Gluten: How to determine if you should avoid it

Over the course of the last few years, many people have removed gluten from their diet and noticed dramatic changes in their health.  In response, the food industry has flooded the market with gluten free items ranging from bread to cookies to pasta.  Many people look at this shift to gluten free eating as a fad, but is there something more to it?  Is gluten a problem for everyone, or should some people be more vigilant than others?  Let's take a look at gluten and some things you should be on the lookout for to determine if gluten is something you should avoid.

What is gluten?

Gluten is a protein that contains gliadin and is found in certain grains including wheat, barley, and rye.  Gluten is a storage protein, also called a prolamin.  In fact, all grains have prolamins, the reason we know a lot about gluten is because of it's relationship with celiac disease.  When the gliadin found in gluten interacts with the intestinal wall of people with celiac disease, it causes the release of zonulin, a protein that opens up the intestinal wall and allows the contents of the intestine to react with the immune system.  This is called intestinal permeability.  It does this by dissolving tight junctions between cells that seal the contents of the intestine and prevent it's contents from reacting with the immune system.  This is a less than ideal scenario obviously, but should people without celiac disease be concerned?

In addition to celiac disease, there is a condition called non-celiac gluten sensitivity that some people experience.  People with non-celiac gluten sensitivity react to gluten, their reaction just isn't quite as severe as people with celiac disease.  But how common is this?  It's really hard to say.  Even for a concrete condition like celiac disease, it's very difficult to diagnose because different people tend to have different symptoms and lab tests are not currently up to snuff.  While most people with celiac disease have digestive symptoms, not all do(1).  For some people, symptoms can involve rashes and for others symptoms can be neurological.   In addition, the symptoms differ for adults and children.  Since it is so difficult to categorize the symptoms of celiac disease, the less severe reaction seen in non-celiac gluten sensitivity makes it even more difficult to pin down.

Is gluten sensitivity becoming more common?

One of the first things people point out when discussing the rise in celiac disease is that we are simply better at diagnosing it.  A study carried out in 2009 showed that the rise isn't simply a matter of better diagnosis.  Researchers looked at the blood of Air Force personnel collected from 1948 to 1954 and compared it to the recently collected blood of people from Minnesota of similar age to determine if the prevalence of undiagnosed celiac disease has increased or if the increase was simply due to better diagnosis.  The researchers found that the people from Minnesota were more than 4x more likely to have the antibodies associated with celiac disease in their blood than the Air Force personnel(2).  This suggests that there is something else at play other than better diagnosis.

How can you go from not reacting to gluten to having a reaction

One of the more frustrating things about gluten sensitivity is that people can eat gluten for many years without having a problem and then all of a sudden begin reacting to it.  One thing that gets brought up when people feel they may be reacting negatively to gluten is that the condition is new.  How can someone seemingly go from having absolutely no reaction to gluten at all to having one so severe that they can't function normally?  The key to gluten sensitivity, celiac or otherwise, may lie with the trillions of bacteria that reside in your gut, and there is ample evidence to suggest so.


Some research points to gluten being a potential problem for most people.  Eighty percent of humans produce zonulin and intestinal tissue samples from both celiacs and non-celiacs produce zonulin when treated with gluten(3).  The reason people with celiac disease have a more severe reaction than people without celiac disease appears to be because the intestinal permeability related to zonulin lasts much longer in celiacs than non-celiacs.  We know that the beneficial bacteria within the gut ferment plant fibers that we can't digest in to short chained fatty acids that repair the tight junctions between cells of the intestinal wall.  In people with gut dysboisis, the composition of gut bacteria is changed and can lead to digestive problems and there is evidence that people with celiac disease have gut dysbiosis(4).  Perhaps this is one of the reasons that zonulin has a greater effect on people with celiac disease than those without it.

Other factors affecting intestinal wall integrity

Aside from gluten, there is another trigger that causes zonulin to dissolve the tight junctions between cells of the intestinal wall.  When bacteria overgrow from the large intestine in to the small intestine, or when pathogenic bacteria overpopulate and beneficial ones underpopulate, zonulin opens up the tight junctions to pull water in to the intestine to flush the pathogenic bacteria out.  A recent article in the NY Times went through quite a bit of the current theories on celiac disease and a change in gut bacteria is right up at the forefront.  Not only can it impact a person's ability to re-seal the tight junctions, but it can compound the effect zonulin has on intestinal permeablity. 

Zonulin is not the only thing that causes a problem in the intestinal wall, inflammation also causes the integrity of the intestinal barrier to be compromised.  Obese people tend to have increased levels of inflammation as well as a population of gut bacteria that make this inflammation worse.  They also tend to have higher levels of zonulin circulating in their blood(5).  There have been many studies in mice showing that simply giving the bacteria of lean mice to obese mice not only made the obese mice lean, it also decreased systemic inflammation.  This effect is also dependent on diet(6).  Obese mice who eat a diet low in vegetable fiber don't get the benefits from ingesting the bacteria from the lean mice.  In the future, fecal transplants may be capable of putting a person with celiac disease in to remission, allowing them to eat wheat with no problem,  but we aren't there yet and it would still require a change in diet.  Of the factors that a person can manipulate, diet is currently the best option.

What to be on the lookout for

As mentioned above, a diet low in soluble fiber from fruits and vegetables can cause gut dysbiosis over a long period of time.  Frequent use of antibiotics, currently or in the past, also can have an affect.  In addition, other factors out of your control can increase your likelihood of becoming sensitive to gluten through changes in gut bacteria.  Being born by C-section and not being breastfed increase a person's likelihood of gut dysbiosis later in life, so people who satisfy either or both conditions should be vigilant and consume a diet high in vegetables.  In addition, if your mother was obese she could have passed on her less than ideal gut bacteria to you in the event you were born vaginally.

Other conditions associated with intestinal permeability and, therefore, linked to gluten sensitivity include most autoimmune diseases including asthma, rheumatoid arthritis, Type 1 diabetes, Lupus, seasonal allergies, and multiple sclerosis.  It is theorized that one of the conditions underlying all autoimmune diseases is intestinal permeability so removing gluten is prudent if you have one of these conditions.  In addition to autoimmune disorders, people with irritable bowel syndrome/disorders should also avoid gluten due to high levels of intestinal inflammation and potential gut dysbiosis.

