As the presidential election draws closer, controversy continues over how the two major presidential candidates have handled the release of their personal health information, as well as what experts are saying about the candidates’ health. The interesting thing is that our nation is poised to elect one of its oldest presidents. Trump at 70 would be months older than Ronald Reagan on his election day, and Clinton will have just turned 69.

Joyce Frieden the News editor for MedPage expanded on the issues that the Presidential candidates Donald Trump and Hillary Clinton have both revealed more information about their own health, although it is unclear whether they’ll satisfy critics — and the method of delivery may also raise additional questions. Actual knowledge of the candidates’ physical fitness has come so far from letters released by their personal physicians.

Clinton recently released a letter from her physician and Trump took to the airwaves: handing “Dr. Oz” a two-page document detailing the results of his latest exam.

“On Friday, September 2nd, I evaluated Mrs. Clinton for a 24-hour history of a low grade fever, congestion and fatigue,” Lisa Bardack, MD, wrote in a letter released by the Clinton campaign. “On examination, she was noted to have a temperature of 99.4; her vital signs were otherwise normal as was her physical exam. She was advised to rest, put on a short course of antibiotics and continued on her allergy medications for an upper respiratory tract infection in the setting of her seasonal allergies. Over the next several days as she traveled, her congestion worsened and she developed a cough. She was advised to see me when she returned from her travels for further testing.”

Bardack continued: “On Friday, September 9th, she was seen and evaluated in my office. A non-contrast chest CT scan, including a CTA calcium score, was performed. This test allowed for specific imaging of her lungs while also following up on cardiac risk stratification from 2010 given her family history of heart disease. The results of the CT scan revealed a small right middle lobe pneumonia; her coronary calcium score was again zero. She was treated with antibiotics for pneumonia and advised to rest. This was a mild non-contagious bacterial pneumonia.”

“On Sunday, September 11 at the 9/11 Memorial event, she became overheated and dehydrated and as a result felt dizzy,” Bardack wrote. “I examined her immediately upon her return home; she was rehydrating and recovering nicely. I advised her to stay home and rest for the next several days. Mrs. Clinton has since been evaluated by me several times and continues to improve.” The letter also addressed other areas of Clinton’s medical history, noting “Mrs. Clinton’s current medications include Armor Thyroid, Coumadin dosed as directed, Levaquin (for a total ten days), Clarinex, as well as B12 as needed. … She remains up to date on all of her immunizations, including Prevnar and Pneumovax. Her Coumadin levels have been adjusted as needed according to regular lab testing. She had a normal mammogram and breast ultrasound.”

In terms of lab tests, “Her laboratory testing … was normal, including cholesterol of 189, LDL of 103, HDL of 56 and triglycerides of 159,” Bardack said. “Her vital signs showed blood pressure of 100/70, heart rate of 70, respiratory rate of 18, temperature of 97.8 and pulse-oximetry of 99%. The remainder of her complete physical exam was normal and she is in excellent mental condition.”

Several physicians weighed in on the results. “From a cardiovascular risk point of view, she is low-risk with her coronary calcium score of 0 and her excellent lipid levels,” Christopher Cannon, MD, professor of medicine at Harvard Medical School, in Boston, wrote in an email to MedPage Today.

However, he added, “It is not specified why she is taking warfarin/Coumadin. This would be additional information that would be helpful to fully understand her health status.”

Stephen Cook, MD, MPH, an internist at the University of Rochester (N.Y.), applauded Clinton’s disclosures. “I’m remarkably pleased with the objective and open information that was provided by Mrs. Clinton’s doctor, and assuming with her permission,” Cook wrote in an email. “I’m very much into prevention, so hearing that candidates are up to date with immunizations and cancer screening is great to hear.”

Remember, that we were also previ to another letter from her physician. The first letter to be released came in July 2015 from Lisa Bardack, MD, an internist in Mount Kisco, N.Y. and Hillary Clinton’s personal physician. Bardack’s letter, which was eight paragraphs long, contained both specific and general information about Clinton — for example, it said that Clinton’s most recent physical, in March 2015, found that her blood pressure was 100/65 and that her total cholesterol was 195, with an HDL of 64 and triglycerides of 69. It also noted that she is taking vitamin B12, antihistamines, and Armour Thyroid for hypothyroidism.

More generally, the letter said that Clinton “does not smoke and drinks alcohol occasionally. … She eats a diet rich in lean protein, vegetables, and fruits. She exercises regularly, including yoga, swimming, walking, and weight training.” Question: How does she do these exercises with her schedule?

