Projected Lifespan and Healthspan of Joe Biden and Donald Trump Before the 2020 Election

DRAFT

Projected lifespan and healthspan of Joe Biden and Donald Trump before the 2020 election

Authors

S. Jay Olshansky, PhD, corresponding author, Professor of Public Health, University of Illinois at Chicago, Chicago, Illinois, [email protected]

Hiram Beltrán-Sánchez, PhD, UCLA

Yang Claire Yang, PhD, University of North Carolina at Chapel Hill

Yi Li, PhD, University of Macao

Nir Barzilai, MD, Ingeborg and Ira Leon Rennert Chair in Aging Research, and Director, Institute for Aging Research, Albert Einstein College of Medicine

Paola Rode, MD, Former Medical Director of Hematology Oncology, Lahey North Medical Center; and Former Assistant Clinical Professor of Medicine, Tufts School of Medicine

Bradley Willcox, MD, Professor and Director of Research, Department of Geriatric Medicine, John A. Burns School of Medicine University of Hawaii

The Journal on Active Aging® is releasing this draft special feature early due to the timeliness of its content. This article is in progress. Changes can be expected in a final version published online at a later date. DRAFT DRAFT

Projected lifespan and healthspan of Joe Biden and Donald Trump before the 2020 election

by S. Jay Olshansky, PhD; Hiram Beltrán-Sánchez, PhD; Yang Claire Yang, PhD; Yi Li, PhD; Nir Barzilai, MD; Paola Rode, MD; and Bradley Willcox, MD

To be eligible to become president of the leads to the question whether presidential United States one must be a natural born candidates and sitting presidents should be U.S. citizen; a resident for at least 14 years; required (or encouraged) to make their and at least 35 years of age. There is no le- detailed medical records available for pub- gally determined disqualifying upper age lic scrutiny. Such a prerequisite, if required limit to be president. In the forthcoming today, would violate current Health Insur- election an unprecedented event will oc- ance Portability and Accountability Act cur—the person elected president will be (HIPAA) privacy rules involving personal the oldest elected president in American health information.2 history. In this analysis, empirically based estimates The health and longevity of presidential of the lifespan and healthspan of Joe Biden candidates and sitting presidents is import- and Donald Trump are provided based on ant regardless of age. Questions have been personal medical history data from publicly raised as to whether voters should accept a available records. Contained in these re- presidential candidate’s declaration of cords are attributes of both candidates that health at face value.1 A candidate of any age reflect acquired and inherited risk factors that is harboring a lethal known condition for disease and survival that are more de- that is likely to lead to death while in office, tailed and personalized relative to generic or a high risk for cognitive impairment that assessments previously published for both could influence the ability to discharge the candidates,3 and which can be used to esti- powers and duties of the office, could influ- mate survival and health with validated ence an election outcome. This concern methods of analysis from epidemiology

2 Special online feature to the Journal on Active Aging September 2020 DRAFT

September 2020 Special online feature to the Journal on Active Aging 3 DRAFT Projected lifespan and healthspan of Joe Biden and Donald Trump before the 2020 election and the demographic/actuarial sciences. lant stopped when clots resolved and were Current: Unavailable These records have also been reviewed in- attributed to immobilization from intracra- Medications: Rosuvastatin (Crestor), Ace- dependently by three physicians with ex- nial hemorrhage, subsequent testing re- tylsalicylic Acid (Aspirin), Finasteride pertise in aging for the purpose of assessing vealed no innate hypercoagulability disor- (Propecia), Ivermectin Cream (Soolantra), the prospective survival and health status der; 2014 CT angiogram showed no recur- Multivitamin (Centrum Silver) of both candidates for the next four years, rence of disease. He has also been surgically independent of the assessments of life- treated for benign prostatic hypertrophy See Table 1 for demographic and medi- span and healthspan using risk assessment (BPH); gallbladder was removed in 2003. cal history summaries6,7,8,9 of the two methods from the demographic/actuarial He has also had mild diverticulosis; candidates. sciences. non-cancerous tubular adenoma in 2008. These are benign aging-related conditions. Methods[b] Data[a] Current: Atrial fibrillation (AF): asymp- The methodology used to estimate lifespan Joe Biden tomatic cardiac arrythmia with normal is based on the use of acquired and inherit- Baseline biological, demographic, behav- ventricular response, no medication reed attributes of each candidate that are ioral risk factor, and family history of lon- quired for rate or rhythm control, on documented in the scientific literature to gevity is contained in a publicly available chronic anticoagulation for AF stroke risk; influence lifespan and survival in a U.S. medical record published on December 15, history of hyperlipidemia; gastroesophage- population.10 These covariates or risk fac- 2019, by Biden’s personal physician (see al reflux; seasonal allergies. tors include well established biological, Appendix A; summarized in Table 1). It is Medications: Eliquis; Crestor; Nexium; social and behavioral determinants of assumed that there has been no change in Dymista and Allergan health and longevity such as blood bio- Biden’s health status since this medical re- markers, physical activity, income, educa- cord summary was published; the data Donald Trump tion, marital status, smoking status, obesity, made available are accurate; and the surviv- The medical records for Trump are publicly etc., that have mortality risk ratios estimat- al estimate is based on the candidate’s age available and provided by his personal phy- ed from U.S. population based samples.11 A as of last birthday. A full medical history sician following his 2018 and 2019 annual personalized summary risk ratio based on summary—including past and current physical exams (summarized in Table 1). all of the observed attributes of each candi- medical conditions and current prescrip- Additionally, baseline biological, demo- date (see Table 1) was created and applied tion and non-prescription medications— graphic, behavioral risk factor, and family to a base complete U.S. period life table along with biomarkers drawn from blood history of longevity data are publicly avail- drawn from national vital statistics for the and urine, are contained in this source. able for Trump because the personal and resident male population of the U.S. (e.g., These data also serve as the source of infor- family history of sitting presidents is heavi- Human Mortality Database; resident pop- mation used by the physicians to evaluate ly scrutinized by the media. Other relevant ulation observed in 2017)12 matching the survival and health status of Biden in- health statistics have been revealed during Trump or Biden’s age at last birthday. The dependent of baseline demographic data. press conferences following annual health result is a personalized complete life table Provided below is a summary of Biden’s exams.4,5 It is assumed that there has been for each candidate that yields expected re- reported disease history and current no change in Trump’s health status since his maining years of life and annual survival medications. vital statistics contained in the medical probabilities to all subsequent ages based record were last made public; the data on the unique combination of health risk Disease history made available are accurate; and the surviv- factors documented to exist for each candi- Past: Cerebral aneurysm in 1988, repaired al estimate is based on the candidate’s age date and their established influence on surgically; second aneurysm discovered at as of last birthday. Provided below is a sum- survival.13,14 that time and also treated; hospital course mary of Trump’s reported disease history complicated by postoperative hospitaliza- and current medications. Healthy life expectancy (referred to here as tion for a deep vein thrombosis (DVT), ‘healthspan’) is calculated using the Sulli- with subsequent pulmonary embolism, Disease history van method15 as applied to National treated with an inferior vena caval filter and Past: Hypercholesterolemia, rosacea, Health Interview Survey data from 2017, short-term oral anticoagulant; anticoagu- appendectomy at age 11 and based on the white college-educated

Footnote

[a] Data and results are presented for the candidates in alphabetical order. It is assumed here that the medical records provided by the personal physicians of both candidates are complete and accurate as reported; we acknowledge the possibility that information could be missing and/or unreported.