Type 2 diabetes and obesity are associated with higher levels of inflammation and zonulin and could also be related to gluten sensitivity.  Since zonulin also regulates the tight junctions of the blood brain barrier and the lungs(7), people with a family history of Alzheimer's disease or who have frequent respiratory infections should probably limit their exposure to gluten.  Finally, high stress levels as well as increased age are related to changes in both gut bacteria as well as immune system function and may impact a person's sensitivity to gluten.  A recent study showed smoking cessation can lead to the same changes in gut bacteria that is associated with obesity(8), so if you plan on quitting smoking it may be a good idea to limit gluten exposure during this time,

While this is certainly quite a list of possible issues that gluten sensitivity can contribute to, the treatment is the same: Remove gluten and consume more vegetables.  Note that the solution isn't to start consuming gluten free snacks, as they will only contribute to gut dysbiosis by not providing soluble fibes for the good bacteria in your gut to ferment.  While probiotics are also an attractive option, there is no point in taking them unless you are eating foods that will support their proliferation in your gut.  In time, I believe quite a few people who are sensitive to gluten can tolerate it once they re-establish the proper balance of bacteria in their gut.  For some people this will be easier than others depending on which other foods they are sensitive to and how much damage they have caused.

Health Research Recap (10/21/2013-10/27/2013)

Alzheimer's/Brain

In Alzheimer's research, researchers found an association between poor sleep duration/quality and an increase in beta-amyloid plaque burden in subjects with a mean age of 76.

In a study on mice, researchers found a possible link between why quality sleep may improve brain function and why poor sleep may increase the amount of plaques in Alzheimer's patients.  The study found that, in sleeping mice, the clean up system of the brain went in to overdrive and removed toxins that are a natural byproduct of brain cell use, including beta amyloid plaque.  During sleep, the cells even shrink to make it easier to clean up the spaces between cells. 

Another link between sleep quality and brain function may be mediated through the immune system.  Researchers restricted the sleep of young healthy men to 4 hours for 5 nights and measured gene expression.  They found an increase in the activity of genes associated with producing antigens and inflammation as well as a host of other immune system related genes.

Another study found a link between high blood glucose and memory function.  What is interesting about this study is that people with blood glucose levels that would be considered within the normal range but at the higher end were associated with poorer performance on a memory test as well as reduced size of the hippocampus.  This confirms a previous study that also found a relationship between high blood glucose and hippocampal volume.  The hippocampus plays a crucial role in memory, and this research can link back to the studies on Alzheimer's and sleep as poor sleep duration and quality are both linked to poor blood glucose control.


Also in Alzheimer's news, researchers found a link between a gene associated with Alzheimer's and an "anti-aging" gene targeted by reseveratrol, the powerful antioxidant found in red wine. While this doesn't mean that drinking tons of red wine or taking resveratrol will prevent Alzheimer's, it gives us a look at a potentially interesting mechanism of the disease.

In more brain news, researchers found an association between teens who regularly exercised moderately to vigorously and better brain performance.  Researchers in the UK used an accelerometer to measure daily movement characteristics and compared those to performance in Math, Science, and English.  The effect of regular intense exercise at age 11 was associated with better performance in all 3 subjects.  At age 13, 15, and 16, academic performance was associated with the amount of intense exercise the child had at age 11.  There was a dose-response meaning that the more intense exercise a child partook in, the greater the benefits.  The benefit appeared to be boost girls science performance the most.

Obesity

Here's another good reason to dine out with people with good dietary habits.  A study found that people tended to order the same food choices at restaurants when they state their choices out loud.  The study used 3 different menu types with differing types of information (No info, calorie counts, calorie counts and a traffic light green:400cals or less, yellow:401-800 cals, red:>800 cals).  The study found that eaters were happier when they ate the same foods as others in their group, regardless of their initial percepton of the food item.  Previous studies have shown that when people don't order aloud, they just get what they want.

In obesity news, researchers found a transgenerational effect of DDT exposure to mice and obesity in mice 3 generations later.  Researchers injected pregnant rats with DDT and followed them for multiple generations.  While the pregnant rat, her offspring, and her offspring's offspring showed no signs of obesity.  However, the more than half of the great grandchildren of the exposed mouse were obese.  Michael Skinner, the lead researcher, has found similar effects in other environmental pollutants including other pesticides and BPA, but the effect of DDT was far greater.  The effects are due to epigenetics, the silencing and activating of certain genes due to enviromental factors.  Often times, these epigenetic changes can be forced on future generations through lifestyle choices or exposures that occur in older generations long before the affected are born.

The Gut/Bacteria

In gut news, researchers found that obesity may increase the risk of C. Difficile infection.  This study backs up an earlier study this year that found the same relationship.  While this relationship is very interesting, what is more interesting is why this study came about.  The amount of C. Difficile infections has more than doubled from 139,000 to 336,600 over the past 10 years, and physicians are seeing people with C. Difficile infection that do not have the traditional risk factors (being in a hospital, lowered immunity, antiobiotic exposure).  What may be the culprit?  A change in gut bugs.  Both obesity and C. Difficile infection are related to an increased Firmicutes/Bacteroidetes ratio.

Finally, in the "Gross, you shoulda brushed" category, researchers found that the bacteria in people's mouth create a fingerprint that could predict a person's ethnicity.  In addition, no 2 people had the same bacterial make up.  What is even more interesting is that, despite common nutritional and environmental exposure over many generations, African Americans and white Americans had different oral bacteria "fingerprints".

Why applying an evolutionary approach to health is necessary

When most people decide they want to take charge of their life and undertake a wellness program, they typically begin by cutting calories and exercising a few times a week to help burn calories.  This paradigm seems as American as apple pie to me, and I followed it for most of my life until I came upon a much better approach.  The evolutionary approach to health and wellness satisfied me in a way that the standard protocol failed to do so.  Not only did it make sense on a logical level, it seemed to guide me to much better results than I was seeing parroting the approach everyone else seemed hellbent on using.  But why does the evolutionary approach seem to work so well?  Let's take a look at why an evolutionary approach to health and wellness is a great way to guide lifestyle choices.

Why nutrition research is flawed

If you're like most people, you probably get dizzy with how quickly science seems to change.  One day coffee is bad for you, the next day it is good, a week later it's bad again.  The reason the nutritional science seems to change so quickly is because people are using the data incorrectly.  The vast majority of nutritional research is a type of research called epidemiological research.  Epidemiological research is a type of research that identifies relationships between variables, but can't be used to come to conclusions on what causes what.  What this means is that the conclusions in epidemiological research can be used to say that there is a relationship between A and B, but it can't say that A causes B or B causes A.  This is because this type of research doesn't do a good job of controlling for other variables, called confounders, that could impact the results.  So while A and B may have a relationship between one another, there could be a third variable C that is also related to A and B that is actually driving the change.

Let's look at an example.  Many people have heard how healthy whole grains are, and it comes from this very type of research.  However, there are a number of confounders that these studies fail to control.  Certainly diet isn't the only factor in how healthy you are.  Physical activity, not smoking, managing stress, and getting quality sleep all have an impact on health, and these studies don't control for these things.  Since we've been told, prematurely must add, that grains are a part of a healthy diet, people who are interested in health would tend to flock towards them.  Healthy people also tend to exercise, get quality sleep, limit alcohol consumption, and avoid smoking.

