DRAFT

Projected lifespan andhealthspan ofJoe 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, sjayo@uic.edu
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; andFormer 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.

DRAFTDRAFT

Projected lifespan andhealthspan of Joe Biden and
Donald Trump before the2020 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 theUnited States one must be a natural born
U.S. citizen; a resident for at least 14 years;
and at least 35 years of age. There is no legally determined disqualifying upper age
limit to be president. In the forthcoming
election an unprecedented event will occur—the person elected president will be
the oldest elected president in American
history.
The health and longevity of presidential
candidates and sitting presidents is important regardless of age. Questions have beenraised as to whether voters should accept apresidential candidate’s declaration ofhealth at face value.1 A candidate of any age
that is harboring a lethal known condition
that is likely to lead to death while in office,or a high risk for cognitive impairment that
could influence the ability to discharge thepowers and duties of the office, could influence an election outcome. This concern
2

Special online feature to the Journal on Active Agingleads to the question whether presidential
candidates and sitting presidents should be
required (or encouraged) to make theirdetailed medical records available for public scrutiny. Such a prerequisite, if required
today, would violate current Health Insurance Portability and Accountability Act(HIPAA) privacy rules involving personal
health information.2
In this analysis, empirically based estimatesof the lifespan and healthspan of Joe Bidenand Donald Trump are provided based on
personal medical history data from publicly
available records. Contained in these records are attributes of both candidates thatreflect acquired and inherited risk factors
for disease and survival that are more detailed and personalized relative to genericassessments previously published for bothcandidates,3 and which can be used to estimate survival and health with validated
methods of analysis from epidemiology
September 2020

DRAFT

September 2020

Special online feature to the Journal on Active Aging

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DRAFT

Projected lifespan and healthspan of Joe Biden and
Donald Trump before the 2020 election
and the demographic/actuarial sciences.
These records have also been reviewed independently by three physicians with expertise in aging for the purpose of assessing
the prospective survival and health statusof both candidates for the next four years,
independent of the assessments of lifespan and healthspan using risk assessment
methods from the demographic/actuarial
sciences.
Data[a]Joe Biden
Baseline biological, demographic, behavioral risk factor, and family history of longevity is contained in a publicly available
medical record published on December 15,
2019, by Biden’s personal physician (seeAppendix A; summarized in Table 1). It is
assumed that there has been no change in
Biden’s health status since this medical record summary was published; the data
made available are accurate; and the survival estimate is based on the candidate’s age
as of last birthday. A full medical history
summary—including past and current
medical conditions and current prescription and non-prescription medications—along with biomarkers drawn from bloodand urine, are contained in this source.
These data also serve as the source of information used by the physicians to evaluate
the survival and health status of Biden independent of baseline demographic data.
Provided below is a summary of Biden’sreported disease history and current
medications.
Disease history
Past: Cerebral aneurysm in 1988, repaired
surgically; second aneurysm discovered atthat time and also treated; hospital course
complicated by postoperative hospitalization for a deep vein thrombosis (DVT),
with subsequent pulmonary embolism,
treated with an inferior vena caval filter andshort-term oral anticoagulant; anticoagu-

lant stopped when clots resolved and were
attributed to immobilization from intracranial hemorrhage, subsequent testing revealed no innate hypercoagulability disorder; 2014 CT angiogram showed no recurrence of disease. He has also been surgicallytreated for benign prostatic hypertrophy(BPH); gallbladder was removed in 2003.
He has also had mild diverticulosis;
non-cancerous tubular adenoma in 2008.
These are benign aging-related conditions.
Current: Atrial fibrillation (AF): asymptomatic cardiac arrythmia with normal
ventricular response, no medication required for rate or rhythm control, on
chronic anticoagulation for AF stroke risk;
history of hyperlipidemia; gastroesophageal reflux; seasonal allergies.
Medications: Eliquis; Crestor; Nexium;
Dymista and Allergan
Donald Trump
The medical records for Trump are publicly
available and provided by his personal physician following his 2018 and 2019 annual
physical exams (summarized in Table 1).
Additionally, baseline biological, demographic, behavioral risk factor, and family
history of longevity data are publicly available for Trump because the personal andfamily history of sitting presidents is heavily scrutinized by the media. Other relevant
health statistics have been revealed during
press conferences following annual healthexams.4,5 It is assumed that there has been
no change in Trump’s health status since hisvital statistics contained in the medical
record were last made public; the data
made available are accurate; and the survival estimate is based on the candidate’s age
as of last birthday. Provided below is a summary of Trump’s reported disease history
and current medications.
Disease history
Past: Hypercholesterolemia, rosacea,
appendectomy at age 11

Current: Unavailable
Medications: Rosuvastatin (Crestor), Acetylsalicylic Acid (Aspirin), Finasteride(Propecia), Ivermectin Cream (Soolantra),Multivitamin (Centrum Silver)
See Table 1 for demographic and medical history summaries6,7,8,9 of the twocandidates.
Methods[b]The methodology used to estimate lifespanis based on the use of acquired and inherited attributes of each candidate that are
documented in the scientific literature to
influence lifespan and survival in a U.S.
population.10 These covariates or risk factors include well established biological,
social and behavioral determinants ofhealth and longevity such as blood biomarkers, physical activity, income, education, marital status, smoking status, obesity,
etc., that have mortality risk ratios estimated from U.S. population based samples.11 A
personalized summary risk ratio based on
all of the observed attributes of each candidate (see Table 1) was created and applied
to a base complete U.S. period life tabledrawn from national vital statistics for the
resident male population of the U.S. (e.g.,
Human Mortality Database; resident population observed in 2017)12 matching
Trump or Biden’s age at last birthday. The
result is a personalized complete life tablefor each candidate that yields expected remaining years of life and annual survival
probabilities to all subsequent ages basedon the unique combination of health risk
factors documented to exist for each candidate and their established influence on
survival.13,14
Healthy life expectancy (referred to here as‘healthspan’) is calculated using the Sullivan method15 as applied to National
Health Interview Survey data from 2017,and based on the white college-educatedFootnote[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 bothcandidates are complete and accurate as reported; we acknowledge the possibility that information could be missing and/or unreported.

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DRAFT

Executive summary• Donald Trump and Joe Biden comefrom family histories of exceptional
longevity (e.g., familial longevity). As
such, there is suggestive evidence thatboth candidates are likely to be “superagers”—a subgroup of people thatmaintain their mental and physicalfunctioning into late life and tend tolive longer than the average person
their age.
• Both candidates have a higher than
average probability of surviving thenext four years relative to other men
their age (95.2% for Biden—average is
82.2%; 90.3% for Trump—average is
86.2%). The main force influencing
these favorable survival estimates isfamilial longevity. Socioeconomic
factors contributing to this conclusion
are that both have access to excellent
health care, high income, they arehighly educated, and both are married.
• Both candidates are expected to havehigher than average healthspans
relative to other men their age in the
US (about 10 years more than
average).
• Biden is expected to outlive Trump,even though he is three years older.
The reasons are that Biden has an
exceptional health profile for a man
his age (e.g., ideal Body Mass Index[BMI], physically active, few
prescription medications, noidentifiable lethal conditions, excellent
cholesterol profile, low inflammation).
He also has a family history of
longevity. Trump also shares most of
this profile, except his obesity andsedentary lifestyle work against his
familial longevity history and hisotherwise healthy biological profile.
Trump’s risk factors are significant but
modifiable—it is unknown whether
he has adhered to lifestyle recommendations from his physicians.
However, this is not a longevity
competition—both have a high probSeptember 2020