The letter also makes note of two episodes of deep vein thrombosis in 1998 and 2009, and an incident in December 2012, in which Clinton “suffered a stomach virus after traveling, became dehydrated, fainted, and sustained a concussion.” Clinton had follow-up evaluations that found a transverse sinus venous thrombosis, and she was given anticoagulation therapy as well as glasses with a Fresnel prism to treat double vision resulting from the concussion.

“She had follow-up testing in 2013, which revealed complete resolution of the effects of the concussion as well as total dissolution of the thrombosis,” the letter continued. “As a precaution, however, it was decided to continue her on daily anticoagulation” in the form of warfarin (Coumadin). Bardack concluded by saying that Clinton “is in excellent physical condition and fit to serve as president of the United States.”

First, regarding Mr. Trump, lets start with his physician’s letter. Donald Trump’s physician, Harold Bornstein, MD, of New York City, released a letter in December 2015 that was much shorter and lighter on details. “Mr. Trump had a recent complete physical examination that showed only positive results,” Bornstein wrote in a four-paragraph letter. “Actually, his blood pressure, 110/65, and laboratory results were astonishingly excellent.”

Bornstein wrote that Trump had lost 15 pounds in the past year and that he takes 81 mg of aspirin daily along with a low dose of a statin. “His PSA test score is 0.15 … His physical strength and stamina are extraordinary.” Trump’s cardiovascular status is “excellent,” and he has no history of alcohol or tobacco use, Bornstein added.

After noting that Trump has no cancer and has never had any orthopedic surgery, Bornstein concluded, “If elected, Mr. Trump, I can state unequivocally, will be the healthiest individual ever elected to the presidency.”

That last line raised concerns for Peter Whitehouse, MD, PhD, and professor of neurology at Case Western Reserve University, in Cleveland. “The physician who wrote this letter undermined his credibility by saying that,” he said in a phone interview. “The physician who wrote this letter undermined his credibility by saying that,” he said in a phone interview. “Based on reading the letter, I would have doubts about referring to that physician; he has limited knowledge of the [health of] the 40-odd presidents we have had.”

These health disclosures should be seen in the same light as candidates’ income tax disclosures, Whitehouse continued. “I’d do it on a voluntary basis” — that is, candidates shouldn’t be required to disclose their health records, “but if you don’t … you’re subject to scrutiny as to why not.”

Meanwhile, Trump appeared on the “Dr. Oz” syndicated television show on Thursday with his own medical report. The show’s host, Mehmet Oz, MD, went through a brief review of systems with Trump, who answered “no” to questions about whether he had any history of neurologic problems, stroke, cancer, stomach problems, or other ailments. As far as his family medical history, Trump mentioned that his father developed “what was probably Alzheimer’s” during the last few years of his life; he died at age 93.

Trump also handed Oz two pages that the candidate said included results of his latest exam and test results from a series done at Lenox Hill Hospital last week. Oz read the results to the audience and Trump campaign released the documents.

• Height: 6’3″                                         PSA: 0.15 ng/mL
•          Weight: 236 lbs.                                 Blood pressure: 116/70 mmHg
• Total cholesterol: 169 mg/dL         Blood sugar: 99 mmol/L
• Calcium score: 98 HU                       HDL: 63 mg/dL
• LDL: 94 mg/dL                                   Testosterone level: 441 ng/dL
• Triglycerides: 61 mg/dL

As for exercise, Trump said he was “speaking in front of 15,000 or 20,000 people and I am up there using a lot of motion; in its own way it’s a pretty healthy act. A lot of times these rooms are very hot, like saunas, so I guess it’s a form of exercise.”

His doctor, Harold N. Bornstein, MD, wrote that Trump takes rosuvastatin (Crestor) and low dose aspirin, but he did not indicate the exact dose in either case. Trump said he has never needed much sleep and noted, “I feel as good today as I did when I was 30. When I play golf, I feel may be a better golfer today than I was 15-20 years ago … I hit the ball better; I putt just as well.”

According to the American College of Cardiology/American Heart Association’s cardiovascular disease risk calculator, Trump’s numbers put him at about a 13% risk of developing cardiovascular disease in the next 10 years, Cannon wrote. Using that same risk calculator, Robert Eckel, MD, professor of medicine and director of the lipid clinic at the University of Colorado Denver Anschutz Medical Campus, noted that Clinton’s 10-year risk score comes out to 4.7%. “Her coronary calcium score by CTA is zero — good news. I don’t feel that I have sufficient information to comment on her need for Coumadin or thyroid hormone.”

Greg Rosencrance, MD, chairman of the Cleveland Clinic Medicine Institute, said that overall, “The health information on the candidates is useful, but it’s important to recognize that it’s in the form of a summary, not the full records, and therefore we would be reliant on others for interpretation. The details included along with the vital signs are good indicators of someone’s overall current state of health.”