Also, in an attempt to torture the data until it tells them what they want to hear, researchers often perform statistical analyses to tease out these confounders so that they can come to conclusions.  However, if I wanted to "tease out" what percentage of a dead person's coronary blockage was from a lack of physical activity and which percentage was from smoking, I couldn't do that reliably.  Even if I cut them open and looked directly at their blockage, I couldn't tell what percentage came from which poor lifestyle decision.  So how certain are we that the mathematical models these scientists use are valid?

This isn't to say that this data is useless, the point of epidemiological research is to help generate hypotheses for stronger research that does control confounders.  The problem is, that's not how it gets reported, and the popular press often draws conclusions from research that can't be used to draw definitive conclusions.  Another problem is that research is expensive and the only way you could run a proper experiment and draw conclusions from it would be to take a group of people, lock them in a metabolic ward for 3-6 months, and control every aspect of their life.  Very few people would be willing to do that.  Even then, what if the poor health outcomes take years to develop?

Why an evolutionary approach is necessary

An evolutionary approach to health and wellness is better than just using epidemiological data for a couple of reasons.  First and foremost, it starts the discussion closer to the beginning.  As much as it pains people to hear, nutrition research didn't start 100 years ago.  Long before we were filling out questionnaires on what foods we were eating and measuring how healthy we were, traditional cultures were observing how food affected their people over the course of thousands of years.

For example, most traditional cultures prepared grains and legumes by first soaking them for 24-48 hours.  They obviously did this for a reason, if these foods were health promoting in their natural form why make all of the extra work?  When we look at what this process does, it makes sense.  These foods contain anti-nutrients that bind minerals found in them and make them unable to be absorbed from the intestine.  Soaking them removes some of these anti-nutrients.  If your goal is survival in an environment where food is scarce and you need to expend a lot of energy to get it, it doesn't make sense to gather food that isn't going to give you what you need to survive.

What is even more astonishing about this process is that these people didn't even know what minerals were, they just knew the outcome of eating these foods in different forms and chose the best option.  So why did we stop doing this?  For some reason we chose to ignore thousands of years of observational experience just because there wasn't a randomized clinical trial showing it's effectiveness.  However, there was never a randomized clinical trial showing bread to be healthy to eat, but it is a large part of most people's diet regardless.

Another reason an evolutionary approach to health is beneficial is that it gives you another tool in your tool chest.  Just because you choose to look at things from an evolutionary perspective doesn't mean you can't also look at it from a different perspective as well.  In fact, you should look at health from as many perspectives as possible to come to your conclusions.  You should use the nutritional sciences, biological/evolutionary sciences, physical sciences, and any other science that you can.  Any time you can use multiple areas of research to formulate a conclusion you should.


Finally, an evolutionary approach to health is effective because evolution is the guiding tenet of biology, the science of life.  Every science dealing with health is based on biology.  Since biological functions are driven by evolution by natural selection, most decisions within biology should take evolution in to account.  This includes health, weight loss, and anything you imagine any human does on a day to day basis.  Not using evolution to help guide health is like being a pilot and flying a plane without using the principles of flight.

We know that the environment has shaped who we are, and looking at how that environment has changed and how we interact differently with our environment can give us many clues as to what is the best environment (Food-wise, activity-wise, environmental condition-wise, etc.) for optimal health.  We know processed foods were not the norm.  We know regular physical activity throughout the day was the norm.  We know regular light and dark cycles coinciding with being awake during the day and asleep during the night were the norm.  We know that none of these things appear to be the norm for most people today.

As you look at research in all of these fields, there is nothing but support for the way our environment shapes who we are and contributes to our overall health.  We know shift-workers and people who don't sleep well tend to be prone to Type 2 diabetes.  We know sitting all day long leads to a host of health problems.  In many ways we have found workarounds that may or may not be suitable.  We know Vitamin D3 is vital to our physiology, so people often take D3 supplements.  Whether or not this is a suitable replacement for getting D3 directly from the Sun is something we don't know, so why not try to approximate the conditions by which we seem to be engineered to get Vitamin D3?  Is it that difficult to get out in to the sun for 30-40 minutes a day?  In certain climates, D3 is unavailable from the Sun during certain times of the year so there is likely a benefit to supplementing during these times.

Conclusion

Using many perspectives to guide lifestyle, including an evolutionary one, is a winning strategy.  Using as much of the science that is available will help narrow down conflicting data and drive you in the right direction where data is not available.  This is one of the primary failings in nutritional research, no college level programs incorporate these principles in their coursework.  There are many logical fallacies that people make when they take a narrow approach to health.  On one end, many people who only use an evolutionary perspective make a naturalistic fallacy that all things natural and in their normal form are healthy.  There are many natural things that are unhealthy, many poisonous mushrooms, berries, and plants that will kill us if we eat them.  Just because something is in it's natural form doesn't mean it is a healthy choice.

On the other end you have what I call the legacy fallacy, since we've always done it that way it's fine to do it that way.  An example of this is people who defend the consumption of a food product just because we have been consuming it regularly during our recent past.  Unless there are well controlled clinical trials showing it to be healthy, we have no idea whether something is healthy or not.  It also works both ways, just because we haven't consumed a food doesn't mean we can't consume that food or that consuming it is unhealthy.  Looking at things from multiple perspectives will help you avoid these fallacies and drive you to better health decisions.

Are you thriving or just surviving? My thought process behind assessing overall health.

When I first sit down with clients, I try to get a feel of what is going on in their life.  Whether the client is there to lose some weight, improve pain, or just feel better overall, I find it useful to get an overall picture of how their health is doing compared to what I consider ideal.  With most of the clients I see, I break the body down in to 3 primary systems; metabolic, adrenal/stress, and digestive and try to determine where people are doing things that can muck these systems up.  This process helps me determine the right protocol to help each person achieve their goals.  Below is my thought process in assessing each system.

Medications

Before I delve in to people's lifestyle, it is important to get an idea of which medications they are taking.  Not only will this give me an idea of which systems are failing, but it also tells me a lot about what I am likely to find going further and helps direct my line of questioning.  This is a very important step as it begins to establish buy-in with the client.  Most people are still stuck in the genetic determinism mindset where they believe their genes pretty much determine their health.  Sure, they may believe that lifestyle changes can help a little bit, but for the most part they believe they need their medication.  That is not to say that medicine isn't necessary, under certain situations it is a life saver.  However, I find them overused when taken chronically to regulate something like blood pressure and/or blood glucose.  Below is a sample line of questioning I may use with a client during an initial assessment.