ability of surviving a full term in office
after the election.
• Trump does face an elevated familial riskof late onset Alzheimer’s disease (AD)as this was a major contributor to hisfather’s death (died of pneumonia, acommon immediate cause of death in AD
patients); and he also faces an elevated riskof heart disease due to verified risk factors
publicly revealed by his personal physician.
• There is no evidence available in the publicrecord to indicate that either candidate isfacing a major cognitive functioning
challenge—either now or during the next
four years. Trump does face an elevatedrisk of Alzheimer’s disease due to a family
history of the disease on his father’s side.
It may be tempting to conclude that
evidence of cognitive decline does notexist because extensive diagnostic assessments of cognitive functioning havenot been completed, and if done, something significant might be revealed.
Presidential candidates are evaluated bytheir personal physicians in much the same
way the rest of the population is assessed.
Diagnostic tests of cognitive function are
not done unless the physician suspects thepresence of a problem or if requested, andeven then, a dementia screening test likethe one completed by Trump (Montreal
Cognitive Assessment Test–MoCA) is
done first. There is no single diagnostic
test that can determine if someone has
Alzheimer’s disease. The decision not toorder an extended battery of medical,
neuropsychological and other diagnostic
tests during the candidates’ most recent
physicals is evidence for an absence ofissues involving cognitive functioning forboth Biden and Trump. It is unclear what
would occur if a candidate or sitting
president refused to undergo a screening
or diagnostic test—if recommended bytheir physician.
• This review of inherited and acquired risk
factors combined with an assessment ofavailable medical records for bothcandidates is not a guarantee of an
anticipated survival or health outcome.
Risk factors for health, longevity andcognitive functioning are subject tomodification in either direction byboth candidates; random elements toaging make it difficult to generate
forecasts with precision; and bothcandidates are subject to health risks
due to Covid-19.* Nevertheless, thefamilial, and personal health andmedical history information publicly
available from both candidates tend tofavor the projected outcomes discussed
here.
• Based on a personalized assessment that
includes an evaluation of inherited
and acquired risk factors for health andlongevity from a demographic andactuarial perspective; and from independent reviews of publicly available
medical record data on both candidates
by three independent physicians withexpertise in aging; it is our conclusionthat chronological age is not a relevant
factor for either candidate running forpresident of the United States. Bothcandidates face a lower than average riskof experiencing significant health or
cognitive functioning challenges during
the next four years.
* Donald Trump has tested positive for
Covid-19 as this article is in production.
This diagnosis raises his immediate andlong-term risk of death by an undetermined amount. If Trump is a super ager,
it’s possible that the same factors that leadto decelerated aging, also offer added
protection from the harmful effects of
Covid-19 on his immune system. Initialevidence from centenarians infected with
Covid-19 suggest that super agers weather
this challenge quite effectively.

Special online feature to the Journal on Active Aging

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DRAFT

Projected lifespan and healthspan of Joe Biden and
Donald Trump before the 2020 election
population. Needing help with at least
one activity of daily living (ADL), such as
bathing and dressing, defined disability.
Healthspan corresponds to remaining lifespan without disability. The metric ofhealthspan is a byproduct of decades ofresearch by scientists across the globe withthe goal of devising a summary measure of
population health that combines mortality
risk with non-fatal health conditions.
Healthspan was first measured in the late1970s by Sullivan, and it is now a standard
reporting metric by the Global Burden of
Disease project, the World Health Organization, and in thousands of research articles
since first developed.16 Healthspan is astandardized reliable health metric that isreported annually for most countries.17
Results
Lifespan (independent of medical
history)• Biden life expectancy estimate using a
combined risk factor approach = 96.8
years (average is 87.4 years)• Biden probability of surviving a fouryear term as president = 95.2% (averageis 82.2%)• Biden probability of surviving to age 85
years = 66% (average is 61.2%)• Trump life expectancy estimate using a
combined risk factor approach = 88.6
years (average is 86.2 years)• Trump probability of surviving a second
four-year term as president = 90.3%(average is 86.2%)• Trump probability of surviving to age
85 years = 60% (average is 55.0%)
HealthspanIn an earlier assessment of healthspan for
Biden and Trump,3 it was estimated thatmen in the U.S. that are Biden’s age have,on average, about 9 years of healthy life
remaining while men in the U.S. that are
Trump’s age have an average of 10.9 years ofhealthy life remaining. Those assessments
were based on expectations for a white college-educated subgroup of men, so they are
consistent with what is expected for bothcandidates—which is an estimatedhealthspan that is higher than average.
Since there is no reason to believe that either candidate has lost any of their activities of daily living (ADLs) or instrumental
activities of daily living (IADLs), there isno basis for adjusting these healthspan estimates. However, given the more favorable
overall health profile of Biden relative toTrump, even in spite of being three years
older, it is safe to assume that the projected
healthspans of the two candidates areroughly equal at approximately 10 years.
Both candidates are projected to have ahealthspan that extends beyond the end of
the next presidential term.
Physician reviews(summary)Dr. Nir Barzilai
Considering that over 90% of people over
65 in the U.S. have more than two morbidities (obesity considered one), the available
medical records reveal an excellent overall
health status of Joe Biden—placing him in
the top 10% of his birth cohort for older
adults. His most challenging condition is
his atrial fibrillation that seems stable andasymptomatic with treatment to prevent
thrombosis. There is nothing in his medical
record to suggest that he is at a higher thannormal risk for cardiovascular diseases, cancer, type 2 diabetes mellitus, cognitive de-cline or death during a first term in office.
The aneurysms he experienced in 1990 are
no longer a significant health risk for him
given his healthy survival during the past
30 years. He’s on a limited number of prescription medications—implying a better-than-average set of health risks. The
best piece of evidence in the medical recordsuggesting that Biden could be long-lived isthe exceptional longevity of his parents;
both of whom reached advanced ages fortheir birth cohort—with his father surviving into his 80’s and mother into her 90s.
Having long-lived parents has independent
effects on the longevity of offspring, evenindependent of risk factors and physicaldysfunction.18,19,20,21 For example, Alzheimer’s disease and type 2 diabetes mellitus
can be significantly delayed for people
with long-lived parents. Overall, basedon Biden’s behavioral and medical risk
profiles and his family history of exceptional longevity, there is a high probability
Biden will survive with his physical andmental health intact through a first term in
office.
Based on the available data, Trump has two
major documented health issues, obesityand a level of physical activity defined as
sedentary. There is suggestive evidence that
his dietary and sleep habits are unfavorable,
but in the absence of definitive evidence forboth of these covariates, it is assumed herethat these are non-issues. Aside from obesity and a lack of physical activity, the rest of
the data available on Trump reveals excellent overall health prospects for a 74-yearold male in the U.S. relative to other men
his age. Trump’s high LDL levels suggest arisk for cardiovascular disease, especiallybecause these high levels are observed while

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 durationof 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 ouranalysis 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 alreadybeen established in advance that American presidents—and by extension presidential candidates—are almost always highly educated; with high incomes; they have accessto 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, havealready been documented to be long-lived.

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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
MarriedMarriedHeight/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)
Smoking status
Physical activity
Alcohol consumption
Family history of longevity
Total cholesterol (mg/dL)
Triglycerides (mg/dL)
HDL (mg/dL)

128/84 (normal)
Nonsmoker
Moderate/vigorous
None
Mother: 92 (complications from broken hip);
Father: 86 (complications during heart surgery)

118/809 (normal)
Nonsmoker
Sedentary
None
Mother: 88 (unknown); Father: 93(pneumonia and AD)

126
106
36

223
129
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 countWBC (K/UL)
HGB (g/dL)
HCT (percent)
PLT (K/UL)
Cardiac C-reactive protein

0.29

Fasting blood glucose81

BUN (mg/dL)
CREAT (mg/dL)
ALT (U/L)AST (U/L)
Hemoglobin AlC

5.1

Vitamin D (ng/ml)
PSA (ng/ml)
TSH (uIU/ml)
Urinalysis
Appearance
Protein
Ketones
Glucose
Blood

5.5
16.1
48.7
241
0.7
(optimal if < 1; recommended < 3; normal < 10)89(normal if < 100; mg/dL)
19.0
0.98
27
19
5.0
(percent; normal is less than 5.7%)
20.0
0.12
1.76