4 Special online feature to the Journal on Active Aging September 2020 DRAFT

Executive summary

• Donald Trump and Joe Biden come ability of surviving a full term in office candidates is not a guarantee of an from family histories of exceptional after the election. anticipated survival or health outcome. longevity (e.g., familial longevity). As • Trump does face an elevated familial risk Risk factors for health, longevity and such, there is suggestive evidence that of late onset Alzheimer’s disease (AD) cognitive functioning are subject to both candidates are likely to be “super as this was a major contributor to his modification in either direction by agers”—a subgroup of people that father’s death (died of pneumonia, a both candidates; random elements to maintain their mental and physical common immediate cause of death in AD aging make it difficult to generate functioning into late life and tend to patients); and he also faces an elevated risk forecasts with precision; and both live longer than the average person of heart disease due to verified risk factors candidates are subject to health risks their age. publicly revealed by his personal physician. due to Covid-19.* Nevertheless, the • Both candidates have a higher than • There is no evidence available in the public familial, and personal health and average probability of surviving the record to indicate that either candidate is medical history information publicly next four years relative to other men facing a major cognitive functioning available from both candidates tend to their age (95.2% for Biden—average is challenge—either now or during the next favor the projected outcomes discussed 82.2%; 90.3% for Trump—average is four years. Trump does face an elevated here. 86.2%). The main force influencing risk of Alzheimer’s disease due to a family • Based on a personalized assessment that these favorable survival estimates is history of the disease on his father’s side. includes an evaluation of inherited familial longevity. Socioeconomic It may be tempting to conclude that and acquired risk factors for health and factors contributing to this conclusion evidence of cognitive decline does not longevity from a demographic and are that both have access to excellent exist because extensive diagnostic assess- actuarial perspective; and from inde- health care, high income, they are ments of cognitive functioning have pendent reviews of publicly available highly educated, and both are married. not been completed, and if done, some- medical record data on both candidates • Both candidates are expected to have thing significant might be revealed. by three independent physicians with higher than average healthspans Presidential candidates are evaluated by expertise in aging; it is our conclusion relative to other men their age in the their personal physicians in much the same that chronological age is not a relevant US (about 10 years more than way the rest of the population is assessed. factor for either candidate running for average). Diagnostic tests of cognitive function are president of the United States. Both • Biden is expected to outlive Trump, not done unless the physician suspects the candidates face a lower than average risk even though he is three years older. presence of a problem or if requested, and of experiencing significant health or The reasons are that Biden has an even then, a dementia screening test like cognitive functioning challenges during exceptional health profile for a man the one completed by Trump (Montreal the next four years. his age (e.g., ideal Body Mass Index Cognitive Assessment Test–MoCA) is * Donald Trump has tested positive for [BMI], physically active, few done first. There is no single diagnostic Covid-19 as this article is in production. prescription medications, no test that can determine if someone has This diagnosis raises his immediate and identifiable lethal conditions, excellent Alzheimer’s disease. The decision not to long-term risk of death by an undeter- cholesterol profile, low inflammation). order an extended battery of medical, mined amount. If Trump is a super ager, He also has a family history of neuropsychological and other diagnostic it’s possible that the same factors that lead longevity. Trump also shares most of tests during the candidates’ most recent to decelerated aging, also offer added this profile, except his obesity and physicals is evidence for an absence of protection from the harmful effects of sedentary lifestyle work against his issues involving cognitive functioning for Covid-19 on his immune system. Initial familial longevity history and his both Biden and Trump. It is unclear what evidence from centenarians infected with otherwise healthy biological profile. would occur if a candidate or sitting Covid-19 suggest that super agers weather Trump’s risk factors are significant but president refused to undergo a screening this challenge quite effectively. modifiable—it is unknown whether or diagnostic test—if recommended by he has adhered to lifestyle recom- their physician. mendations from his physicians. • This review of inherited and acquired risk However, this is not a longevity factors combined with an assessment of competition—both have a high prob- available medical records for both

September 2020 Special online feature to the Journal on Active Aging 5 DRAFT Projected lifespan and healthspan of Joe Biden and Donald Trump before the 2020 election population. Needing help with at least men in the U.S. that are Biden’s age have, cline or death during a first term in office. one activity of daily living (ADL), such as on average, about 9 years of healthy life The aneurysms he experienced in 1990 are bathing and dressing, defined disability. remaining while men in the U.S. that are no longer a significant health risk for him Healthspan corresponds to remaining life- Trump’s age have an average of 10.9 years of given his healthy survival during the past span without disability. The metric of healthy life remaining. Those assessments 30 years. He’s on a limited number of pre- healthspan is a byproduct of decades of were based on expectations for a white col- scription medications—implying a bet- research by scientists across the globe with lege-educated subgroup of men, so they are ter-than-average set of health risks. The the goal of devising a summary measure of consistent with what is expected for both best piece of evidence in the medical record population health that combines mortality candidates—which is an estimated suggesting that Biden could be long-lived is risk with non-fatal health conditions. healthspan that is higher than average. the exceptional longevity of his parents; Healthspan was first measured in the late Since there is no reason to believe that ei- both of whom reached advanced ages for 1970s by Sullivan, and it is now a standard ther candidate has lost any of their activi- their birth cohort—with his father surviv- reporting metric by the Global Burden of ties of daily living (ADLs) or instrumental ing into his 80’s and mother into her 90s. Disease project, the World Health Organi- activities of daily living (IADLs), there is Having long-lived parents has independent zation, and in thousands of research articles no basis for adjusting these healthspan esti- effects on the longevity of offspring, even since first developed.16 Healthspan is a mates. However, given the more favorable independent of risk factors and physical standardized reliable health metric that is overall health profile of Biden relative to dysfunction.18,19,20,21 For example, Alzhei- reported annually for most countries.17 Trump, even in spite of being three years mer’s disease and type 2 diabetes mellitus older, it is safe to assume that the projected can be significantly delayed for people Results healthspans of the two candidates are with long-lived parents. Overall, based Lifespan (independent of medical roughly equal at approximately 10 years. on Biden’s behavioral and medical risk history) Both candidates are projected to have a profiles and his family history of exception- • Biden life expectancy estimate using a healthspan that extends beyond the end of al longevity, there is a high probability combined risk factor approach = 96.8 the next presidential term. Biden will survive with his physical and years (average is 87.4 years) mental health intact through a first term in • Biden probability of surviving a four- Physician reviews office. year term as president = 95.2% (average (summary) is 82.2%) Based on the available data, Trump has two • Biden probability of surviving to age 85 Dr. Nir Barzilai major documented health issues, obesity years = 66% (average is 61.2%) Considering that over 90% of people over and a level of physical activity defined as 65 in the U.S. have more than two morbid- sedentary. There is suggestive evidence that • Trump life expectancy estimate using a ities (obesity considered one), the available his dietary and sleep habits are unfavorable, combined risk factor approach = 88.6 medical records reveal an excellent overall but in the absence of definitive evidence for years (average is 86.2 years) health status of Joe Biden—placing him in both of these covariates, it is assumed here • Trump probability of surviving a second the top 10% of his birth cohort for older that these are non-issues. Aside from obesi- four-year term as president = 90.3% adults. His most challenging condition is ty and a lack of physical activity, the rest of (average is 86.2%) his atrial fibrillation that seems stable and the data available on Trump reveals excel- • Trump probability of surviving to age asymptomatic with treatment to prevent lent overall health prospects for a 74-year- 85 years = 60% (average is 55.0%) thrombosis. There is nothing in his medical old male in the U.S. relative to other men record to suggest that he is at a higher than his age. Trump’s high LDL levels suggest a Healthspan normal risk for cardiovascular diseases, can- risk for cardiovascular disease, especially In an earlier assessment of healthspan for cer, type 2 diabetes mellitus, cognitive de- because these high levels are observed while Biden and Trump,3 it was estimated that

Footnote

[b] It must be acknowledged that it is not possible for anyone to forecast in advance exactly how long someone will live. Using population-based data to estimate duration of life of individuals looks like an example of an “ecological fallacy”. This fallacy or error occurs when inferences are inappropriately made about individuals based on inferences about a group to which those individuals belong. Predicting the duration of life for an individual using generic data, without prior knowledge of mortality risk, and without taking into account the personal attributes of the individual, is in fact an ecological fallacy. The ecological fallacy is not applicable in this case because our analysis is based on the personal biological and psychosocial attributes of each candidate—available in the public record; consistent with our findings is that it has already been established in advance that American presidents—and by extension presidential candidates—are almost always highly educated; with high incomes; they have access to the best health care in the country; they are already self-selected for greater longevity because of the age requirement to be eligible for the office; and they, in fact, have already been documented to be long-lived.