"So you take metformin to help regulate your blood sugar, and your fasting glucose is normally between 100-120.  Would you consider your job stressful or do you feel anxious at times?  Would you say you have no trouble falling asleep and get a good 8 hours of sleep every night?  Are you having any troubles with digestion?"

Normally, people are on multiple medications which pretty much drives the questioning as to which systems are failing.  What could they be doing in their everyday life that would give them anxiety?  Do they get enough regular physical activity?  Are they even attempting to manage their stress?  Are the foods they're eating right for them?  Most people take 1 medicine for every decade they've been alive, so when I get a 45 year old woman who's taking 4 medications, I get a pretty clear picture of where I have to go simply from asking them about the medicine they take.  When you can direct your line of questioning in a way that makes the client go, "How did you know that?", they start drinking the sugar-free Kool-aid and begin to believe that a lifestyle intervention will help.

Metabolic System

When assessing the metabolic system, I look at 3 primary things: blood glucose, appetite, and energy levels.  I like to see fasting blood glucose around 90mg/dL, no snacking between meals, and constant energy levels.  In addition, if they are willing to test, I like to see blood glucose remain below 130mg/dL 1 hour after a meal and back to fasting within 2-3 hours.  Normally I see people whose fasting glucose is over 100mg/dL and need to eat every 3 hours or they feel an energy crash.  This is indicative of being broken metabolically and requires significant lifestyle change.  It also tends to mean their digestive barrier is compromised and as a result their adrenal/stress system is thrown out of whack.

Typical signs and symptoms of a broken metabolic system: Uneven energy levels, feeling tired after meals high in carbohydrate, irritability, anxiety, poor sleep, profuse sweating, high blood glucose, never feeling full after meals.

Adrenal/Stress System

We all experience stress on an ongoing basis.  When you combine what goes on in your life with what goes on in your job, we are pretty much bombarded by stress 24/7.  Our adrenal system is not meant to be under a constant barrage of stress, we are meant to experience stress and then have it resolved relatively quickly.  Like it or not, this is the world we live in so we need tools to manage it.  Probably the best way to manage stress is to take it head on.  Rather than letting things fester until the last minute, resolve as much stress as you can right away.  If you forget to pay bills, sign up for autopay and have them taken directly out of your bank account on the day you get paid.  If you need to arrange a ride for your daughter because you have to work late, take care of that immediately.  These things sound pretty self-explanatory, but most people who have problems with this kind of stuff just don't do them.

Another thing that helps regulate the adrenal system is physical activity and exercise.  If you wake up every day, take a 30 minute commute to work, get to your desk and sit for 8 hours, then go home and sit down and watch TV, you have caged animal disease.  Caged animal disease is a term I made up for what you typically see in high energy dogs who are kept in their cage all day long.  When they get out they go nuts and tear through the house.  Humans, like dogs, need lots of physical activity, and when they aren't getting it the first place it shows up is in higher levels of stress and anxiety.  This will also affect their ability to sleep, their digestion, and their metabolism.  Most people's exercise program should be predominantly walking, a little strength training, and some form of relaxation exercise such as stretching, yoga, tai chi, or meditation.

Typical signs and symptoms of a broken adrenal/stress system: Poorly regulated blood glucose(High or low), an inability to concentrate, poor digestion, joint pain, poor sleep, feeling wired but tired, low energy, anxiety/depression, relying on coffee for am energy, feeling tired when awaking but wide awake when trying to fall asleep at night..

Digestive/Immune System

Most people don't associate their immune system with their digestive system, but 80% of your immune system is housed in your gut.  Since your gut is the primary barrier through which the outside environment communicates with your internal environment, this is the best place for your immune system to reside.  The problem is, since your immune system is housed in your gut, eating things that aren't right for you can cause major problems with nearly every aspect of your life.

The digestive system is so important that regardless of what I find elsewhere during the assessment, treatment begins in the gut.  In order to have a properly working metabolic or adrenal system, you need the nutrients that these systems run on to make it in to the bloodstream.  If you have a compromised gut, this doesn't happen.  You may be eating all of the nutrients you need, but if they don't enter the blood they don't do their job.  This is why I am a big pusher of the Paleo diet.  Not only is it high in nutrients, it's also high in prebiotics that help maintain a healthy gut.  In certain situations the Paleo diet isn't enough and people with major digestive problems may need to try a specific carbohydrate or GAPS diet.

Typical signs and symptoms of a broken digestive/immune system: Gas/bloating, poor sleep, anxiety/depression, poor energy, high blood glucose, increased appetite, skin conditions, headaches, food intolerances, allergies, constipation, diarrhea.

Conclusion

As you can tell by the common signs and symptoms, there is a lot of overlap between these systems.  In addition, other systems such as the neuromuscular and detoxification system can also be involved.  This is because each system doesn't act in a vacuum, they are all dependent on the other systems doing their job.  In some instances you can find a clear smoking gun, but in most cases there is typically a few things going on that contribute to poor health.  One thing that I am sure to make clear up front is that positive outcomes are not going to be quick.  Most people like the idea of being able to take a little pill and have their problem resolved within a few hours or days.  The problem is, that pill typically isn't solving the problem.  Typically, they simply mask a symptom that is telling you that one of these 3 systems, or another, isn't working properly.  For optimal health, your best bet is to fix the system rather than mask the symptom.

The walking dead: Is American agricultural policy creating a legion of zombies that will eventually break the bank?

When most people hear the term "the walking dead", it conjures up the image of zombies running amuck in a post-apocalyptic world.  Legions of the brain dead undead doing the Frankenstein and looking to devour the brains of any live person within their grasp.  However, many of us know a different type of walking dead, one whose transition is far slower.  It may begin in their late 40s or early 50s as they lose track of where they put things or misremember things that have happened in their past.  Slowly but surely the zombification progresses until they no longer remember friends and family, eventually losing the ability to express themselves, understand a conversation, or even respond to the environment.  The walking dead I am referring to are people going through dementia and/or Alzheimer's disease.

While there is an enormous emotional price to having a loved one with dementia or Alzhemier's disease that can't be quantified, there is also an enormous price tag to go along with it.  In 2013 alone, the direct costs of Alzheimer's disease in the US was $203 billion and is expected to balloon up to $1.2 trillion per year by 2050(1).  Not included in this number is the unpaid care that family give to people with Alzheimer's disease, estimated to be $216 billion in 2012. 

Many people associate dementia and Alzheimer's as being a normal part of aging.  While it is true that Alzheimer's progresses with age, it is certainly not a normal part of aging.  With Alzheimer's comes structural changes within the brain, an accumulation of beta amyloid plaques and tangles in a protein called tau that interfere with normal brain function.  While these plaques and tangles tend to accumulate in everyone as they age, they accumulate to a far greater extent and in a consistent pattern in people with Alzheimer's disease.  Furthermore, quite a bit of research has recently pointed to dementia and Alzheimer's disease as autoimmune diseases.  This is evidenced by high levels of cells of the immune system called immunoglobulins(2) and other immune system proteins(3) in the brains of people with varying degrees of dementia, including Alzheimer's disease.