–
Negative
Negative
Negative
Negative

Clear
Negative
Negative
Negative
Negative

Table 1. Demographic and medical history summaries of Joe Biden and Donald Trump
September 2020

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DRAFT

Projected lifespan and healthspan of Joe Biden and
Donald Trump before the 2020 election
on cholesterol-reducing medication.
Trump’s level of obesity places him at risk
for type 2 diabetes mellitus. He has no
known risks for cancer, cognitive decline ordeath during the next term. The best pieceof evidence suggesting that Trump could belong-lived is the familial exceptional longevity of his parents; both of whom
reached advanced ages—with his father
surviving into his 90s and mother into herlate 80s. When familial longevity is considered together with his behavioral risk profile, it is my conclusion that there is a highprobability Trump would survive with his
physical and mental health intact through asecond term in office.
Dr. Paola Rode
Recognizing that there are constraints on
publicly available medical records, available
data suggest that both candidates have ahigh likelihood of surviving the next four
years. Biden may have a slight longevity advantage over Trump due to his lifestylechoices such as exercise and diet regimen as
well as a Body Mass Index (BMI) within thenormal range. Both candidates take less than
the national average prescription medications for men their age in the U.S. A National Center for Health Statistics investigation
reported that approximately a third of persons over age 60 were on ≥ 5 prescription
medications in 2007–2008 (see detailed
review below) As higher prescription medication use can be associated with worse
health status than those on less medication,
the fact that they are both taking fewer medications than average makes them less vulnerable. Both candidates have access to excellent health care and are known to have ahigher income which correlates with an increased life expectancy. This speaks to thefact that despite the age difference, bothcandidates are expected to survive a fouryear term with their mental and physicalcapacities intact.
Dr. Bradley Willcox
Joe Biden is in excellent overall health for a
77-year-old American male. His primary
medical impairment is non-valvular atrial
fibrillation (AF). This is a common age-as8

sociated arrhythmia and does not appear tobe due to underlying coronary artery disease. He has never had any cardiovasculardisease (CVD) complications attributable
to AF, does not require rate or rhythm control, and it is considered fairly benign. Casein point, he engages in vigorous physicalactivity that might overly stress a typicalAF patient, without incident, and has done
so most of his life. He has no clear evidence
for CAD; he has a distant history of cerebral aneurysms, which were successfully
treated after discovery and are no longer arisk; he has no other major age-related diseases, and all physiological systems appear
to be functioning well. Biden’s laboratory
blood work is exceptional, particularly his
metabolic/lipid profile (excellent cholesterol, fasting blood sugar, hemoglobin A1C).
His C-reactive protein (CRP) is very low,suggesting very low systemic inflammation,
which is a major driver of the aging process
known as “inflammaging”.22 His medications are low-risk and minimal. His father
and mother far outlived their birth cohort,living into their 80s and 90s, respectively.
In addition to his family history of longevity, Biden has a healthy BMI, and practices
excellent health habits, particularly eating ahealthy diet and vigorous exercise. This
includes aerobic activity and strength training, which are very important for healthy
aging. Biden’s overall health profile suggeststhat he has a very high probability of surviving through his first term in office withhis physical and cognitive function intact.
Donald Trump’s overall health profile suggests that he has been quite healthy over
the years, but he now is aging at an accelerated pace. He has clear evidence (on several
Cardiac CT scans) for subclinical CAD,
the leading cause of mortality in the U.S.,
that has been worsening over the past decade. His otherwise lack of major disease
and disability thus far may be largely genetic since his parents lived into their octogenarian and nonagenarian years, although
his father had Alzheimer’s disease for approximately six years before his death.
However, family history is not destiny (twoof his brothers have died younger than ex-

Special online feature to the Journal on Active Aging

pected) and Trump’s poor lifestyle (unhealthy diet, lack of physical activity) may
be catching up with him. This is evident
from a worrisome increase in his coronary
artery calcium (CAC) score over the past
decade (2009–18), which has progressedfrom a low CAC score to a moderately
high-risk score (approximately 7-fold increased risk for a major cardiovascular
event [MI or sudden death] versus a scoreof zero23). On the positive side, other thanobesity, he has a very good metabolic profile, he appears to be on few prescription
medications for a man his age (less than ahalf-dozen low risk medications), appears
to receive excellent medical care, practices
some preventive health behaviors (e.g. takes
a multivitamin, screening tests and immunizations appear up to date) and is married.
In sum, based on these data, and assuming there is no further comorbidity inthe limited medical records, he will likely
live longer than a typical 74-year-old
male.
Overall, the medical records and/or publicly available information suggest that Biden
maintains an edge over Trump in terms of
his chances of surviving, and surviving
healthfully, over the next four years—inspite of the fact that Biden is three years
older than Trump. However, both Biden
and Trump are expected to survive the nextpresidential term with their mental andphysical functioning intact.
Discussion
Both candidates are projected to live longer
than the average man their age in the U.S.
Lifespan forecasts suggest that Biden is
likely to live longer than Trump, but bothcandidates are expected to survive past thefour years following inauguration in 2021.
The probability that Biden and Trump willreach age 85 is 66% and 60%, respectively.
Biden is expected to live longer than
Trump because Biden exhibits an ideal
health risk profile while the president has
significant but modifiable risk factors for
mortality. Both candidates are likely to bein possession of familial attributes associated with exceptional longevity.
September 2020

DRAFT

The medical reviews presented here suggestthat there is no evidence for cognitive decline in either candidate. It may be tempting to conclude that such evidence does
not exist because an extensive battery of
diagnostic assessments of cognitive functioning has not been ordered by their personal physicians, and if done, something
significant might be revealed. It is important to keep in mind that at present, presidential candidates are evaluated by their
physicians in much the same way the rest of
the population is assessed. Cognitive functioning tests are not done unless the physician suspects the presence of a problem or
if requested by the patient, and even then, ascreening test of cognitive function is done
first, as was done with Trump (with theMoCA), followed by a battery of diagnostic assessment tools if the screen shows aworrisome score. Since the personal physicians of each candidate did not see theneed for a detailed cognitive assessment,
this represents suggestive evidence thatsuch issues are not present. Whether candidates for the office or sitting presidents
should be required or encouraged to voluntarily submit themselves to be evaluated forcomprehensive cognitive functioning assessments is a subject for public debate.
Regardless of who is projected to live thelongest, both candidates show signs thatthey would have no difficulty with their
physical or mental functioning during thenext four years. A review of the available
personal medical history of Biden by three
independent physicians yielded a consensus
that his cerebral aneurysms and DVT/PE
over 32 years ago are no longer relevant to
his current or projected health and longevity, and that he is currently in exceptional
health with no known significant inheritedor acquired risk factors.
A comparable review of the medical information on Trump yielded a consensus that
he too is in possession of a familial propensity for exceptional longevity, but this optimistic outlook based on family history
alone is mitigated by the president’s main
acquired risk factors—obesity, a poor diet,
September 2020a lack of physical activity, and evidence of
subclinical cardiovascular disease from his
cardiac CT tests—and the fact that both of
his brothers died at significantly younger
ages than what would have been projected
for them. Most of the president’s risk factors are modifiable—we cannot ascertain
definitively whether he is following thehealth advice of his physicians who are encouraging him to eat more healthfully andbe more physically active.24
Keep in mind that similar projections for
exceptional longevity would have also been
made for Trump’s two brothers, and neither survived even close to the observed
longevity of their father. This implies thatwhile family history of longevity is important in estimating duration of life of offspring, even those in possession of a favorable genetic predisposition for longevity
can override that advantage by acquiring
unfavorable behavioral risk factors. Finally,
the president does have a family history of
Alzheimer’s disease on his father’s side,which places him at a several-fold higher
risk of cognitive challenges in the coming
years.25
The analysis presented here is no guaranteethat long life or good health will ensue for
either candidate as aging is unpredictable,
and it is possible to enhance or diminish agenetic predisposition for exceptional longevity. However, there is evidence to suggest that presidents, and by extension presidential candidates, possess potential biological and socioeconomic advantages, including resilient phenotypes, high education, high income, and access to the best
health care in the world, that favor longer
and healthier lives.12 There is no reason tobelieve either of these candidates will be
any different with regard to the exceptional
lifespan and healthspan experienced bymany previous U.S. presidents.26