6 Special online feature to the Journal on Active Aging September 2020 DRAFT Table 1. Demographic and medical history summaries of Joe Biden and Donald Trump

Joe Biden6 Donald Trump7 Date of birth 11/20/1942 6/14/1946 Gender Male Male Education 16+ years 16+ years Marital status Married Married Height/Weight/Body Mass Index (BMI) 5’11.65” / 178 / 24.38 6’3” / 244 / 30.1 [2020]8 [Underweight if BMI < 20; normal if BMI >= 20 and < 25; overweight if BMI >=25 < 30; obese if BMI ≥ 30]

Blood pressure (mm Hg) 128/84 (normal) 118/809 (normal) Smoking status Nonsmoker Nonsmoker Physical activity Moderate/vigorous Sedentary Alcohol consumption None None Mother: 92 (complications from broken hip); Mother: 88 (unknown); Father: 93 Family history of longevity Father: 86 (complications during heart surgery) (pneumonia and AD)

Total cholesterol (mg/dL) 126 223 Triglycerides (mg/dL) 106 129 HDL (mg/dL) 36 67 (risk if < 35; protective if ≥ 60) LDL (mg/dL) 69 143 (normal < 100 unless CHD present, then < 70); high risk if ≥ 130 plus one risk factor) Cholesterol to HDL ratio 3.5 3.3 (optimal < 4)

Complete blood count WBC (K/UL) 5.5 HGB (g/dL) 16.1 HCT (percent) 48.7 PLT (K/UL) 241 Cardiac C-reactive protein 0.29 0.7 (optimal if < 1; recommended < 3; normal < 10) Fasting blood glucose 81 89 (normal if < 100; mg/dL) BUN (mg/dL) 19.0 CREAT (mg/dL) 0.98 ALT (U/L) 27 AST (U/L) 19 Hemoglobin AlC 5.1 5.0 (percent; normal is less than 5.7%) Vitamin D (ng/ml) 20.0 PSA (ng/ml) 0.12 TSH (uIU/ml) 1.76

Urinalysis Appearance – Clear Protein Negative Negative Ketones Negative Negative Glucose Negative Negative Blood Negative Negative Table 1. Demographic and medical history summaries of Joe Biden and Donald Trump

September 2020 Special online feature to the Journal on Active Aging 7 DRAFT Projected lifespan and healthspan of Joe Biden and Donald Trump before the 2020 election on cholesterol-reducing medication. sociated arrhythmia and does not appear to pected) and Trump’s poor lifestyle (un- Trump’s level of obesity places him at risk be due to underlying coronary artery dis- healthy diet, lack of physical activity) may for type 2 diabetes mellitus. He has no ease. He has never had any cardiovascular be catching up with him. This is evident known risks for cancer, cognitive decline or disease (CVD) complications attributable from a worrisome increase in his coronary death during the next term. The best piece to AF, does not require rate or rhythm con- artery calcium (CAC) score over the past of evidence suggesting that Trump could be trol, and it is considered fairly benign. Case decade (2009–18), which has progressed long-lived is the familial exceptional lon- in point, he engages in vigorous physical from a low CAC score to a moderately gevity of his parents; both of whom activity that might overly stress a typical high-risk score (approximately 7-fold in- reached advanced ages—with his father AF patient, without incident, and has done creased risk for a major cardiovascular surviving into his 90s and mother into her so most of his life. He has no clear evidence event [MI or sudden death] versus a score late 80s. When familial longevity is consid- for CAD; he has a distant history of cere- of zero23). On the positive side, other than ered together with his behavioral risk pro- bral aneurysms, which were successfully obesity, he has a very good metabolic profile, it is my conclusion that there is a high treated after discovery and are no longer a file, he appears to be on few prescription probability Trump would survive with his risk; he has no other major age-related dis- medications for a man his age (less than a physical and mental health intact through a eases, and all physiological systems appear half-dozen low risk medications), appears second term in office. to be functioning well. Biden’s laboratory to receive excellent medical care, practices blood work is exceptional, particularly his some preventive health behaviors (e.g. takes Dr. Paola Rode metabolic/lipid profile (excellent cholester- a multivitamin, screening tests and immu- Recognizing that there are constraints on ol, fasting blood sugar, hemoglobin A1C). nizations appear up to date) and is married. publicly available medical records, available His C-reactive protein (CRP) is very low, In sum, based on these data, and assum- data suggest that both candidates have a suggesting very low systemic inflammation, ing there is no further comorbidity in high likelihood of surviving the next four which is a major driver of the aging process the limited medical records, he will likely years. Biden may have a slight longevity ad- known as “inflammaging”.22 His medica- live longer than a typical 74-year-old vantage over Trump due to his lifestyle tions are low-risk and minimal. His father male. choices such as exercise and diet regimen as and mother far outlived their birth cohort, well as a Body Mass Index (BMI) within the living into their 80s and 90s, respectively. Overall, the medical records and/or public- normal range. Both candidates take less than In addition to his family history of longevi- ly available information suggest that Biden the national average prescription medica- ty, Biden has a healthy BMI, and practices maintains an edge over Trump in terms of tions for men their age in the U.S. A Nation- excellent health habits, particularly eating a his chances of surviving, and surviving al Center for Health Statistics investigation healthy diet and vigorous exercise. This healthfully, over the next four years—in reported that approximately a third of per- includes aerobic activity and strength train- spite of the fact that Biden is three years sons over age 60 were on ≥ 5 prescription ing, which are very important for healthy older than Trump. However, both Biden medications in 2007–2008 (see detailed aging. Biden’s overall health profile suggests and Trump are expected to survive the next review below) As higher prescription medi- that he has a very high probability of sur- presidential term with their mental and cation use can be associated with worse viving through his first term in office with physical functioning intact. health status than those on less medication, his physical and cognitive function intact. the fact that they are both taking fewer med- Discussion ications than average makes them less vul- Donald Trump’s overall health profile sug- Both candidates are projected to live longer nerable. Both candidates have access to ex- gests that he has been quite healthy over than the average man their age in the U.S. cellent health care and are known to have a the years, but he now is aging at an acceler- Lifespan forecasts suggest that Biden is higher income which correlates with an in- ated pace. He has clear evidence (on several likely to live longer than Trump, but both creased life expectancy. This speaks to the Cardiac CT scans) for subclinical CAD, candidates are expected to survive past the fact that despite the age difference, both the leading cause of mortality in the U.S., four years following inauguration in 2021. candidates are expected to survive a four- that has been worsening over the past de- The probability that Biden and Trump will year term with their mental and physical cade. His otherwise lack of major disease reach age 85 is 66% and 60%, respectively. capacities intact. and disability thus far may be largely genet- Biden is expected to live longer than ic since his parents lived into their octoge- Trump because Biden exhibits an ideal Dr. Bradley Willcox narian and nonagenarian years, although health risk profile while the president has Joe Biden is in excellent overall health for a his father had Alzheimer’s disease for ap- significant but modifiable risk factors for 77-year-old American male. His primary proximately six years before his death. mortality. Both candidates are likely to be medical impairment is non-valvular atrial However, family history is not destiny (two in possession of familial attributes associat- fibrillation (AF). This is a common age-as- of his brothers have died younger than ex- ed with exceptional longevity.