The brain is meant to be a sanctuary from immune activity.  The blood brain barrier prevents large particles such as bacteria and antibodies from entering the brain and causing problems.  Within the blood brain barrier are proteins called tight junctions that seal off the area and help regulate what can or cannot enter the brain.  These tight junctions are dissolved by a protein called zonulin(4, 5).  What makes this interesting is the fact that both the lungs and the gut also contain tight junctions, and zonulin has the same effect on the tight junctions in those tissues as well.  Intestinal permeability occurs when the tight junctions between cells of the intestine fail to prevent large particles from entering the blodstream.  It is believed that this is due to zonulin dissolving the tight junction.  Making this an even more intriguing relationship is that intestinal permeability appears to be a necessary component of many, if not most, autoimmune diseases(6, 7).

A recent study comparing the postmortem brains of people with Alzheimer's disease to healthy controls found the presence of an oral bacteria known to cause periodontal disease in 4 out of the 10 brains of people with Alzheimer's disease and none in the controls(8).  Many look at this as evidence of there being a link between periodontal disease and Alzheimer's disease, but if it were a direct link all of the samples of brain tissue from people with Alzheimer's would have it.  However, in a person with a properly working blood brain barrier, this bacteria should not have access to the brain.  This study supports the notion that a poorly functioning blood brain barrier is a significant causative factor in Alzheimer's disease.  Could this be the result of zonulin dissolving the tight junctions?  We don't know for sure, but there is ample reason to suggest so.

Many people are aware of gluten.  All you have to do is walk in to any grocery store and you get bombarded with gluten free this, or gluten free that.  While many people go gluten free, many have no idea what gluten is or why they are going gluten free.  One of the few groups who do know what gluten is are people with celiac disease.  Celiac disease is an autoimmune disorder that affects the intestinal lining.  When someone with celiac disease eats gluten or any other grain containing gliadin, damage occurs to their intestinal tract that causes pain and discomfort as well as malabsorption of nutrients.  This can eventually put them in a malnourished state.  Part of this response is due to the release of zonulin, which occurs when gliadin interacts with the intestinal wall and causes intestinal permeability..

However, in a study looking at the intestinal tissue of people with celiac disease and people without celiac disease, zonulin appears to be released in both scenarios, albeit for 30 times longer in people with celiac disease(9).  It appears that gut bacteria may have a big role in this as people with celiac disease have different gut bacteria than healthy people, and gut bacteria heal the tight junctions when they ferment soluble fiber and resistant starch in to butyric acid.  It is important to point out that these tissue samples were removed from people and then treated with zonulin, and were not tested in a living person.

So we have a potential mechanism for Alzheimer's disease where gluten is ingested and interacts with the cells of the intestine causing zonulin release that dissolves the tight junctions there as well as in the blood brain barrier.  This allows particles, including inflammatory ones, that shouldn't be in the brain to cross the blood brain barrier and react with structures within the brain.  This doesn't necessarily mean that anyone who experiences intestinal permeability will experience Alzheimer's disease, there are far too many factors to take in to consideration.  However, I tend to think that people can realize that the blood brain barrier is there for a reason.  Compromising the blood brain barrier is a bad idea whether you are genetically prone to Alzheimer's disease or not.  One of the problems is you wouldn't know if this was happening or not, there are no pain receptors in the brain so inflammation doesn't typically show up as pain, it shows up slowly as brain dysfunction over time.  Furthermore, inflammation compromises the blood brain barrier further.

So what role does American agricultural policy play in this mess?  It's very simple.  Every year the federal government gives subsidies to "farmers" to grow wheat.  I put farmers in quotation marks because most of the people receiving these subsidies are not family farmers, they are large corporations that do farming.  The USDA, a lobbying group for these corporate farmers, lobbies the federal government to get these subsidies and then distributes the money to farmers.  From 1995-2012, farm subsidies for wheat alone were $35.5 billion(10).  This is the reason it's cheaper to buy bread than it is to buy fruits and vegetables.  Most people assume it's because bread is cheaper to grow, but this is only the case if you are subsidizing it's production.

This seems innocent enough, the purpose of most lobbying groups is to lobby the federal government for the organizations they represent.  However, the USDA has another role.  Many of you are familiar with the Food Pyramid/MyPlate which dictates which foods you should be eating regularly.  The problem is that it's not written by a bunch of doctors commissioned to make Americans healthy.  It's written by the USDA, a trade group that helps determine which foods can be easily produced and which ones are most profitable.  There was no grand experiment decades ago to help determine the foods that are fit for human consumption and then translated in to a set of ground rules for healthy human eating.  The USDA stated what could be made and that became the contents of the Food Pyramid, which most people assume are a set of healthy eating rules.  To make maters worse, physicians and nutritionists in the healthcare industry push these rules as if that is exactly what they are.

The problem doesn't end there.  As many of you know, much of the nutritional research to date has shown grains, especially wheat, to be a healthy food option that leads to positive health outcomes.  However, this research is tainted because they essentially told everyone that grains are a healthy food choice without having the research to back it up.  If you tell a group of people that a certain food product is healthy, which people do you think are going to consume that product?  Typically, you are going to get people who are interested in being healthy.  This means they are interested in doing other healthy things like exercising, not smoking, getting quality sleep, and a host of other healthy lifestyle choices.  This throws off the research because on one side you have people who are doing everything right and on the other side you have people doing everything wrong.  If the side doing everything right is told that they should be eating grains and they do, it's not scientifically valid to compare the 2 groups.

As you can see, there is much to be frustrated about with the way we determine which foods people should eat.  When you make foods cheap, you make them more appealing to people and increase the likelihood that people will consume them.  This drives people to make the wrong choices, especially poor people who are on a limited income.  What people don't realize is that these foods really aren't cheap when you factor in the tax dollars needed to subsidize them and the potential health ramifications they can cause before they are adequately tested.  Grains, especially wheat, may be costing us money up front in the form of tax dollars as well as on the back end with the emotional and financial costs associated with Alzheimer's disease.  Many people will read this statement and say that there is no research that supports this notion.  However, just because there is no research directly linking the consumption of grains with Alzheimer's disease doesn't mean it's not true.  At one time the "research" pointed to the Earth being flat, that doesn't mean it was flat until the research showed it to be round.