their physical and mental capacity well pastage 80.27 Without further testing and actually surviving to age 80+ years, it is notpossible to determine definitively whether
either candidate will fall into this unique
category of exceptionally healthy men, butsuggestive evidence and reviews by physicians suggest they both are likely to do so.
Conclusion
If the lower limit of age 35 was chosen by
America’s founding fathers because theyenvisioned the presidency requiring theexperience, maturity, and wisdom thatcomes with age; or that time allows the voting public to make judgments based on a
candidate’s established track record; thenboth candidates qualify as ideally suited forthe presidency because of their chronological age. The empirical evidence presented
here, when combined with assessments ofmedical information publicly available on
both candidates, suggests that both Biden
and Trump are likely to survive the nextpresidential term with their mental andphysical attributes intact, and therefore,
their chronological ages are not relevant
factors in the forthcoming presidential
election.

Finally, it is worth noting that both candidates could be potential members of an
extremely unusual subgroup of the population known as “super-agers”—this is a robust population subgroup known to retain
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9DRAFT
References1.

https://www.washingtonexaminer.com/policy/
healthcare/2020-candidates-are-too-old-warnsobamas-former-doctor-were-asking-for-trouble
2. https://www.hhs.gov/hipaa/for-individuals/
medical-records/index.html
3. Olshansky, S. J., Beltrán-Sánchez, H., Carnes, B.
A., Yang, C., Li, Y., Willcox, B. (2020). Longevity and health of U.S. presidential candidates forthe 2020 election. Public Policy & Aging Report,
30(2), 67–72. https://doi.org/10.1093/ppar/
praa007
4. https://abcnews.go.com/Politics/
white-house-releases-results-trumps-annualphysical-president/story?id=71049289
5. https://www.theguardian.com/us-news/2018/
jan/17/donald-trump-medical-exam-fulltranscript
6. See Appendix A.
7. Most of the data on Trump’s medical statistics arefrom this source provided by his personal physician: https://www.politico.com/story/2018/01/16/donald-trump-physical-results2018-343092
8. https://www.foxbusiness.com/healthcare/trumps-health-records-hydroxychloroquineimpact-on-his-health
9. https://abcnews.go.com/Politics/trumpsphysical-results-show-gained-weight-goodhealth/story?id=61064837
10. Yang, Y., & Kozloski, M. (2012). Change in sex
gaps and cause-specific mortality over the life
span in the United States. Annals of Epidemiology, 22(2), 94–103.
11. Rizzuto, D., & Fratiglioni, L. (2014). Lifestylefactors related to mortality and survival: A
mini-review. Gerontology, 60, 327–335. https://doi.org/10.1159/000356771
12. https://www.mortality.org/
13. Lloyd-Jones, D. M., Wilson, P. W., Larson, M. G.,
et al. (2004). Framingham risk score and prediction of lifetime risk for coronary heart disease.
American Journal of Cardiology, 94(1), 20–24.
14. Karlamangla, A. S., Singer, B. H., McEwen, B. S.,
et al. (2002). Allostatic load as a predictor offunctional decline. MacArthur studies of successful aging. Journal of Clinical Epidemiology, 55, 7,
696–710.
15. Sullivan, D. F. (1971). A single index of mortality
and morbidity. HSMHA Health Reports, 86(4),347–354. Rockville, MD: Health Services andMental Health Administration.
16. Robine, J. M., & Ritchie, K. (1991). Healthy life
expectancy: evaluation of global indicator ofchange in population health. BMJ, 302(6774),
457–460. https://doi.org/10.1136/bmj.302.
6774.457
17. Kyu, H. H., Abate, D., Abate, K. H., et al.
(2018). Global, regional, and national disability-adjusted life-years (DALYs) for 359 diseases
and injuries and healthy life expectancy (HALE)
for 195 countries and territories, 1990–2017: asystematic analysis for the Global Burden of
Disease Study 2017. The Lancet, 392(10159),
1859–1922. https://doi.org/10.1016/
s0140-6736(18)32335-3
18. Gubbi, S., Schwartz, E., Crandall, J., et al. (2017).
Effect of exceptional parental longevity and lifestyle factors on prevalence of cardiovasculardisease in offspring. American Journal of

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Cardiology, 120(12), 2170–2175. https://doi.
org/10.1016/j.amjcard.2017.08.040. Epub 2017
Sep 18. PMID: 29050682
19. Ayers, E., Barzilai, N., Crandall, J. P., et al.
(2014). Association of exceptional parental longevity and physical function in aging. Age (Dordrecht, Netherlands), 36(4), 9677. https://doi.
org/10.1007/s11357-014-9677-5. Epub 2014 Jul
5. PMID: 24997018 Free PMC article.
20. Lipton, R. B., Hirsch, J., Katz, M. J., … Barzilai,N., & Derby, C. A. (2010). Exceptional parental
longevity associated with lower risk of Alzheimer’s disease and memory decline. Journal of theAmerican Geriatrics Society, 58(6), 1043–1049.
https://doi.org/10.1111/j.1532-5415. 2010.
02868.x. Epub 2010 May 7. PMID: 20487085
21. Florez, H., Ma, Y., Crandall, J. P., et al; Diabetes
Prevention Program Research Group. (2011).
Parental longevity and diabetes risk in the Diabetes Prevention Program. Journals of Gerontology,
Series A: Biological Sciences and Medical Sciences,66(11), 1211–1217. https://doi.org/10.1093/
gerona/glr114. Epub 2011 Aug 17. PMID:
21852284
22. Franceschi, C., Garagnani, P., Parini, P., et al.
(2018). Inflammaging: a new immune–metabolic
viewpoint for age-related diseases Nature Reviews
Endocrinology, 14, 576–590.
23. Weintraub, W. S., & Diamond, G. A. (2008).
Predicting cardiovascular events with coronary
calcium scoring. New England Journal of
Medicine, 358(13), 1394–1396. https://doi.
org/10.1056/nejme0800676.
24. https://www.usatoday.com/story/news/
politics/2020/02/26/ronny-jackson-effortsimprove-trump-diet/4878600002/
25. Mayeux, R., Sano, M., Chen, J., et al. (1991). Riskof dementia in first-degree relatives of patientswith Alzheimer’s disease and related disorders.
Archives of Neurology, 48(3), 269–273. https://doi.org/10.1001/archneur.1991.00530150037014
26. Olshansky, S. J. (2011). Aging of US presidents.
JAMA, 306(21), 2328–2329. https://doi.
org/10.1001/jama.2011.1786
27. Rogalski, E. J., Gefen, T., Shi, J., & Samimi, M.
(2013). Youthful memory capacity in old brains:
anatomic and genetic Clues from the Northwestern SuperAging Project. Journal of Cognitive
Neuroscience, 25(1), 29–36. https://doi.org/
10.1162/jocn_a_00300
28. Liptak, K. (2020, June 3). White House releases
results of Trump’s annual physical. https://www.
cnn.com/2020/06/03/politics/donaldtrump-annual-physical/index.html
29. Rumberger, J. A., Brundage, B. H., Rader, D. J, &Kondos, G. (1999). Electron beam computed
tomographic coronary calcium scanning: a review and guidelines for use in asymptomatic
persons [published correction appears in Mayo
Clinic Proceedings, 74(5), 538, 1999]. Mayo Clinic Proceedings, 74(3), 243–252.
30. Lautenschlager, N. T., Cupples, L. A., Rao, V. S.,
et al. (1996). Risk of dementia among relatives of
Alzheimer’s disease patients in the MIRAGE
study. What is in store for the oldest old? Neurology, 46(3), 641–650. https://doi.org/10.1212/
WNL.46.3.641
31. Breitner, J. C., Silverman, J. M., Mohs, R. C., &Davis, K. L. (1988). Familial aggregation in Alzheimer’s disease: comparison of risk among rela-Special online feature to the Journal on Active Aging