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The medical reviews presented here suggest a lack of physical activity, and evidence of their physical and mental capacity well past that there is no evidence for cognitive de- subclinical cardiovascular disease from his age 80.27 Without further testing and actu- cline in either candidate. It may be tempt- cardiac CT tests—and the fact that both of ally surviving to age 80+ years, it is not ing to conclude that such evidence does his brothers died at significantly younger possible to determine definitively whether not exist because an extensive battery of ages than what would have been projected either candidate will fall into this unique diagnostic assessments of cognitive func- for them. Most of the president’s risk fac- category of exceptionally healthy men, but tioning has not been ordered by their per- tors are modifiable—we cannot ascertain suggestive evidence and reviews by physi- sonal physicians, and if done, something definitively whether he is following the cians suggest they both are likely to do so. significant might be revealed. It is import- health advice of his physicians who are en- ant to keep in mind that at present, presi- couraging him to eat more healthfully and Conclusion dential candidates are evaluated by their be more physically active.24 If the lower limit of age 35 was chosen by physicians in much the same way the rest of America’s founding fathers because they the population is assessed. Cognitive func- Keep in mind that similar projections for envisioned the presidency requiring the tioning tests are not done unless the physi- exceptional longevity would have also been experience, maturity, and wisdom that cian suspects the presence of a problem or made for Trump’s two brothers, and nei- comes with age; or that time allows the vot- if requested by the patient, and even then, a ther survived even close to the observed ing public to make judgments based on a screening test of cognitive function is done longevity of their father. This implies that candidate’s established track record; then first, as was done with Trump (with the while family history of longevity is import- both candidates qualify as ideally suited for MoCA), followed by a battery of diagnos- ant in estimating duration of life of off- the presidency because of their chronologi- tic assessment tools if the screen shows a spring, even those in possession of a favor- cal age. The empirical evidence presented worrisome score. Since the personal physi- able genetic predisposition for longevity here, when combined with assessments of cians of each candidate did not see the can override that advantage by acquiring medical information publicly available on need for a detailed cognitive assessment, unfavorable behavioral risk factors. Finally, both candidates, suggests that both Biden this represents suggestive evidence that the president does have a family history of and Trump are likely to survive the next such issues are not present. Whether candi- Alzheimer’s disease on his father’s side, presidential term with their mental and dates for the office or sitting presidents which places him at a several-fold higher physical attributes intact, and therefore, should be required or encouraged to volun- risk of cognitive challenges in the coming their chronological ages are not relevant tarily submit themselves to be evaluated for years.25 factors in the forthcoming presidential comprehensive cognitive functioning as- election. sessments is a subject for public debate. The analysis presented here is no guarantee that long life or good health will ensue for Regardless of who is projected to live the either candidate as aging is unpredictable, longest, both candidates show signs that and it is possible to enhance or diminish a they would have no difficulty with their genetic predisposition for exceptional lon- physical or mental functioning during the gevity. However, there is evidence to sug- next four years. A review of the available gest that presidents, and by extension presi- personal medical history of Biden by three dential candidates, possess potential bio- independent physicians yielded a consensus logical and socioeconomic advantages, in- that his cerebral aneurysms and DVT/PE cluding resilient phenotypes, high educa- over 32 years ago are no longer relevant to tion, high income, and access to the best his current or projected health and longevi- health care in the world, that favor longer ty, and that he is currently in exceptional and healthier lives.12 There is no reason to health with no known significant inherited believe either of these candidates will be or acquired risk factors. any different with regard to the exceptional lifespan and healthspan experienced by A comparable review of the medical infor- many previous U.S. presidents.26 mation on Trump yielded a consensus that he too is in possession of a familial propen- Finally, it is worth noting that both candi- sity for exceptional longevity, but this opti- dates could be potential members of an mistic outlook based on family history extremely unusual subgroup of the popula- alone is mitigated by the president’s main tion known as “super-agers”—this is a ro- acquired risk factors—obesity, a poor diet, bust population subgroup known to retain

September 2020 Special online feature to the Journal on Active Aging 9 DRAFT

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(2020). Longevi- 5. PMID: 24997018 Free PMC article. 33. Centers for Disease Control and Prevention. ty and health of U.S. presidential candidates for 20. Lipton, R. B., Hirsch, J., Katz, M. J., … Barzilai, Overweight and obesity. Atlanta, GA: Centers the 2020 election. Public Policy & Aging Report, N., & Derby, C. A. (2010). Exceptional parental for Disease Control and Prevention; 2011. Avail- 30(2), 67–72. https://doi.org/10.1093/ppar/ longevity associated with lower risk of Alzhei- able at: http://www.cdc.gov/obesity praa007 mer’s disease and memory decline. Journal of the 34. Gu, Q., Dillon, C. F., & Burt, V. L. (2010). Pre- 4. https://abcnews.go.com/Politics/ American Geriatrics Society, 58(6), 1043–1049. scription Drug Use Continues to Increase: U.S. white-house-releases-results-trumps-annual- https://doi.org/10.1111/j.1532-5415. 2010. Prescription Drug Data for 2007–2008. Hyatts- physical-president/story?id=71049289 02868.x. Epub 2010 May 7. PMID: 20487085 ville, MD: National Center for Health Statistics. 5. https://www.theguardian.com/us-news/2018/ 21. Florez, H., Ma, Y., Crandall, J. P., et al; Diabetes 35. Charlesworth, C. J., Smit, E., & Lee, D. S. (2015). jan/17/donald-trump-medical-exam-full- Prevention Program Research Group. (2011). Polypharmacy among adults aged 65 years and transcript Parental longevity and diabetes risk in the Diabe- older in the United States: 1988–2010. Journals 6. See Appendix A. tes Prevention Program. Journals of Gerontology, of Gerontology, Series A: Biological Sciences and 7. Most of the data on Trump’s medical statistics are Series A: Biological Sciences and Medical Sciences, Medical Sciences, 70(8), 989–995. https://doi. from this source provided by his personal physi- 66(11), 1211–1217. https://doi.org/10.1093/ org/10.1093/gerona/glv013 cian: https://www.politico.com/story/2018/ gerona/glr114. Epub 2011 Aug 17. PMID: 36. Chetty, R., Stepner, M., Abraham, S., et al. 01/16/donald-trump-physical-results- 21852284 (2016). The association between income and life 2018-343092 22. Franceschi, C., Garagnani, P., Parini, P., et al. expectancy in the United States, 2001–2014 8. https://www.foxbusiness.com/healthcare/ (2018). Inflammaging: a new immune–metabolic [published correction appears in JAMA, 317(1), trumps-health-records-hydroxychloroquine- viewpoint for age-related diseases Nature Reviews 90, 2017]. JAMA, 315(16), 1750–1766. https:// impact-on-his-health Endocrinology, 14, 576–590. doi.org/10.1001/jama.2016.4226 9. https://abcnews.go.com/Politics/trumps- 23. Weintraub, W. S., & Diamond, G. A. (2008). 37. Benjamin, E. J., Wolf, P. A., D’Agostino, R. B., et physical-results-show-gained-weight-good- Predicting cardiovascular events with coronary al. (1998). Impact of atrial fibrillation on the risk health/story?id=61064837 calcium scoring. New England Journal of of death: The Framingham Heart Study.Circula - 10. Yang, Y., & Kozloski, M. (2012). Change in sex Medicine, 358(13), 1394–1396. https://doi. tion, 98, 946–952. https://doi.org/10.1161/01. gaps and cause-specific mortality over the life org/10.1056/nejme0800676. CIR.98.10.946 span in the United States. Annals of Epidemiolo- 24. https://www.usatoday.com/story/news/ 38. Li, X-Y., Zhang, M., Xu, W., et al. (2019). Mid- gy, 22(2), 94–103. politics/2020/02/26/ronny-jackson-efforts- life modifiable risk factors for dementia: a sys- 11. Rizzuto, D., & Fratiglioni, L. (2014). Lifestyle improve-trump-diet/4878600002/ tematic review and meta-analysis of 34 prospec- factors related to mortality and survival: A 25. Mayeux, R., Sano, M., Chen, J., et al. (1991). Risk tive cohort studies. Current Alzheimer Research, mini-review. Gerontology, 60, 327–335. https:// of dementia in first-degree relatives of patients 16(14), 1254–1268(15). https://doi.org/10.217 doi.org/10.1159/000356771 with Alzheimer’s disease and related disorders. 4/1567205017666200103111253 12. https://www.mortality.org/ Archives of Neurology, 48(3), 269–273. https:// 39. McClelland, R. B., Nasir, K., Budoff, M., et al. 13. Lloyd-Jones, D. M., Wilson, P. W., Larson, M. G., doi.org/10.1001/arch- (2009). Arterial age as a function of coronary et al. (2004). Framingham risk score and predic- neur.1991.00530150037014 artery calcium (from the Multi-Ethnic Study of tion of lifetime risk for coronary heart disease. 26. Olshansky, S. J. (2011). Aging of US presidents. Atherosclerosis [MESA]). American Journal of American Journal of Cardiology, 94(1), 20–24. JAMA, 306(21), 2328–2329. https://doi. Cardiology, 103(1), 59–63. https://doi.org/ 14. Karlamangla, A. S., Singer, B. H., McEwen, B. S., org/10.1001/jama.2011.1786 10.1016/j.amjcard.2008.08.031 et al. (2002). Allostatic load as a predictor of 27. Rogalski, E. J., Gefen, T., Shi, J., & Samimi, M. 40. Smith, G. I., Mittendorfer, B., & Klein, S. (2019). functional decline. MacArthur studies of success- (2013). Youthful memory capacity in old brains: Metabolically healthy obesity: facts and fantasies. ful aging. Journal of Clinical Epidemiology, 55, 7, anatomic and genetic Clues from the Northwest- Journal of Clinical Investigation, 129(10), 696–710. ern SuperAging Project. Journal of Cognitive 3978–3989. https://doi.org/10.1172/ 15. Sullivan, D. F. (1971). A single index of mortality Neuroscience, 25(1), 29–36. https://doi.org/ jci129186 and morbidity. HSMHA Health Reports, 86(4), 10.1162/jocn_a_00300 41. Letter to Rear Admiral Jackson, January 11, 347–354. Rockville, MD: Health Services and 28. Liptak, K. (2020, June 3). White House releases 2018. http://cdn.cnn.com/cnn/2018/images/ Mental Health Administration. results of Trump’s annual physical. https://www. 01/12/letter.to.radm.jackson.january.11.2018. 16. Robine, J. M., & Ritchie, K. (1991). Healthy life cnn.com/2020/06/03/politics/donald- pdf expectancy: evaluation of global indicator of trump-annual-physical/index.html 42. Alzheimer’s Association. (2018). 2018 Alzhei- change in population health. BMJ, 302(6774), 29. Rumberger, J. A., Brundage, B. H., Rader, D. J, & mer’s disease facts and figures.Alzheimer’s & 457–460. https://doi.org/10.1136/bmj.302. Kondos, G. (1999). Electron beam computed Dementia, 14(3), 367–429. https://doi.org/ 6774.457 tomographic coronary calcium scanning: a re- 10.1016/j.jalz.2018.02.001 17. Kyu, H. H., Abate, D., Abate, K. H., et al. view and guidelines for use in asymptomatic (2018). Global, regional, and national disabili- persons [published correction appears in Mayo ty-adjusted life-years (DALYs) for 359 diseases Clinic Proceedings, 74(5), 538, 1999]. Mayo Clin- and injuries and healthy life expectancy (HALE) ic Proceedings, 74(3), 243–252. for 195 countries and territories, 1990–2017: a 30. Lautenschlager, N. T., Cupples, L. A., Rao, V. S., systematic analysis for the Global Burden of et al. (1996). Risk of dementia among relatives of Disease Study 2017. The Lancet, 392(10159), Alzheimer’s disease patients in the MIRAGE 1859–1922. https://doi.org/10.1016/ study. What is in store for the oldest old? Neurol- s0140-6736(18)32335-3 ogy, 46(3), 641–650. https://doi.org/10.1212/ 18. Gubbi, S., Schwartz, E., Crandall, J., et al. (2017). WNL.46.3.641 Effect of exceptional parental longevity and life- 31. Breitner, J. C., Silverman, J. M., Mohs, R. C., & style factors on prevalence of cardiovascular Davis, K. L. (1988). Familial aggregation in Alz- disease in offspring.American Journal of heimer’s disease: comparison of risk among rela-