Why Paleo? Endurance athlete edition

Call it Paleo, call it Primal, for the most part you see many in either lifestyle poo-pooing endurance activities as unnecessary.  Personally, I don't do endurance type activities because I really don't like doing them.  Perhaps if I was better suited to doing them I would, but I am not.  I also don't recommend clients do them unless they like to do them.  More than any other criteria, your physical activity should be something you like to do, that way you do it often.  However, I feel the Paleo and Primal crowds aren't using very good logic when they say endurance exercise is unnecessary.  Is slamming in to a 300lbs lineman necessary?  Is lifting weights at an explosive pace with terrible form necessary?  For the most part, any sort of physical activity that doesn't involve you trying to attain food or procreate is unnecessary, so why try to exclude a group just because their mode of exercise isn't your cup of tea?  Let's take a look at how the benefits of a Paleo diet translate in to performance benefits for endurance athletes.

Many people are confused with what a Paleo diet is and what it can do for them.  Part of this can be blamed on the original message insinuating that if a food wasn't consumed regularly by your ancestors then it wasn't good for you and part of it can be blamed on people currently pushing Paleo that don't really know why it works.  Paleo does not mean that any food or environmental factor that has come in the last X number of years is necessarily harmful, there are many examples to the contrary.  Olive oil and broccoli are relatively new and are great for health as evidenced by the ample clinical research supporting both.

One of the biggest examples occurred millions of years ago when some of our herbivorous ancestors climbed out of the trees and began scavenging on the DHA rich carcasses left by carnivorous land animals.  Organ meats rich in DHA provided a nutrient that is vital for human brain development, and is potentially one of the primary reasons we branched away from other primates and developed a much better brain.  If this had never happened, certainly it would be seen as missing out on something that was a complete game changer for life on the planet.

However, on the flip side, many critics also create a logical fallacy.  The fallacy on the other side of the fence is that since we have been eating something for the last 30,000 or so years that it is a healthy food.  Look at the diseases killing humans today: Diabetes, heart disease, cancer, and Alzheimer's disease to name a few.  Few of these diseases affect younger people, they are called chronic diseases of aging because you get them in your 40s, 50s, and beyond.  Since these diseases don't typically affect your ability to reproduce and don't kill you before you can reproduce, you can't logically assume they are healthy unless your goal in life is to live to the age of 30, have 3 kids, and then die.

So then why should you be eating a Paleo diet?  Let's take a look at the primary reasons, the proteins in grains, legumes, and dairy.  The proteins in grains(1), legumes and dairy are immunogenic, meaning they elicit an immune response.  In a healthy person without celiac disease this doesn't mean they are necessarily toxic.  Look at hay fever.  Pollen isn't toxic, it just elicits an immune response that gives you itchy eyes, causes you to sneeze and cough, and gives a headache.  Does that mean not being able to see or constantly sneezing is something you want to do all day long?  It would certainly affect your performance.  Ironically, seasonal allergies as well as most other autoimmune diseases are linked to intestinal permeability(2) and many resolve on a Paleo diet.

However, therein lies the problem with the immune response to the proteins in grains, legumes, and dairy; the symptoms can range from headaches to gastrointestinal flares to metabolic dysfunction and can affect any system in the body.  In fact, a lot of people have no idea they have this response until they completely remove them from the diet for a couple of months because their body has become adapted to the constant firing of the immune system and the low grade inflammation accompanying it.  However, there are quantifiable things going on in your body that you may not be aware of.

When these proteins interact with the intestinal wall, they can cause intestinal permeability.  Intestinal permeability is a fancy way of saying that your gut is leaking it's contents in to your bloodstream.  By releasing a protein called zonulin, proteins found in grains, legumes, and dairy(Especially gluten) may dissolve the tight junctions between the cells that separate the contents of your digestive tract from your blood.  This process is well known in people with celiac disease, but studies on intestinal tissue taken from healthy people indicates that it may happen in everyone who consumes gluten, it just takes longer to repair in people with celiac disease(3).  In addition, zonulin is known to regulate the tight junctions in the lungs(4, ) and blood brain barrier(5).  Since zonulin from the gut enters the circulation, this means it is free to interact with the tight junctions in these areas, potentially compromising brain and lung function by increasing their permeability to toxins.

This can lead to some pretty serious performance consequences.  Obviously poor brain or lung function will have a big impact on performance in endurance sports.  An increase in airway infections will also negatively impact training.  However, one of the bigger impacts has to do with glucose utilization and insulin sensitivity.

Lipopolysaccharide(LPS) is a component of the cell membranes of bacteria found in your gut.  When it enters your bloodstream, your body sense it is under attack.  As a result, your immune system fires off and produces inflammation that signals your muscle and fat tissue to become insulin resistant.  This spares glucose for the immune system to fight off the attacker, which isn't even really there.  In addition, your immune system signals your liver to start dumping glucose in to the blood to help provide more glucose to the immune system.  This is one of the reasons fasting blood glucose is high in diabetics, even if they haven't been eating carbohydrates.

Now think about that from an endurance performance perspective.  You train hard which empties out your glycogen stores and burns some fat, but when you recover and eat some carbohydrate from grains you fire off the immune system.  This causes your immune system to consume some of the carbohydrate you take in to fight off the infection caused by what you are eating.  In addition, your muscles and fat tissue become insulin resistant so they aren't getting the energy they need to get ready for your next training session until the immune system clears the mess you created with what you chose to eat.  Maybe performance isn't affected immediately because you consume so many carbohydrates, but over time you are causing progressively more damage to your digestive tract and metabolism by consuming more grains.  Couple that with the fact that you are training hard which will compromise your immune system further.  Also, if your liver is constantly called upon to pump glucose in to your bloodstream, cortisol may increase due to gluconeogenesis.  I think all of these issues warrant some attention from the endurance sport crowd given how hard they train and how many events they participate in annually.

Before I go, let me preface what I say with a caveat.  We are all different, each and every one of us.  Some of us may be able to eat dairy, some may not.  Some of us may be able to eat a lot of grains, some of us a few, some of us none at all.  Unless there has been a 2-3 month period in your life where you've completely abstained from grains, legumes, and dairy you have no idea whether or not they are affecting your health and/or performance.  That's why you should just give it a try, replace grains with dextrose, potatoes, or other tubers.  If you or anyone in your family has Type 2 diabetes, heart disease, get frequent respiratory infections, or experience any form of autoimmunity I would strongly suggest you look in to the Paleo diet, not only from a performance perspective but also for general health as these conditions are associated with intestinal permeability.

Why Paleo? The primary reason I avoid grains and legumes.

I was recently having a discussion with a few people on the reasons I eat a Paleo diet.  Like most discussions on religion and politics, it quickly degraded in to more of a name calling contest.  Rather than get involved in any of that, I simply provided my case and let it be.  However, I realized there's probably quite a few people who don't know why they are eating Paleo or why it may be a healthier way of eating.  In this blog we will go over why much of the data you read on nutrition is probably wrong, why there is a lack of evidence for Paleo, and the primary reason grains and legumes are probably not wise nutritional choices if health is your goal.

