn't going to work for us. 

49:09
Jennifer Milner
As much as we wish that it could. 

49:10
Kristen Koskinen
Right, I know, and I'm not opposed to caffeine. Anyone who's hung out with me for like more than 2 hours. 

49:20
Dr. Linda Bluestein
But we can end up in a cycle, it seems like patients, especially if they once things start I love what you were saying about momentum. I think it's so true. Once things start to go in a certain direction, then we can end up using I mean, I get requests all the time for prescriptions for stimulants and. 

49:35
Kristen Koskinen
I do prescribe them sometimes because I. 

49:37
Dr. Linda Bluestein
Think there are cases where it's appropriate. But you can end up using caffeine during the day to stay awake and then alcohol at night to help you go to sleep. And we know that does not lead to good quality sleep. So then you just are getting up the next day just as fatigued, if not more so. And the alcohol depletes the B vitamins and they both contribute in negative ways. The caffeine stimulating your sympathetic nervous system and so you kind of end up in this vicious cycle where like you said, you need to start doing things that change the momentum in the other direction. 

50:09
Kristen Koskinen
Yeah, absolutely. And how are we using the caffeine? Are you using the caffeine to stay awake? By using the caffeine, are you blunting your appetite and therefore not eating what you need to eat? Starting all of these things are interrelated. This is why it's do we really need to get to the intention of the caffeine? Why are you really using it? We have to ask some tough questions. Is it caffeine? The stimulant helps me to focus. I've got ADHD and if I can have some caffeine then that's different than I'm trying to not fall asleep, then I'm trying to suppress my appetite. So all these things, that's why there is no one answer. Is caffeine bad? Depends. A lot of times it's great. What's the context? Who's the person? You've heard me say this before and it's so to n equals one and even within the same person. 

51:03
Kristen Koskinen
What's your situation now? Are you using it? It can even be situational. 

51:11
Jennifer Milner
Well, just reminding us once again that there are no easy answers. N equals one always makes me think of you. And just keeping in mind, as you said, caffeine might be great in one situation and not great in another. Folic acid might be great in one situation and working against you in another. Which just reminds us again that it's always great to reach out to an expert if you're really trying to get to the bottom of it and not try to figure out your own quick fixes or Band AIDS. So, speaking of reaching out, where could people find you? 

51:42
Kristen Koskinen
Sure. You can reach me on Instagram at Kristen K-R-I-S-T-I-N underscore Koskanan. K-O-S-K-I-N-E-N underscore R-D-N. Those magical letters. You can find me on my website, which is WW dot eatwellprospros.com. Or you can send me an email at kristen kristin at eatwellpros.com. Or with bendy bodies. 

52:17
Jennifer Milner
Or with Bendy Bodies, because we love having you on Team Bendy Bodies. And I will say, and I know Dr. Bluestein feels the same way, we love your Instagram posts. You know, I am constantly stealing whatever recipes you put up there so I can make them myself. But you give such great information in really small, easy to understand ways, and so if people don't follow you, they should follow you because it's great. 

52:41
Kristen Koskinen
It's great information and hopefully people will. 

52:44
Dr. Linda Bluestein
Take away from this, although there's no one single fix to understand that if you are having problems, that having an RDN as part of your team is essential and can really make the difference between success and lack of success. 

53:00
Kristen Koskinen
Yeah, it is. It's that idea of, I'm going to have the eyes to come in and maybe pinpoint something that seems off the wall, but I've seen stuff and it's like, oh, let's start here. You want to start here? But how about we start may and that may be the turning point. 

53:19
Jennifer Milner
And that's all it takes, is that one pivot point. 

53:22
Kristen Koskinen
That's what we like. 

53:23
Jennifer Milner
Yep. Well, you have been listening to Bendy Bodies with the Hypermobility MD, and today we have been speaking with Kristen Koskinen RDN. Kristen, thank you so much for sharing your expertise with us again today and for being such a big part of Team Bendy Bodies. 

53:39
Kristen Koskinen
Thank you, ladies. It is always my pleasure. 

53:41
Dr. Linda Bluestein
Great chatting with you. 

53:43
Dr. Linda Bluestein
Thank you for joining us for this episode of Bendy Bodies with the Hypermobility MD, where we explore the intersection of health and hypermobility for dancers and other aesthetic athletes. If you found this information valuable, please share it with a colleague or friend and leave us a review on your favorite podcast player. Remember to subscribe so you won't miss future episodes. If you want to follow us on Instagram, it's at bendy underscore Bodies and our website is WW bendibodies.org. If you want to follow Bendy Bodies founder and cohost Dr. Bluestein on Instagram, it's at hypermobilitymd all one word. And her website is WW dot hypermobilitymd.com. If you want to follow cohost Jennifer Milner on Instagram, it's at jenniferperiodmillner Milner and her website is www.jennifermillner.com. Thank you for helping us spread the word about hypermobility and associated conditions. We want to hear from you. Please email us at info@bendybodies.org to share feedback. 

54:53
Dr. Linda Bluestein
The thoughts and opinions expressed on this podcast are solely of the cohost and their guests. They do not necessarily represent the views and opinions of any organization. The thoughts and opinions do not constitute medical advice and should not be used in any legal capacity whatsoever. This information is not intended to diagnose, treat, cure or prevent any disease. As this information is for educational purposes only and is not a substitute for medical advice, diagnosis, or treatment, please refer to your local qualified health practitioner for all medical concerns. We'll catch you next time on The Bendy Bodies podcast.