10 Special online feature to the Journal on Active Aging September 2020 DRAFT Appendix A[c]

[c] Source: https://go.joebiden.com/page/-/CiU2iAa4Ig_%20j5EQzueoad.pdf

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September 2020 Special online feature to the Journal on Active Aging 13 DRAFT Appendix B. Medical reviews

terol, but with low LDL cholesterol and no cline or death during his first term in office. Medical review by Dr. diabetes, this does not represent a signifi- The aneurysms experienced by Biden in Nir Barzilai, MD, cant health risk for him. His medications 1990 are no longer a significant health risk Ingeborg and Ira Leon are only for disease prevention or allergies. for him given his healthy survival during Rennert Chair in Aging His past experience with an intracranial the past 30 years; he’s on a limited number hemorrhage, which was repaired surgically of prescription medications—implying a Research, and in 1988, showed no signs of returning better-than-average set of health risks. For Director, Institute based on a CT angiogram in 2014; and me the best prediction of Biden’s survival for Aging Research given that he’s now 32 years post repair, prospects is familial exceptional longevity https://www.einstein.yu.edu/ this issue is no longer a significant health (father surviving to his 80s and mother faculty/484/nir-barzilai/ concern. From a physical perspective, surviving into her 90s). This information, Biden is in my opinion likely in the top 5% when combined with his behavioral risk Joe Biden of the population of men his age in terms profile, suggests that there is a high proba- Survival of health status. bility he will survive with his physical and The biodemographic analysis of Biden’s mental health intact through a first term in personal attributes independent of his Cognitive functioning office. medical records suggest that he has a high There are no independently verified medi- chance of surviving through his first four- cal records available that measured and Donald Trump year term—his survival prospects are better documented the cognitive functioning of Survival than anticipated for most men his age in Biden. However, his appearance on the The biodemographic analysis of Trump’s the U.S. The additional information con- campaign trail during the past year suggests personal attributes independent of his tained in the medical records suggest that that he is currently operating at an excep- medical records suggest that he has a high- his survival prospects could be 10% higher tionally high level. He is likely to pass the er than average chance of surviving through than the elevated survival prospects already common screening tests for dementia like a second four-year term. The additional present based on his personal attributes. the mini-mental status exam (MMSE) and information contained in the medical re- Biden currently has no significant physical MoCA with a perfect score, but these tests cords do not yield enough information to or cognitive impairments that would be would not be predictive because they’re adjust that favorable survival probability in commonly observed in a man his age; his only screening tools used to determine either direction. On the positive side, level of physical activity is exceptional; his whether a full diagnostic assessment is re- Trump comes from a family history of ex- BMI places him in the lowest mortality quired. His stuttering and speech reaction ceptional longevity—and this will no risk group; the medications he is now tak- time is typical at his age and are not indica- doubt influence his survival prospects in ing are treating minor health conditions, tive of cognitive decline. The Framingham the next four years—but he also exhibits and he’s tolerating his prescription medica- Heart Study estimates that in the general several behavior risk factors that are docu- tions without incident. I would place Biden population, the risk for Alzheimer’s disease mented to shorten longevity; including in the top 10% in terms of prospective sur- is around 10% at age 82 (Biden’s age at the obesity, a sedentary lifestyle, and dietary vival for his birth cohort. end of his first term).25 Since Biden (and habits associated with a high intake of fat, Trump) do not have dementia currently the sugar, and carbohydrates. There is also sug- Health risk is significantly lower. gestive evidence that his sleeping pattern is Biden’s current health status based on the not ideal. somewhat limited information indicates Summary that he is likely to be in the top 10–20% for Considering that over 90% of people over Health a man his age. Most men age 77 in the U.S. 65 in the U.S. have more than 2 morbidities Trump’s current health status based on lim- are taking an average of 5 prescription (obesity considered one), the data here re- ited information, suggests that he is likely medications and exhibit 2–3 primary im- veals excellent overall health status of Biden to be in the top 10–20% in projected pairments—at least one of which will be relative to other 77-year-old men in the health for a man his age. Most men age 74 life limiting. Biden currently exhibits no U.S. Biden’s most abnormal condition is his in the U.S. are taking an average of 4–5 life-limiting impairments. Normal BMI atrial fibrillation that seems stable and as- prescription medications and exhibit 2–3 and low levels of cholesterol, homocyste- ymptomatic with treatment to prevent primary impairments—at least one of ine, CRP and HbA1c crosses off lots of thrombosis. There is nothing in his medical which will be life limiting. Trump currently risks for age-related diseases. His major record to suggest that he is at a higher than exhibits no life limiting impairments al- abnormal condition is atrial fibrillation and normal risk for cardiovascular diseases, can- though he is obese. This means he is at risk his worst test result is his low HDL choles- cer, type 2 diabetes mellitus, cognitive de- for severe illness if he were to contract