tives of early-and late-onset cases, and among
male and female relatives in successive generations. Neurology, 38(2), 207–212. https://doi.
org/10.1212/wnl.38.2.207
32. World Health Organization. Health topics:
obesity. Geneva, Switzerland: World HealthOrganization; 2011. Available at: http://www.
who.int/topics/obesity/en/
33. Centers for Disease Control and Prevention.
Overweight and obesity. Atlanta, GA: Centers
for Disease Control and Prevention; 2011. Available at: http://www.cdc.gov/obesity
34. Gu, Q., Dillon, C. F., & Burt, V. L. (2010). Prescription Drug Use Continues to Increase: U.S.
Prescription Drug Data for 2007–2008. Hyattsville, MD: National Center for Health Statistics.
35. Charlesworth, C. J., Smit, E., & Lee, D. S. (2015).
Polypharmacy among adults aged 65 years andolder in the United States: 1988–2010. Journalsof Gerontology, Series A: Biological Sciences andMedical Sciences, 70(8), 989–995. https://doi.
org/10.1093/gerona/glv013
36. Chetty, R., Stepner, M., Abraham, S., et al.
(2016). The association between income and life
expectancy in the United States, 2001–2014[published correction appears in JAMA, 317(1),90, 2017]. JAMA, 315(16), 1750–1766. https://doi.org/10.1001/jama.2016.4226
37. Benjamin, E. J., Wolf, P. A., D’Agostino, R. B., etal. (1998). Impact of atrial fibrillation on the riskof death: The Framingham Heart Study. Circulation, 98, 946–952. https://doi.org/10.1161/01.
CIR.98.10.946
38. Li, X-Y., Zhang, M., Xu, W., et al. (2019). Midlife modifiable risk factors for dementia: a systematic review and meta-analysis of 34 prospective cohort studies. Current Alzheimer Research,
16(14), 1254–1268(15). https://doi.org/10.217
4/1567205017666200103111253
39. McClelland, R. B., Nasir, K., Budoff, M., et al.
(2009). Arterial age as a function of coronary
artery calcium (from the Multi-Ethnic Study ofAtherosclerosis [MESA]). American Journal of
Cardiology, 103(1), 59–63. https://doi.org/
10.1016/j.amjcard.2008.08.031
40. Smith, G. I., Mittendorfer, B., & Klein, S. (2019).
Metabolically healthy obesity: facts and fantasies.
Journal of Clinical Investigation, 129(10),3978–3989. https://doi.org/10.1172/
jci129186
41. Letter to Rear Admiral Jackson, January 11,
2018. http://cdn.cnn.com/cnn/2018/images/
01/12/letter.to.radm.jackson.january.11.2018.
pdf
42. Alzheimer’s Association. (2018). 2018 Alzheimer’s disease facts and figures. Alzheimer’s &Dementia, 14(3), 367–429. https://doi.org/
10.1016/j.jalz.2018.02.001

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Appendix A[c][c] Source: https://go.joebiden.com/page/-/CiU2iAa4Ig_%20j5EQzueoad.pdf
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Appendix B. Medical reviews
Medical review by Dr.
Nir Barzilai, MD,
Ingeborg and Ira Leon
Rennert Chair in Aging
Research, andDirector, Institutefor Aging Researchhttps://www.einstein.yu.edu/
faculty/484/nir-barzilai/

Joe Biden
Survival
The biodemographic analysis of Biden’s
personal attributes independent of his
medical records suggest that he has a highchance of surviving through his first fouryear term—his survival prospects are better
than anticipated for most men his age inthe U.S. The additional information contained in the medical records suggest that
his survival prospects could be 10% higher
than the elevated survival prospects alreadypresent based on his personal attributes.
Biden currently has no significant physicalor cognitive impairments that would becommonly observed in a man his age; hislevel of physical activity is exceptional; his
BMI places him in the lowest mortality
risk group; the medications he is now taking are treating minor health conditions,and he’s tolerating his prescription medications without incident. I would place Bidenin the top 10% in terms of prospective survival for his birth cohort.
HealthBiden’s current health status based on thesomewhat limited information indicatesthat he is likely to be in the top 10–20% fora man his age. Most men age 77 in the U.S.
are taking an average of 5 prescription
medications and exhibit 2–3 primary impairments—at least one of which will belife limiting. Biden currently exhibits nolife-limiting impairments. Normal BMI
and low levels of cholesterol, homocysteine, CRP and HbA1c crosses off lots ofrisks for age-related diseases. His major
abnormal condition is atrial fibrillation andhis worst test result is his low HDL choles14

terol, but with low LDL cholesterol and nodiabetes, this does not represent a significant health risk for him. His medications
are only for disease prevention or allergies.
His past experience with an intracranial
hemorrhage, which was repaired surgicallyin 1988, showed no signs of returning
based on a CT angiogram in 2014; andgiven that he’s now 32 years post repair,this issue is no longer a significant healthconcern. From a physical perspective,
Biden is in my opinion likely in the top 5%of the population of men his age in termsof health status.
Cognitive functioning
There are no independently verified medical records available that measured anddocumented the cognitive functioning ofBiden. However, his appearance on the
campaign trail during the past year suggeststhat he is currently operating at an exceptionally high level. He is likely to pass thecommon screening tests for dementia likethe mini-mental status exam (MMSE) andMoCA with a perfect score, but these tests
would not be predictive because they’re
only screening tools used to determine
whether a full diagnostic assessment is required. His stuttering and speech reaction
time is typical at his age and are not indicative of cognitive decline. The Framingham
Heart Study estimates that in the general
population, the risk for Alzheimer’s diseaseis around 10% at age 82 (Biden’s age at theend of his first term).25 Since Biden (andTrump) do not have dementia currently therisk is significantly lower.
Summary
Considering that over 90% of people over
65 in the U.S. have more than 2 morbidities(obesity considered one), the data here reveals excellent overall health status of Biden
relative to other 77-year-old men in the
U.S. Biden’s most abnormal condition is his
atrial fibrillation that seems stable and asymptomatic with treatment to prevent
thrombosis. There is nothing in his medical
record to suggest that he is at a higher thannormal risk for cardiovascular diseases, cancer, type 2 diabetes mellitus, cognitive de-Special online feature to the Journal on Active Aging