Many people point to the data that shows grains and legumes to be healthy food options.  The problem is this data doesn't show what they propose that it does.  Most of this data is epidemiological data.  The researchers provide food questionnaires that people fill out and the researchers compare this data to predetermined health outcomes.  There are many problems with this type of data.  The primary reason it is faulty is that the researchers are not controlling extraneous variables.  For example, if you tell a population that whole grains are healthy, people who are interested in health will gravitate towards eating whole grains.  People who are interested in health also tend to exercise, limit alcohol consumption, don't smoke, and keep a pretty regular sleep schedule.  As such, these people will skew the results toward better health outcomes, not necessarily because whole grains are healthy, but because these people lead otherwise healthy lives.  Because of this, epidemiological can show that there is a relationship between two variables, it cannot say the direction of the relationship.  In other words, it could be that people who eat whole grains are healthy, but it could also be that people who are healthy eat whole grains.  This means that this type of data is good for establishing relationships that can be further studied in a controlled clinical trial, not to say whether something is healthy to consume or not.

The other studies typically cited to show that grains or legumes are healthy foods don't have a proper control group.  When you are trying to determine whether something is beneficial or not, you would want to compare a diet that is otherwise identical between two groups with the exception that one group contains that food and the other doesn't.  Obviously this is very difficult to do, few people want to be locked in a metabolic ward and have their food weighed and prepared for them for long periods of time.  In addition, you would have to do these studies over very long periods of time which is probably not something you're going to see happen.  This is why most of the data is epidemiological.  Of the few studies we have, none compare eating whole grains to eating no grains, they compare eating whole grains to refined grains.  If a study shows a difference between the two, and most do, it doesn't necessarily mean that the one that is better is a healthy food.  If you ran a study and compared heroin to crack and heroine was better than crack, that wouldn't make crack a healthy option, only healthier than crack.

This presents a problem.  At the end of the day, research is unlikely to give us solid answers as to what is healthy.  So if the studies don't appear to be of any help, how do you make a decision?  When studies are of no help you want to look at mechanism.  Mechanism refers to a specific way that something could lead to beneficial or bad health outcomes.  The criteria I use is whether a food provides a wide range of essential nutrients, contains some nutrient that is hard to get from other foods, or contains some nonessential nutrient that provides a health benefit.  When you look at grains and legumes, none of these apply.  For a more thorough explanation of why watch this.

Now, is there something in grains or legumes that should give you reservations in consuming them?  Many things have been brought up that really didn't pan out in the research such as phytic acid and lectins.  However, there is one potential issue that has been supported by the research that should give you concern with consuming grains or legumes.  Grains and legumes contain hard to digest storage proteins called prolamins.  Humans do not produce enough of the enzymes used to digest these proteins so they pretty much go through the intestinal tract untouched.  Gluten is probably the best known prolamin, is  contained in wheat, and causes major problems in people with celiac disease.  This may not seem like an issue, but these prolamins have other insidious properties.  All of the prolamins in grains, particularly the gliadin in gluten, are immunogenic.  In fact, gluten will elicit an immune response, and it will do this in all people whether they have celiac disease or not(1).  This doesn't mean they are necessarily toxic, but firing off the immune system without reason shouldn't be one of your primary nutritional goals if health is your goal. The prolamins in legumes haven't been specifically studied, but given that their structure is basically the same as the prolamins in grains, I see no reason to test the waters.

If grains and legumes provided something you couldn't get elsewhere, were loaded with nutrients that are hard to get, or possessed some phytonutrient that is of benefit I would say go ahead and eat them.  But their lack of nutrient density coupled with their immunogenic properties give me good reason to not recommend people consume them on a regular basis, and certainly not as a staple in their diet.  Will you die if you eat a sandwich?  Nope.  Are you ever going to find a solid clinical study showing them to be unhealthy over the long term?  Probably not.  Just ask yourself, would you submit yourself to stay in a metabolic ward away from your family for 6-9 months while you eat a strict diet of measured food that may or may not contain legumes or grains.  Do you think researchers are going to find 100 people to do so and who would fund that study?  If the day ever comes that we see that study and the data supports grain and legume consumption I'll be all in.  Until that day, I am going to go with my N=1 study that shows I am missing nothing from passing on those foods and potentially improving my health by avoiding them.  I certainly feel better, have more energy, and get sick far less often.

Adrenal Fatigue and Resistant Starch

On July 29, 2012 I woke up and did not feel right.  I was getting heavy heart palpitations/arrythmias  and felt a bit dizzy.  Prior to this I had some symptoms that were telling me something I couldn't hear.  I would wake up at 4am and not be able to go back to sleep and my blood sugar was doing some crazy stuff.  My fasting blood sugar upon awakening was routinely in the 120s and would sometimes climb to over 200 when I would eat.  My A1c was fine so I thought I was experiencing something called the Dawn Phenomenon.  The Dawn Phenomenon occurs when your blood sugar crashes in the wee hours of the morning. As a result, your adrenals secrete cortisol to increase the blood glucose available to your brain.  Eventually, my adrenals crapped out and I experienced adrenal insufficiency.  My digestion was messed up and I developed a candida overgrowth.  Four months to the day later and I got an actual diagnosis.

Adrenal insufficiency is a tricky thing.  I have no doubt mine was induced by heavy coffee drinking, alcohol consumption on the weekends, and exercising way too much.  My exercise was intense in nature and I believe my carbohydrate intake was a bit too low to support that.  The problem is, getting out of adrenal fatigue is tough.  It takes a notoriously long time to get your adrenals functioning properly once they are shot and for good reason.  Your autonomic nervous system tethers your adrenals to your digestive tract.  When your adrenals aren't functioning properly, neither is your digestion.  As a result, I experienced loose stools, random bouts of constipation, and an occasional good bowel movement each week.  Therein lies the problem, if you aren't digesting your food properly you are more than likely not absorbing the nutrients from it.  In addition, if you have intestinal permeability you are absorbing stuff you shouldn't that will fire off your immune system.  As a result, your adrenals are not getting the nutrients they need and the overactive immune system is screwing with your autonomic nervous system.

My functional medicine doctor had me tighten up my diet and gave me meds for the candida as well as some supplements.  Once the candida was taken care of, we worked on the adrenal fatigue.  When I first started dealing with this, I couldn't figure out which happened first, the candida or the adrenal fatigue.  However, once the candida was gone, my digestion was still messed up.  I began to understand that the adrenal fatigue(And probably the beer) provided an environment that allowed the candida to overgrow and cause problems.  When it appeared the candida was coming back, I decided I needed to make my intestinal environment as uninhabitable as possible for candida.  I was also looking for a way to improve my digestion as my stools were still pretty loose most of the time and my blood glucose was still wonky.  I was still experiencing intestinal permeability and if I wanted both issues to clear up and to ultimately get rid of my adrenal fatigue, I needed to fix that.