14 Special online feature to the Journal on Active Aging September 2020 DRAFT

Covid-19, and he is at risk for Type 2 dia- exercise regimes; do they walk at least of rosuvastatin and there is no evidence betes mellitus. His worst test result is his 10,000 steps a day or even have the results that he has cardiac disease. Apart from par- high LDL cholesterol in spite of being on of a physiological provocation (exercise oxysmal atrial fibrillation, which is rate lipid lowering drugs. test). While stress is also a risk for mortali- controlled and asymptomatic, recent echo- ty, here I assume that they are at similar cardiogram showed no evidence of cardiac Cognitive functioning risks. Screening cognitive tests are of limit- impairment or insufficiency. He is on apix- There are no independently verified medi- ed value, all readers of this article will score aban for stroke prevention. For mild gas- cal records available that have extensive, top scores in a screening test. Finally, study- troesophageal reflux, he is controlled on documented cognitive tests for Trump. ing centenarians, I believe that the best pre- over the counter (OTC) esomeprazole However, his appearance on the campaign diction for exceptional longevity is having (Nexium). An upper endoscopy did not trail during the past year suggests that he is parents with exceptional longevity. Again, show anything of concern. Additionally, he currently operating at an exceptionally high these candidates are tied. In fact, they both takes medication for seasonal allergies with level. While a man Trump’s age does face a had parents that lived past the age of 90 fluticasone/azelastine (dymista) and fex- 7% risk of cognitive impairment during the while their spouses lived to high 80s. It is ofenadine (Allegra) OTC. In the past, he next four years, his family history includes unusual considering their parents belonged had sinus and nasal passage surgeries. Sig- a father that lived into his 90s with at least to a cohort born ~100 years ago when life nificantly, he had an intracranial hemor- 6 years of a period during which Alzhei- expectancy was much lower. This under- rhage from a cerebral aneurysm in 1988. mer’s disease was documented—this ele- lines for me the main conclusion to keep in This was repaired surgically, and screening vates Trump’s risk of dementia. mind that biological aging and not chrono- revealed a second aneurysm that was re- logical age is what counts and that these paired and never bled. Post-operatively, he Summary candidates can have extended lifespans be- had a provoked deep vein thrombosis and Donald Trump appears to have only one yond their next terms. pulmonary embolus. This was treated with major comorbidity (obesity) and the rest of placement of an inferior vena cava filter (as the data here reveals excellent overall Biden maintains a slight edge over Trump was the practice at that time) and he re- health status for a 74-year-old male in the in terms of his chances of surviving, and ceived oral anticoagulation for many U.S. His high LDL levels suggest a risk for surviving healthy, during the next four months. Work-up revealed no acquired or cardiovascular diseases, but it should not years—in spite of the fact that Biden is congenital hypercoagulable (clotting) syn- be this high unless he’s not taking his three years older than Trump. drome. It is now over 30 years and there statins. With obesity he is at risk for type 2 have been no recurrent events. In 2014, a diabetes mellitus, but his HbA1c is in the Medical review by Dr. CT angiogram of the brain showed no evi- normal range. He has no known risks for Paola Rode, MD, dence of recurrent disease. He has had no cancer, cognitive decline or death during recurrent clots. He had an enlarged pros- the next term. For me the best prediction Former Medical Director tate (benign prostatic hyperplasia) initially for longevity is familial exceptional longev- of Hematology Oncology, treated medically followed by definitive ity and both parents for their cohort Lahey North Medical Cen- surgery. There is no history of prostate can- reached very advanced age. When com- ter; and Former Assistant cer. Cholecystectomy (gallbladder remov- bined with his behavioral risk profile, the Clinical Professor of al) was performed in 2003. Colonoscopy in available evidence suggests there is a high 2008 was significant for mild diverticulosis probability he will survive with his physical Medicine, Tufts School of and a non-cancerous tubular adenoma was and mental health intact through a second Medicine removed. As he is active, he has had multi- term in office. https://www.lapetussolutions.com/ ple orthopedic injuries treated with either portfolio/paola-rode-m-d/ surgery or physical therapy. There is no his- Comparison tory of diabetes mellitus or any end organ In viewing their medical information, Joe Biden damage (see Appendix A). Biden and Trump are very close with regard Health to their anticipated healthspan and lifes- Biden is in excellent health for a man his Cognitive functioning pan. This is mainly because the risks of obe- age in the United States. His BMI is 24.38 Biden’s family history is significant for lon- sity and high LDL cholesterol in Trump and he is a non-smoker and non-drinker. gevity with his mother living until age 92 are somewhat equal to the risks associated His blood pressure remains well controlled and his father to age 86, with no documen- with chronic atrial fibrillation and low lev- and he is a moderate/vigorous exerciser— tation of any cognitive impairment. Such els of HDL cholesterol in Biden. More working out at least 5 days a week. His lip- families with members who retain their than anything I would like to know their ids are well controlled on a current regimen mental or physical capability into the 70s