cline or death during his first term in office.
The aneurysms experienced by Biden in1990 are no longer a significant health riskfor him given his healthy survival during
the past 30 years; he’s on a limited numberof prescription medications—implying abetter-than-average set of health risks. Forme the best prediction of Biden’s survival
prospects is familial exceptional longevity(father surviving to his 80s and mothersurviving into her 90s). This information,
when combined with his behavioral risk
profile, suggests that there is a high probability he will survive with his physical andmental health intact through a first term in
office.
Donald Trump
Survival
The biodemographic analysis of Trump’s
personal attributes independent of his
medical records suggest that he has a higher than average chance of surviving througha second four-year term. The additional
information contained in the medical records do not yield enough information toadjust that favorable survival probability ineither direction. On the positive side,
Trump comes from a family history of exceptional longevity—and this will no
doubt influence his survival prospects inthe next four years—but he also exhibits
several behavior risk factors that are documented to shorten longevity; including
obesity, a sedentary lifestyle, and dietary
habits associated with a high intake of fat,sugar, and carbohydrates. There is also suggestive evidence that his sleeping pattern is
not ideal.
HealthTrump’s current health status based on limited information, suggests that he is likely
to be in the top 10–20% in projected
health for a man his age. Most men age 74
in the U.S. are taking an average of 4–5
prescription medications and exhibit 2–3
primary impairments—at least one ofwhich will be life limiting. Trump currently
exhibits no life limiting impairments although he is obese. This means he is at risk
for severe illness if he were to contract
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Covid-19, and he is at risk for Type 2 diabetes mellitus. His worst test result is hishigh LDL cholesterol in spite of being on
lipid lowering drugs.
Cognitive functioning
There are no independently verified medical records available that have extensive,
documented cognitive tests for Trump.
However, his appearance on the campaign
trail during the past year suggests that he iscurrently operating at an exceptionally highlevel. While a man Trump’s age does face a
7% risk of cognitive impairment during thenext four years, his family history includes
a father that lived into his 90s with at least
6 years of a period during which Alzheimer’s disease was documented—this elevates Trump’s risk of dementia.
Summary
Donald Trump appears to have only one
major comorbidity (obesity) and the rest of
the data here reveals excellent overall
health status for a 74-year-old male in the
U.S. His high LDL levels suggest a risk for
cardiovascular diseases, but it should not
be this high unless he’s not taking his
statins. With obesity he is at risk for type 2
diabetes mellitus, but his HbA1c is in thenormal range. He has no known risks forcancer, cognitive decline or death during
the next term. For me the best prediction
for longevity is familial exceptional longevity and both parents for their cohort
reached very advanced age. When combined with his behavioral risk profile, theavailable evidence suggests there is a highprobability he will survive with his physicaland mental health intact through a second
term in office.
Comparison
In viewing their medical information,
Biden and Trump are very close with regard
to their anticipated healthspan and lifespan. This is mainly because the risks of obesity and high LDL cholesterol in Trump
are somewhat equal to the risks associatedwith chronic atrial fibrillation and low levels of HDL cholesterol in Biden. Morethan anything I would like to know theirSeptember 2020

exercise regimes; do they walk at least
10,000 steps a day or even have the resultsof a physiological provocation (exercise
test). While stress is also a risk for mortality, here I assume that they are at similarrisks. Screening cognitive tests are of limited value, all readers of this article will score
top scores in a screening test. Finally, studying centenarians, I believe that the best prediction for exceptional longevity is having
parents with exceptional longevity. Again,
these candidates are tied. In fact, they both
had parents that lived past the age of 90
while their spouses lived to high 80s. It is
unusual considering their parents belonged
to a cohort born ~100 years ago when life
expectancy was much lower. This underlines for me the main conclusion to keep inmind that biological aging and not chronological age is what counts and that thesecandidates can have extended lifespans beyond their next terms.
Biden maintains a slight edge over Trumpin terms of his chances of surviving, andsurviving healthy, during the next four
years—in spite of the fact that Biden isthree years older than Trump.

Medical review by Dr.
Paola Rode, MD,
Former Medical Directorof Hematology Oncology,
Lahey North Medical Center; and Former AssistantClinical Professor of
Medicine, Tufts School of
Medicine

https://www.lapetussolutions.com/
portfolio/paola-rode-m-d/

Joe BidenHealthBiden is in excellent health for a man his
age in the United States. His BMI is 24.38
and he is a non-smoker and non-drinker.
His blood pressure remains well controlled
and he is a moderate/vigorous exerciser—
working out at least 5 days a week. His lipids are well controlled on a current regimenof rosuvastatin and there is no evidence
that he has cardiac disease. Apart from paroxysmal atrial fibrillation, which is rate
controlled and asymptomatic, recent echocardiogram showed no evidence of cardiac
impairment or insufficiency. He is on apixaban for stroke prevention. For mild gastroesophageal reflux, he is controlled onover the counter (OTC) esomeprazole(Nexium). An upper endoscopy did notshow anything of concern. Additionally, hetakes medication for seasonal allergies withfluticasone/azelastine (dymista) and fexofenadine (Allegra) OTC. In the past, he
had sinus and nasal passage surgeries. Significantly, he had an intracranial hemorrhage from a cerebral aneurysm in 1988.
This was repaired surgically, and screening
revealed a second aneurysm that was repaired and never bled. Post-operatively, he
had a provoked deep vein thrombosis andpulmonary embolus. This was treated withplacement of an inferior vena cava filter (aswas the practice at that time) and he received oral anticoagulation for many
months. Work-up revealed no acquired orcongenital hypercoagulable (clotting) syndrome. It is now over 30 years and there
have been no recurrent events. In 2014, a
CT angiogram of the brain showed no evidence of recurrent disease. He has had norecurrent clots. He had an enlarged prostate (benign prostatic hyperplasia) initiallytreated medically followed by definitive
surgery. There is no history of prostate cancer. Cholecystectomy (gallbladder removal) was performed in 2003. Colonoscopy in2008 was significant for mild diverticulosis
and a non-cancerous tubular adenoma wasremoved. As he is active, he has had multiple orthopedic injuries treated with either
surgery or physical therapy. There is no history of diabetes mellitus or any end organ
damage (see Appendix A).
Cognitive functioning
Biden’s family history is significant for longevity with his mother living until age 92
and his father to age 86, with no documentation of any cognitive impairment. Suchfamilies with members who retain theirmental or physical capability into the 70s

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Appendix B. Medical reviews Continued
or 80s as opposed to their decades-younger
counterparts, are referred to as “superagers”. Super agers are people who have lessevidence of brain atrophy, have thicker
parts of the brain related to memory, andlower prevalence of the pathological changes associated with Alzheimer’s disease. A
study by scientists at the Northwestern
University Feinberg School of Medicine
suggests that having resilient memory performance during aging could be inherited,
and that a particular gene might be associated with the designation of super ager.27
Biden is a life-long stutterer and he admits
that when fatigued, he can struggle withspeech fluency. A stutter can be a lifelong
articulation disorder that says nothing
about cognitive functioning. No cognitive
study is available to date.
Summary
Biden is in excellent health for a 77-yearold male. His medical record does not reveal any life-limiting health impairmentsthat would place him at an elevated risk ofeither death or cognitive decline while inoffice. He is physically very active and takes
only three prescription medications whichis less than the average for a man his age. As
noted above, he is likely to come from afamily of super agers, which is associatedwith an inherited ability to function at ahigh capacity at an older age. Biden’s vitalstatistics suggest that he has a very highprobability of surviving through his firstterm in office.
Donald Trump
HealthTrump is 6’3” with a weight of 244 pounds,
and a BMI of 30.1. This was recorded at
Walter Reed Medical Center on November
16, 2019. He is known to have a sedentary
lifestyle and takes rosuvastatin to lower
cholesterol as well as a baby aspirin daily
and a multivitamin. In 2018, rosuvastatin
was increased from 10 mg a day to 40 mg aday (maximum dose). His current BMI isin the obese range and despite encouragement to alter lifestyle with diet and an exercise regimen, sources reported in early 2019said that he made some minor changes to16

his diet but he did not adhere to a consistent
exercise regimen.28 His blood pressure iscontrolled at 121/79. At the time of his visit, he was taking hydroxychloroquine. Thiswas done with consultation with his careteam members and close monitoring of the
EKG for changes (in the QT interval). He
was not noted to have suffered any ill effects
from the drug. Cholesterol was found to beeither 167 or 170 depending on the source,and his LDL was less than 100.
The fact that Trump is now obese with a
BMI of 30.1 elevates his risk for heart disease, diabetes, stroke and some forms ofcancer. His resting heart rate is good. Laboratory evaluations from 2018 show a normal glucose level, no evidence for diabetes,
and normal liver, kidney and thyroid function. His PSA is normal and there is noevidence apart for any significant dermatologic disease. He does have rosacea and uses
ivermectin cream as needed. Finasteride isused to prevent male hair pattern baldness.
A screening low dose CT scan of the chestin 2018 was normal, without pulmonary
pathology. An echocardiogram of the heart
showed normal systolic function, exercise
stress echocardiogram demonstrated above
average exercise capacity based on age andsex. No ischemia was noted. A coronary
calcium scan was performed, and his levelwas 133 (a level greater than 100 signifies
that plaque is present). This is in comparison to a 2009 coronary calcium score of 34
and a 2013 score of 98. Based on large, observational studies of asymptomatic patients, calcium scores of 101–400 put apatient in the moderately high-risk category for cardiovascular events.29 According to
his cardiologist, when the test was performed in 2018, he was 71 years of age; and
46% of males had a better score than him.
Colonoscopy in 2013 was apparently without abnormal findings.
Cognitive functioning
The Montreal Cognitive Assessment(MoCA) was performed and his score wasnormal at 30/30. This is a test to screen for
mild cognitive impairment. It is not used
to diagnose dementia.