My research eventually drew me to resistant starch.  I reviewed quite a few papers on the stuff and it seemed to improve blood glucose control as well as digestion and intestinal barrier function.  At some point I was directed to Richard Nikoley's site, "Free the Animal".  On his site, Richard and a commenter named Tatertot Tim were working on some N=1 projects with readers that looked very promising.  They used unmodified potato starch as their resistant starch source and since it was readily available at any grocery store, I picked some up.  I started taking 1 tbsp per day in water in the morning.  This helped my digestion but didn't completely fix it.  If I ate something I shouldn't I would get diarrhea fairly quickly.  Even if I didn't eat something bad, my stools were not consistently perfect, in fact they were mostly bad.  In addition, my blood glucose was still not right.

As I pondered my next move, I decided to run down what I thought was happening.  My belief is that my blood glucose was high because I had too much LPS leaking in to my bloodstream.  I had too much LPS leaking in to my bloodstream because my intestinal barrier was compromised.  During this whole ordeal I dropped from 195lbs to 172lbs so my blood glucose issues were more than likely not from overconsumption of food.  I decided that I should increase my dosage of potato starch to 1tbsp with each meal, maybe the adrenal issue was still compromising my digestion.  Over the course of the next 4 weeks, I would improve more than I had over the course of the last 9 months.

Within 1 week of the potato starch at this dosage I had perfect stools 100% of the time.  By the second week, even drinking beer wouldn't affect my stools.  This is a bonus because I love craft beer.  My fasting blood glucose average was 87 and the highest blood glucose reading I experienced was 101 90 minutes after a meal containing more than 50g of carbohydrates.  Slowly but surely, my orthostatic hypotension is going away and I only get palpitations when I exert myself really hard.  An additional issue I had with adrenal fatigue was muscle twitching in my calves and triceps and occasionally on my lower eyelids.  The calf twitching went from hundreds a day to a couple a day by the fourth week.  Overall, I think resistant starch has been an integral part of my recovery.

None of this is to say that my recovery is due to resistant starch.  I believe the resistant starch is something that should find it's way as a part of treatment for adrenal fatigue but won't cure it altogether.  By improving digestion, your adrenals will get the nutrients they require to pump out hormones, but you need to eat those nutrients.  By reducing the huge fluctuations in blood glucose the adrenals don't need to work as hard to help regulate blood glucose, giving them a chance to heal.  Finally, by reducing the level of LPS in the blood, the immune system remains calm and doesn't hijack nutrients that would be better served feeding the adrenals(Magnesium, thiamin, vitamin C and glucose).  I still have a few more weeks before I am back to normal, but I think that would be months if I hadn't stumbled upon resistant starch and the cool stuff going on at Free the Animal.  Thanks, Richard and Tatertot Tim.

Six habits of a good personal trainer

In my last article I discussed how the "Crossfit's Dirty Little Secret" article is actually a rebuke of the fitness industry's dirty little secret, that anyone can easily become certified to become a personal trainer or group exercise instructor.  In this article, I will discuss things to look out for to determine if a trainer is good or not.  The following habits are common for good personal trainers:

1. Their primary focus is the client
2. They are a reflection of their program
3. Their exercises are rarely machine based
4. Their sessions are comprehensive
5. They are upfront about their place in your fitness journey
6. They are constantly collecting data and adjusting workouts accordingly

Let's go over each one of these one by one.

Their primary focus is the client

This one should seem straightforward, but I see so many trainers break this rule.  I cannot tell you how many times I have seen a trainer talk on their cell phone or carry on a full conversation with someone else while training a client.  You don't need to ignore someone who says hi, but to turn away from the person who is paying you for the hour is ridiculous.  For the entirety of a training session, a good trainer will be reinforcing good technique, walking around you to make sure your form and posture are good, and gathering information that will help them determine if you are on the right track.  If they just sit on a medicine ball and count then you should reconsider.

They are a reflection of their program

I have always been a believer in the notion that a person's outward appearance isn't an accurate reflection of the knowledge they possess.  However, I feel that a person who is going to guide you toward the goal of being fit and healthy should be fit and healthy themselves.  It's not that I don't believe an unfit person can have the knowledge to get you where you want to be, they may have that knowledge.  The problem is that whether or not they understand it or not, they are an example for their client.  There is also something inherently wrong with someone telling you something is doable when they themselves cannot do it.  The final piece of this puzzle is that these people should have some health or training philosophy that should get a client from point A to point B.  It's not just about having the knowledge of how to get from point A to point B, it's about knowing how to get people to do the work.  If the trainer can't do the work themselves, they are an example of how effective that philosophy is, and the answer is "not very".

Their exercises are rarely machine based

On the surface, most people will say that this is a debatable topic.  The problem is that it's not.  I'm not saying a trainer shouldn't use machines at all, there are a few instances where a machine is necessary.  Machines dictate the path of resistance so the muscles that would normally stabilize a load get ignored.  Even if you don't buy in to this notion(You would be wrong, btw), most people sit for 95% of their day, do they really need to sit for the only 5% where they are supposed to be getting physical activity? If I may be so bold, most trainers who program an entirely machine based workout are lazy and are not worthy of your time or money.

Their sessions are comprehensive

A good training philosophy will cover the gamut of health and fitness from strength to balance to flexibility.  I require all of my clients to foam roll, stretch, strength train, do balance work, and so on because all of that stuff is necessary for good health.  In fact, I think it's so necessary that I do all of that stuff myself as well which goes back to being a reflection of your program.

They are upfront about their place in your fitness journey

A good trainer knows that most of the work in a fitness journey is outside of the gym.  This includes avoiding prolonged sitting, getting regular physical activity outside of the gym, getting a full 8 hours of quality sleep, managing stress, and formulating an eating plan that involves quality food.  This is the main course of your health and fitness plan.  Your 2-3 training sessions per week should be looked at as just a side dish unless you have imbalances and weaknesses that are compromising your ability to move properly.

They are constantly collecting data and adjusting workouts accordingly

Every training session, your trainer should be collecting information about how you are feeling, how you have been sleeping, and anything that could affect your workout.  If you have an injury or a part of you hasn't been feeling great, your workout should be adjusted to prevent an injury to the area.  In the same way, if you haven't been sleeping well or have been under a lot of stress, your session should be dialed back.  You don't want your side dish to affect your main course, but it does in so many ways.  It can affect your appetite, your sleep, your willingness to move, and even your ability to move.  A good trainer will save you from yourself by explaining why this isn't a good idea.