September 2020 Special online feature to the Journal on Active Aging 15 DRAFT

Appendix B. Medical reviews Continued

or 80s as opposed to their decades-younger his diet but he did not adhere to a consistent Trump’s family history is significant for counterparts, are referred to as “super exercise regimen.28 His blood pressure is both parents living into their late 80s and agers”. Super agers are people who have less controlled at 121/79. At the time of his vis- 90s. There is no family history of premature evidence of brain atrophy, have thicker it, he was taking hydroxychloroquine. This cardiac or neoplastic disease. Of note, his parts of the brain related to memory, and was done with consultation with his care father had Alzheimer’s disease (AD) for 6 lower prevalence of the pathological chang- team members and close monitoring of the years before his death and developed it at es associated with Alzheimer’s disease. A EKG for changes (in the QT interval). He 87 years of age, which is late-onset AD. The study by scientists at the Northwestern was not noted to have suffered any ill effects likelihood of inheriting late-onset AD University Feinberg School of Medicine from the drug. Cholesterol was found to be from a parent is much lower than the risk suggests that having resilient memory per- either 167 or 170 depending on the source, of inheriting the early-onset form from a formance during aging could be inherited, and his LDL was less than 100. parent with an autosomal dominant gene and that a particular gene might be associ- mutation.30 Still, there is about a five-fold ated with the designation of super ager.27 The fact that Trump is now obese with a greater risk of developing AD by age 87 for Biden is a life-long stutterer and he admits BMI of 30.1 elevates his risk for heart dis- a person of age 65 with a first degree rela- that when fatigued, he can struggle with ease, diabetes, stroke and some forms of tive who has the late-onset form of this speech fluency. A stutter can be a lifelong cancer. His resting heart rate is good. Labo- disease.31 articulation disorder that says nothing ratory evaluations from 2018 show a nor- about cognitive functioning. No cognitive mal glucose level, no evidence for diabetes, Summary study is available to date. and normal liver, kidney and thyroid func- In summary, Trump is 74 years of age with tion. His PSA is normal and there is no a sedentary lifestyle and a BMI which qual- Summary evidence apart for any significant dermato- ifies him as obese. Overweight and obesity Biden is in excellent health for a 77-year- logic disease. He does have rosacea and uses are defined by the World Health Organiza- old male. His medical record does not re- ivermectin cream as needed. Finasteride is tion as abnormal or excessive fat that accu- veal any life-limiting health impairments used to prevent male hair pattern baldness. mulate and present a risk to health. A per- that would place him at an elevated risk of A screening low dose CT scan of the chest son with a BMI of 30 or more is considered either death or cognitive decline while in in 2018 was normal, without pulmonary obese.32,33 Coronary calcium scans have office. He is physically very active and takes pathology. An echocardiogram of the heart been performed intermittently since 2009 only three prescription medications which showed normal systolic function, exercise and the latest result of 133 places him at is less than the average for a man his age. As stress echocardiogram demonstrated above moderate risk of cardiovascular events, noted above, he is likely to come from a average exercise capacity based on age and such as heart attack or other heart disease. family of super agers, which is associated sex. No ischemia was noted. A coronary There is longevity in his family with both with an inherited ability to function at a calcium scan was performed, and his level parents living into their late 80s and 90s. high capacity at an older age. Biden’s vital was 133 (a level greater than 100 signifies Despite his father having late onset AD, statistics suggest that he has a very high that plaque is present). This is in compari- there is to date no evidence of cognitive probability of surviving through his first son to a 2009 coronary calcium score of 34 impairment based on the MoCA—the term in office. and a 2013 score of 98. Based on large, ob- only cognitive screening test known to have servational studies of asymptomatic pa- been performed on Trump. Nevertheless, Donald Trump tients, calcium scores of 101–400 put a his risk is elevated 5-fold in developing AD Health patient in the moderately high-risk catego- by age 87. It is known that one of his broth- Trump is 6’3” with a weight of 244 pounds, ry for cardiovascular events.29 According to ers died at age 43 secondary to alcoholism and a BMI of 30.1. This was recorded at his cardiologist, when the test was per- and a second brother died recently at age Walter Reed Medical Center on November formed in 2018, he was 71 years of age; and 71 of an unknown cause. While exception- 16, 2019. He is known to have a sedentary 46% of males had a better score than him. al longevity is in his family, it is important lifestyle and takes rosuvastatin to lower Colonoscopy in 2013 was apparently with- to note that having two brothers die well cholesterol as well as a baby aspirin daily out abnormal findings. before expected based on familial longevi- and a multivitamin. In 2018, rosuvastatin ty, demonstrates the importance of lifestyle was increased from 10 mg a day to 40 mg a Cognitive functioning and its impact on health which can super- day (maximum dose). His current BMI is The Montreal Cognitive Assessment sede the genetic advantage of exceptional in the obese range and despite encourage- (MoCA) was performed and his score was longevity. Based on his vital statistics, ment to alter lifestyle with diet and an exer- normal at 30/30. This is a test to screen for Trump has a high likelihood of surviving a cise regimen, sources reported in early 2019 mild cognitive impairment. It is not used second term in office. said that he made some minor changes to to diagnose dementia.

16 Special online feature to the Journal on Active Aging September 2020 DRAFT

Comparison rhythm, has an otherwise normal heart and lack of vascular disease are also likely to In summary, within the constraints of avail- function on echocardiogram and EKG, and prolong the duration of his high cognitive able medical or publicly available records, has taken standard anticoagulation (to mit- functionality. Modifiable risk factors for both candidates have a high likelihood of igate stroke risk) without complications for dementia include diet, physical activity, surviving the next four years. Based on the close to two decades, his risk appears to be cardiovascular factors (e.g. hypertension, limited information available, Biden may mild compared to the average case. This is lipid profile, smoking), inflammation, have a slight advantage over Trump due to not expected to influence his projected among other factors.38 None of these fac- his lifestyle choices such as exercise and health in a meaningful way. tors appear to present a risk to Biden. In diet regimen as well as a BMI within the fact, they are working in his favor. His ex- normal range. Both candidates take less Biden currently has no other significant cellent lipid/metabolic profile and low lev- than the national average prescription physical or cognitive impairments that el of inflammation, evident in his blood- medications. A National Center for Health would otherwise be commonly observed in work, are evidence that he has ongoing key Statistics investigation reported that ap- a man his age; his physiological assessment protective factors. While Biden is a life- proximately a third of persons over age 60 and blood work reflect healthy major organ long stutterer and he sometimes struggles were on ≥ 5 prescription medications in systems; his BMI places him in the lowest with speech fluency, this has no relation to 2007–2008.34 As higher prescription medi- mortality risk group; his level of physical cognitive function. cation use can be associated with worse activity is exceptional—encompassing both health status than those on less medica- strength training and aerobic/cardiovascu- Summary tions, the fact that they are on less medica- lar activity, which is very important for Joe Biden is in excellent overall health for a tions makes them less vulnerable.35 Both healthy aging. He takes only a few prescrip- 77-year-old American male. His primary candidates have access to excellent health tion medications (including a statin for his medical impairment is non-valvular atrial care and are known to have a higher in- cholesterol, an anticoagulant for his AF, fibrillation. This is a common age-associat- come which correlates with an increased and a proton pump inhibitor for reflux ed arrhythmia and does not appear to be life expectancy.36 This speaks to the fact esophagitis). Otherwise, he takes common due to underlying coronary artery disease. that despite the age difference, both would over the counter medications for minor He has never had any known complica- be expected to survive a four-year term. issues such as seasonal allergies. His medi- tions, does not require rate or rhythm con- cal history includes cerebral aneurysm re- trol, and it is considered fairly benign. Case Medical Review by pair (complicated by postoperative deep in point, he engages in vigorous physical Dr. Bradley Willcox, MD, vein thrombosis and pulmonary embo- activity that might overly stress a typical lism), sinus/nasal passage surgery, cholecys- AF patient, without incident, and has done Professor and Director of tectomy, sports-related orthopedic proce- so most of his life. He has no other major Research, Department dures, prostate surgery (for benign prostat- age-related diseases, all physiological sys- of Geriatric Medicine, ic hyperplasia), possible sleep apnea, among tems appear to be functioning well, his lab- John A. Burns School other more minor issues. These have all oratory blood work is exceptional, particu- of Medicine, University been medically and/or surgically treated larly his metabolic/lipid profile (excellent and/or cured, per imaging and other stud- cholesterol, fasting blood sugar, hemoglo- of Hawaii ies. He has excellent social support, medical bin A1C). His C-reactive protein (CRP) is https://www.orcls.org care, health behaviors (including up-to- very low, suggesting very low systemic in- date cancer screening and immunizations) flammation (a major driver of the aging Joe Biden and, importantly, a family history of signifi- process known as “inflammaging”). He eats Health cant longevity. This suggests that he could be a healthy diet and is very physically active. Joe Biden is a 77-year-old married never a “super-ager”—someone who is physiologi- His medications are minimal and low-risk. smoker and non-drinker who is in excellent cally younger than his chronological age.27 His father and mother far outlived their health. His primary medical impairment is birth cohort, living into their 80s and 90s, non-valvular atrial fibrillation (AF), an Cognitive functioning respectively. Biden’s overall health profile irregular heart rhythm. This is a common There are no formal cognitive tests for suggests that he has a very high probability age-associated arrhythmia and does not Biden in the available medical records. of surviving through his first term in office appear to be due to underlying coronary However, his mother lived until age 92 and with his physical and cognitive functioning artery disease. AF typically raises the risk of his father to age 86, apparently with no intact. death for men of all ages by 50–90 per- 37 documented cognitive impairment. Much cent. However, given that Biden has never of this may be due to genetic cognitive re- required medication for his heart rate or silience, but Biden’s very healthy lifestyle

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Appendix B. Medical reviews Continued