Special online feature to the Journal on Active Aging

Trump’s family history is significant for
both parents living into their late 80s and90s. There is no family history of premature
cardiac or neoplastic disease. Of note, hisfather had Alzheimer’s disease (AD) for 6
years before his death and developed it at
87 years of age, which is late-onset AD. The
likelihood of inheriting late-onset ADfrom a parent is much lower than the riskof inheriting the early-onset form from aparent with an autosomal dominant genemutation.30 Still, there is about a five-foldgreater risk of developing AD by age 87 fora person of age 65 with a first degree relative who has the late-onset form of thisdisease.31
Summary
In summary, Trump is 74 years of age witha sedentary lifestyle and a BMI which qualifies him as obese. Overweight and obesity
are defined by the World Health Organization as abnormal or excessive fat that accumulate and present a risk to health. A person with a BMI of 30 or more is consideredobese.32,33 Coronary calcium scans havebeen performed intermittently since 2009
and the latest result of 133 places him atmoderate risk of cardiovascular events,
such as heart attack or other heart disease.
There is longevity in his family with bothparents living into their late 80s and 90s.
Despite his father having late onset AD,
there is to date no evidence of cognitive
impairment based on the MoCA—the
only cognitive screening test known to havebeen performed on Trump. Nevertheless,his risk is elevated 5-fold in developing AD
by age 87. It is known that one of his brothers died at age 43 secondary to alcoholism
and a second brother died recently at age
71 of an unknown cause. While exceptional longevity is in his family, it is important
to note that having two brothers die wellbefore expected based on familial longevity, demonstrates the importance of lifestyleand its impact on health which can supersede the genetic advantage of exceptional
longevity. Based on his vital statistics,
Trump has a high likelihood of surviving asecond term in office.
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Comparison
In summary, within the constraints of available medical or publicly available records,
both candidates have a high likelihood ofsurviving the next four years. Based on thelimited information available, Biden may
have a slight advantage over Trump due tohis lifestyle choices such as exercise anddiet regimen as well as a BMI within thenormal range. Both candidates take lessthan the national average prescription
medications. A National Center for Health
Statistics investigation reported that approximately a third of persons over age 60
were on ≥ 5 prescription medications in
2007–2008.34 As higher prescription medication use can be associated with worse
health status than those on less medications, the fact that they are on less medications makes them less vulnerable.35 Bothcandidates have access to excellent healthcare and are known to have a higher income which correlates with an increased
life expectancy.36 This speaks to the factthat despite the age difference, both would
be expected to survive a four-year term.

Medical Review by
Dr. Bradley Willcox, MD,
Professor and Director of
Research, Departmentof Geriatric Medicine,John A. Burns Schoolof Medicine, Universityof Hawaii
https://www.orcls.org

Joe BidenHealthJoe Biden is a 77-year-old married neversmoker and non-drinker who is in excellent
health. His primary medical impairment is
non-valvular atrial fibrillation (AF), an
irregular heart rhythm. This is a common
age-associated arrhythmia and does notappear to be due to underlying coronary
artery disease. AF typically raises the risk ofdeath for men of all ages by 50–90 percent.37 However, given that Biden has neverrequired medication for his heart rate or
September 2020

rhythm, has an otherwise normal heart
function on echocardiogram and EKG, andhas taken standard anticoagulation (to mitigate stroke risk) without complications for
close to two decades, his risk appears to be
mild compared to the average case. This is
not expected to influence his projected
health in a meaningful way.
Biden currently has no other significant
physical or cognitive impairments thatwould otherwise be commonly observed ina man his age; his physiological assessment
and blood work reflect healthy major organsystems; his BMI places him in the lowest
mortality risk group; his level of physicalactivity is exceptional—encompassing bothstrength training and aerobic/cardiovascular activity, which is very important for
healthy aging. He takes only a few prescription medications (including a statin for hischolesterol, an anticoagulant for his AF,
and a proton pump inhibitor for reflux
esophagitis). Otherwise, he takes common
over the counter medications for minor
issues such as seasonal allergies. His medical history includes cerebral aneurysm repair (complicated by postoperative deepvein thrombosis and pulmonary embolism), sinus/nasal passage surgery, cholecystectomy, sports-related orthopedic procedures, prostate surgery (for benign prostatic hyperplasia), possible sleep apnea, among
other more minor issues. These have all
been medically and/or surgically treated
and/or cured, per imaging and other studies. He has excellent social support, medicalcare, health behaviors (including up-todate cancer screening and immunizations)and, importantly, a family history of significant longevity. This suggests that he could bea “super-ager”—someone who is physiologically younger than his chronological age.27
Cognitive functioning
There are no formal cognitive tests for
Biden in the available medical records.
However, his mother lived until age 92 andhis father to age 86, apparently with nodocumented cognitive impairment. Muchof this may be due to genetic cognitive resilience, but Biden’s very healthy lifestyleand lack of vascular disease are also likely to
prolong the duration of his high cognitive
functionality. Modifiable risk factors fordementia include diet, physical activity,
cardiovascular factors (e.g. hypertension,
lipid profile, smoking), inflammation,
among other factors.38 None of these factors appear to present a risk to Biden. In
fact, they are working in his favor. His excellent lipid/metabolic profile and low level of inflammation, evident in his bloodwork, are evidence that he has ongoing key
protective factors. While Biden is a lifelong stutterer and he sometimes struggles
with speech fluency, this has no relation tocognitive function.
Summary
Joe Biden is in excellent overall health for a
77-year-old American male. His primary
medical impairment is non-valvular atrial
fibrillation. This is a common age-associated arrhythmia and does not appear to be
due to underlying coronary artery disease.
He has never had any known complications, does not require rate or rhythm control, and it is considered fairly benign. Casein point, he engages in vigorous physicalactivity that might overly stress a typicalAF patient, without incident, and has done
so most of his life. He has no other major
age-related diseases, all physiological systems appear to be functioning well, his laboratory blood work is exceptional, particularly his metabolic/lipid profile (excellent
cholesterol, fasting blood sugar, hemoglobin A1C). His C-reactive protein (CRP) isvery low, suggesting very low systemic inflammation (a major driver of the aging
process known as “inflammaging”). He eatsa healthy diet and is very physically active.
His medications are minimal and low-risk.
His father and mother far outlived theirbirth cohort, living into their 80s and 90s,
respectively. Biden’s overall health profile
suggests that he has a very high probabilityof surviving through his first term in officewith his physical and cognitive functioning
intact.