Donald Trump both clinical CVD and treated diabetes), tained from his blood work. For example, Survival and is a better predictor of a major cardiac his eGFR is normal (indicating stable renal Donald Trump’s medical records suggest event than the Framingham risk score. His function), and his liver enzymes are nor- that he has an excellent chance of surviving 2018 CAC score39 is almost certainly high- mal. His cholesterol ratio is good with a through a second four-year term. On the er now. Recently Trump was placed on a very healthy Total: HDL (good) cholester- positive side, Trump comes from a family maximal statin dose in an attempt to miti- ol ratio and a high HDL (longevity mark- history of exceptional longevity—and this gate this trend. The CAC score is an inde- er), somewhat mitigated by a high LDL will no doubt influence his survival pros- pendent predictor of the risk of major car- (bad) cholesterol level, currently being pects over the next four years—but he also diovascular events, with demonstrated su- treated with a full-dose statin. Thus, the exhibits several comorbidities and behav- periority over the Framingham risk score, biomarkers available to assess health and ioral risk factors that are documented to CRP level, and carotid intima-media thick- function are consistent with a reasonably shorten life expectancy; including obesity, ness, among 700 other cardiovascular risk healthy septuagenarian whose estimated a sedentary lifestyle, and dietary habits as- factors.23 lifespan is likely to be greater than average sociated with a high intake of unhealthy for a male his age, predicated partly on his fat, sugar, and other high glycemic load In sum, Trump’s major CVD risk factors ability to mitigate further build-up of cho- carbohydrates. are his age, history of high LDL cholesterol lesterol plaque in his coronary arteries. levels, his obesity, his poor diet and seden- Health tary lifestyle. This is balanced by good fam- Cognitive functioning Trump’s primary medical impairment is ily history, avoidance of smoking, high lev- Trump has a family history of Alzheimer’s subclinical coronary artery disease (CAD), els of HDL cholesterol, an excellent blood dementia on his father’s side (onset approx- as evidenced by a cardiac CT scan in 2018 pressure (despite no antihypertensive medi- imately age 87 years). Although this is con- that revealed a coronary artery calcium cations), good fasting blood sugar (89–99; sidered common and late onset (over 40% (CAC) score of 133. This score is consis- normal < 100k); healthy glycosylated he- of 85-year-olds have dementia), this still tent with a moderate level of calcified moglobin (5.0%; normal < 5.7%), and very increases Trump’s risk for dementia versus plaque deposition in his coronary arteries. low CRP level (0.7; optimal < 1). the average male. There have been concerns Findings revealed that a CAC score be- about his cognitive function in the media tween 101 and 300 carries a moderate to Trump’s obesity is of particular concern and among many health professionals, such high relative risk of 7.08 (3.05–16.47) p (increased risk for CAD, stroke, cancer, that 71 health professionals jointly wrote a <0.001 compared to a score of zero—for a etc.). While he appears metabolically letter to his personal physician urging de- major cardiovascular event (e.g., heart at- healthy, the burden of cardiovascular dis- tailed cognitive testing.41 This resulted in tack, sudden death) over the next 10 ease and all-cause mortality in the metabol- the only known cognitive screen for de- years.23 Of concern, Trump’s CAC score ically healthy obese (MHO) population mentia that Trump has undergone—the has increased dramatically from 2009 when where Trump resides, is not benign. It falls Montreal Cognitive Assessment (MoCA) it was 34, to 98 in 2013, and most recently between optimal risk (non-obese, metabol- test. This is a screening test; there is not a his CAC score in 2018 was 133. While this ically healthy), and highest risk (obese, single diagnostic test for dementia, as it’s a scan was performed at close to 72 years of metabolically unhealthy).40 Trump’s other clinical diagnosis based on a battery of age, and placed him at the 44th percentile comorbidities are non-life limiting and tests, including blood tests to rule out oth- for a 72-year old Caucasian male, and his typical of a male septuagenarian. er causes of cognitive impairment. score is better than average, it is far from ideal. His “arterial age”, which is estimated There are no detailed physiological data Apparently, Trump scored 30/30—a com- from a validated algorithm for estimating revealed from assessments of cardiovascu- mon score on the MoCA. A score of 26/30 risk for CVD “Hard end points (MI or lar, pulmonary, hepatic, musculoskeletal, or or higher is considered normal but does sudden death), is estimated at 75 years other major organ system function. How- not completely rule out dementia. A for- (95% CI: 73–77 years. This suggests mildly ever, his exercise stress testing was appar- mal diagnosis of dementia and its clinical accelerated arterial aging relative to a man ently considered by his physician as “above subtype (e.g. Alzheimer’s dementia, vascu- his chronological age and places him at average”, echocardiograms and electrocar- lar dementia, or another subtype) requires moderate risk of CVD death over the next diograms have been considered “normal” a battery of cognitive and neuropsychologi- 10 years (1% per year).39 This algorithm is again, with few details available to assess cal tests. The percentage of people with based on coronary calcium score, chrono- underlying risk. Per a CT scan, his lung Alzheimer’s dementia (the most common logical age, sex, ethnicity, total cholesterol, architecture appears intact and there are no cause of dementia in the U.S.) increases HDL cholesterol, smoking status, systolic obvious, clinically significant anomalies. with age: 3 percent of people age 65–74, blood pressure (assumes the absence of Some additional health clues can be ascer- 17 percent of people age 75–84, and 32

18 Special online feature to the Journal on Active Aging September 2020 DRAFT

percent of people age 85 years and older Comparison have Alzheimer’s dementia.42 Trump would Overall, the limited amount of information be 78 years old at the end of a second term, contained in the medical records and/or and with his family history, he would ex- publicly available information suggest that ceed the dementia risk of the average per- Biden maintains a slight edge over Trump son that age. in terms of his chances of surviving, and surviving healthfully, during the next four Summary years—in spite of the fact that Biden is Trump’s overall health profile suggests that three years older than Trump. The most he has been quite healthy over the years but definitive clinical evidence for CAD, the now has subclinical coronary artery disease leading killer of American men, in either (CAD), with a moderate level of coronary candidate, is Trump’s coronary calcium plaque. His lack of major disease and dis- score on cardiac CT of 133 (in 2018), ability thus far may be largely genetic since which by itself places Trump at a moderate his parents lived into their octogenarian risk for a major CVD event (including sud- and nonagenarian years (mother died at 88 den death) over the next 10 years. The bio- and father at 93 years of age, albeit with logical age of his coronary arteries is also a Alzheimer’s disease for 6 years before his few years (approximately three years) older death). However, family history is not des- than his chronological age.39 There is no tiny (two of his brothers have died young) such evidence for CVD in the Biden medi- and his poor lifestyle (unhealthy diet, lack cal record. Biden has had cerebral aneu- of physical activity) may be catching up rysms, but he received surgical treatment with him. This is evident from a worrisome decades ago, and this is no longer consid- increase in his coronary artery calcium ered a risk. He also has persistent atrial (CAC) score over the past 9+ years (2009– fibrillation (AF) but his rate and rhythm 18), which has progressed from a low CAC have never required treatment and he is on score to a moderately high-risk score (in- an anticoagulant medication that reduces creased risk for a major cardiovascular his risk of stroke (from AF) to near normal. event including sudden death). On the positive side, other than obesity, he has a very While both candidates have a family histo- good metabolic profile with healthy blood ry of longevity, excellent lipid, metabolic pressure, high HDL (good) cholesterol, and inflammatory profiles, Biden has a good hemoglobin A1C level (healthy much healthier BMI, and practices better blood sugar level), and a low C-reactive health habits, particularly a healthier diet protein (CRP) level. CRP is a marker of and vigorous exercise. This includes aerobic inflammation, and a low score suggests that activity and strength training, which are a major driver of the aging process known very important for healthy aging. Genes, as ”inflammaging” is optimal (<1), as op- while important, are not inert and their posed to most people his age. He is also on expression can be modified for better or for few prescription medications for a man his worse, by health behaviors. While not all is age (less than a half-dozen low risk medica- known about Trump family health habits, a tions), appears to receive excellent medical case in point is that two of the three Trump care, practices some preventive health behav- brothers have died young, leaving only one iors (e.g. takes a multivitamin, screening remaining brother, who other than abstain- tests and immunizations appear up to date) ing from alcohol and tobacco, appears to and is married. In sum, based on these data, practice few preventive lifestyle behaviors. and assuming there is no further comorbidity in the medical records, he will likely live longer than a typical 74-year-old male and live through a second term in office with his physical and cognitive functioning intact.

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