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17

DRAFT

Appendix B. Medical reviews Continued
Donald Trump
Survival
Donald Trump’s medical records suggestthat he has an excellent chance of surviving
through a second four-year term. On thepositive side, Trump comes from a family
history of exceptional longevity—and thiswill no doubt influence his survival prospects over the next four years—but he also
exhibits several comorbidities and behavioral risk factors that are documented toshorten life expectancy; including obesity,
a sedentary lifestyle, and dietary habits associated with a high intake of unhealthyfat, sugar, and other high glycemic load
carbohydrates.
HealthTrump’s primary medical impairment is
subclinical coronary artery disease (CAD),
as evidenced by a cardiac CT scan in 2018that revealed a coronary artery calcium(CAC) score of 133. This score is consistent with a moderate level of calcified
plaque deposition in his coronary arteries.
Findings revealed that a CAC score between 101 and 300 carries a moderate tohigh relative risk of 7.08 (3.05–16.47) p<0.001 compared to a score of zero—for amajor cardiovascular event (e.g., heart attack, sudden death) over the next 10
years.23 Of concern, Trump’s CAC score
has increased dramatically from 2009 when
it was 34, to 98 in 2013, and most recently
his CAC score in 2018 was 133. While thisscan was performed at close to 72 years ofage, and placed him at the 44th percentile
for a 72-year old Caucasian male, and hisscore is better than average, it is far from
ideal. His “arterial age”, which is estimatedfrom a validated algorithm for estimatingrisk for CVD “Hard end points (MI or
sudden death), is estimated at 75 years(95% CI: 73–77 years. This suggests mildly
accelerated arterial aging relative to a man
his chronological age and places him atmoderate risk of CVD death over the next
10 years (1% per year).39 This algorithm isbased on coronary calcium score, chronological age, sex, ethnicity, total cholesterol,
HDL cholesterol, smoking status, systolicblood pressure (assumes the absence of18

both clinical CVD and treated diabetes),
and is a better predictor of a major cardiac
event than the Framingham risk score. His
2018 CAC score39 is almost certainly higher now. Recently Trump was placed on a
maximal statin dose in an attempt to mitigate this trend. The CAC score is an independent predictor of the risk of major cardiovascular events, with demonstrated superiority over the Framingham risk score,
CRP level, and carotid intima-media thickness, among 700 other cardiovascular risk
factors.23
In sum, Trump’s major CVD risk factors
are his age, history of high LDL cholesterollevels, his obesity, his poor diet and sedentary lifestyle. This is balanced by good family history, avoidance of smoking, high levels of HDL cholesterol, an excellent bloodpressure (despite no antihypertensive medications), good fasting blood sugar (89–99;
normal < 100k); healthy glycosylated hemoglobin (5.0%; normal < 5.7%), and very
low CRP level (0.7; optimal < 1).

tained from his blood work. For example,
his eGFR is normal (indicating stable renal
function), and his liver enzymes are normal. His cholesterol ratio is good with avery healthy Total: HDL (good) cholesterol ratio and a high HDL (longevity marker), somewhat mitigated by a high LDL(bad) cholesterol level, currently being
treated with a full-dose statin. Thus, thebiomarkers available to assess health andfunction are consistent with a reasonably
healthy septuagenarian whose estimatedlifespan is likely to be greater than average
for a male his age, predicated partly on his
ability to mitigate further build-up of cholesterol plaque in his coronary arteries.

Trump’s obesity is of particular concern(increased risk for CAD, stroke, cancer,etc.). While he appears metabolically
healthy, the burden of cardiovascular disease and all-cause mortality in the metabolically healthy obese (MHO) population
where Trump resides, is not benign. It falls
between optimal risk (non-obese, metabolically healthy), and highest risk (obese,
metabolically unhealthy).40 Trump’s othercomorbidities are non-life limiting andtypical of a male septuagenarian.

Cognitive functioning
Trump has a family history of Alzheimer’s
dementia on his father’s side (onset approximately age 87 years). Although this is considered common and late onset (over 40%
of 85-year-olds have dementia), this still
increases Trump’s risk for dementia versus
the average male. There have been concerns
about his cognitive function in the media
and among many health professionals, suchthat 71 health professionals jointly wrote a
letter to his personal physician urging detailed cognitive testing.41 This resulted in
the only known cognitive screen for dementia that Trump has undergone—theMontreal Cognitive Assessment (MoCA)
test. This is a screening test; there is not asingle diagnostic test for dementia, as it’s aclinical diagnosis based on a battery oftests, including blood tests to rule out other causes of cognitive impairment.

There are no detailed physiological data
revealed from assessments of cardiovascular, pulmonary, hepatic, musculoskeletal, orother major organ system function. However, his exercise stress testing was apparently considered by his physician as “above
average”, echocardiograms and electrocardiograms have been considered “normal”
again, with few details available to assess
underlying risk. Per a CT scan, his lungarchitecture appears intact and there are no
obvious, clinically significant anomalies.
Some additional health clues can be ascer-

Apparently, Trump scored 30/30—a common score on the MoCA. A score of 26/30
or higher is considered normal but does
not completely rule out dementia. A formal diagnosis of dementia and its clinicalsubtype (e.g. Alzheimer’s dementia, vascular dementia, or another subtype) requires
a battery of cognitive and neuropsychological tests. The percentage of people with
Alzheimer’s dementia (the most common
cause of dementia in the U.S.) increases
with age: 3 percent of people age 65–74,
17 percent of people age 75–84, and 32

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September 2020

DRAFT

percent of people age 85 years and older
have Alzheimer’s dementia.42 Trump would
be 78 years old at the end of a second term,
and with his family history, he would exceed the dementia risk of the average person that age.
Summary
Trump’s overall health profile suggests that
he has been quite healthy over the years but
now has subclinical coronary artery disease(CAD), with a moderate level of coronary
plaque. His lack of major disease and disability thus far may be largely genetic since
his parents lived into their octogenarianand nonagenarian years (mother died at 88
and father at 93 years of age, albeit with
Alzheimer’s disease for 6 years before his
death). However, family history is not destiny (two of his brothers have died young)and his poor lifestyle (unhealthy diet, lackof physical activity) may be catching up
with him. This is evident from a worrisome
increase in his coronary artery calcium(CAC) score over the past 9+ years (2009–18), which has progressed from a low CAC
score to a moderately high-risk score (increased risk for a major cardiovascular
event including sudden death). On the positive side, other than obesity, he has a very
good metabolic profile with healthy bloodpressure, high HDL (good) cholesterol,
good hemoglobin A1C level (healthy
blood sugar level), and a low C-reactive
protein (CRP) level. CRP is a marker of
inflammation, and a low score suggests thata major driver of the aging process known
as ”inflammaging” is optimal (<1), as opposed to most people his age. He is also on
few prescription medications for a man his
age (less than a half-dozen low risk medications), appears to receive excellent medicalcare, practices some preventive health behaviors (e.g. takes a multivitamin, screening
tests and immunizations appear up to date)and is married. In sum, based on these data,
and assuming there is no further comorbidity in the medical records, he will likely live
longer than a typical 74-year-old male andlive through a second term in office with his
physical and cognitive functioning intact.
September 2020

Comparison
Overall, the limited amount of information
contained in the medical records and/or
publicly available information suggest that
Biden maintains a slight edge over Trumpin terms of his chances of surviving, andsurviving healthfully, during the next four
years—in spite of the fact that Biden isthree years older than Trump. The mostdefinitive clinical evidence for CAD, theleading killer of American men, in either
candidate, is Trump’s coronary calcium
score on cardiac CT of 133 (in 2018),
which by itself places Trump at a moderaterisk for a major CVD event (including sudden death) over the next 10 years. The biological age of his coronary arteries is also a
few years (approximately three years) older
than his chronological age.39 There is nosuch evidence for CVD in the Biden medical record. Biden has had cerebral aneurysms, but he received surgical treatment
decades ago, and this is no longer considered a risk. He also has persistent atrial
fibrillation (AF) but his rate and rhythm
have never required treatment and he is on
an anticoagulant medication that reduces
his risk of stroke (from AF) to near normal.
While both candidates have a family history of longevity, excellent lipid, metabolicand inflammatory profiles, Biden has amuch healthier BMI, and practices better
health habits, particularly a healthier dietand vigorous exercise. This includes aerobic
activity and strength training, which arevery important for healthy aging. Genes,
while important, are not inert and theirexpression can be modified for better or forworse, by health behaviors. While not all isknown about Trump family health habits, acase in point is that two of the three Trumpbrothers have died young, leaving only one
remaining brother, who other than abstaining from alcohol and tobacco, appears topractice few preventive lifestyle behaviors.

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