Maybe, besides the full disclosure of the Candidates’ health information we need to know what type of REAL exercise program they engage in daily, not just standing up in front of a crowd and hand motioning, or whatever! Although Mrs. Clinton’s doctor did say that she engaged in swimming and yoga regularly. Doctors often tout how exercise can help ward off disease, but previous research hasn’t concluded just how much physical activity is needed to reap those benefits. I was going to discuss the benefits of exercise as research has proven, but that would only deflect our discussion about relevance of these other issues.

We all know that this is all a distraction from the real issues….. and yes if you want to stay on the subject… the real issues of the health of the healthcare delivery system and the health of we Americans.

I think that we all agreed that some degree of medical disclosure for candidates was necessary — the question is, how much information should they disclose? “Candidates for very high office, like president, do have an obligation to disclose if they have a serious health problem, like if they have cancer or have had a stroke.” said Doug Brugge, PhD, professor of public health and community medicine at Tufts University in Boston. “If they just have risk factors — like high cholesterol — most of us have risk factors, so that is not such a big deal.”

“As a matter of public policy, public interest and what may remain of a ‘right to know’ for the electorate, the medical fitness of a prospective U.S. president is important,” Jay Wolfson, D.Ph., JD, professor of public health, medicine, and pharmacy at the University of South Florida, in Tampa, wrote in an email to MedPage Today. “Prospective and actual public officials lose some of the private prerogatives they may have enjoyed (or presumed) prior to their entrance on the stage of public service. And being a candidate is being on that stage.”

Clinton’s concussion and its aftermath have been the subject of much speculation, including from physicians. Drew Pinsky, MD, discussed Clinton’s medical record on his TV show in January, saying that as a result of the concussion, “she had to wear these prism glasses. … That is brain damage, and it’s affecting her balance.”

Some mental health specialists have weighed in on Trump as well. Trump has “textbook narcissistic personality disorder,” Ben Michaelis, PhD, a clinical psychologist in New York City, told The Atlantic last November. Howard Gardner, PhD, a professor of cognition and education at Harvard, agreed, calling Trump “remarkably narcissistic.”

I have discussed this in a previous post that many such pronouncements have been made in the press that the American Psychiatric Association reminded its members earlier this month of the association’s “Goldwater Rule” — named for the late Republican presidential candidate Barry Goldwater — which prohibits psychiatrists from offering opinions for someone they haven’t personally evaluated.

Experts were generally in agreement that clinicians of any kind should not be diagnosing either candidate from afar. “I do think it is questionable for physicians to make comments about anyone as it pertains to their health without actually personally evaluating them,” said Mohana Karlekar, MD, medical director for palliative care at Vanderbilt University, in Nashville, Tenn. “Physicians must be mindful that any statement they make that includes a medical assessment will be interpreted by the general public as a valid assessment.”

Neil Wenger, MD, MPH, professor of medicine at the University of California Los Angeles, agreed. “A professional would not act as a physician in this way,” he said in an email. “When doing so, a physician has become a media personality or entertainer or is fulfilling some role, as did Senator Frist in the Schiavo case.” Wenger was referring to Terri Schiavo, a woman in a persistent vegetative state whose husband wanted her life support removed; former senator Bill Frist, MD (R-Tenn.) argued against doing so and suggested that Schiavo might not be in a vegetative state. Schiavo’s life support was eventually removed following a lengthy court battle; she was found on autopsy to have had severe, irreversible brain damage.

As bioethisist Arthur Caplan stated this morning in the Washington Post, “if we really care about Trump’s or Clinton’s health, the way to find out about it is not to ask them, their staff, their doctors, Dr Oz, etc. It is to have them supply their medical histories and submit to a thorough examination by an independent panel of doctors in areas such as internal medicine, oncology, geriatrics, psychiatry and neurology.”

I like his idea. Then the National Academy of Health would appoint the panel of doctors and tell the candidates to show up in August for a 2 day physical, with the results to be reported before the end of the month, not like an IRS audit and take years for the public to see, read or hear about it in the press.

He  also said that although diagnosis from afar is never appropriate, there is a role for historical analysis: “Historians can take a look at people’s behavior and comment on likely pathologies, whether it’s Woodrow Wilson’s stroke or Ronald Reagan’s memory loss; it’s not appropriate to preclude historians from examining how the health of leaders can affect their behavior. What I’m objecting to is clinicians who don’t know the person putting on clinical labels with any degree of certitude.”

“Age always matters” when it comes to risk for disease, said well-known aging researcher S. Jay Olshansky of the University of Illinois at Chicago, but he cautions that it shouldn’t be a litmus test for the presidency.

Trump at 70 would be months older than Ronald Reagan on his election day, and Clinton will have just turned 69. With life expectancy at a record high and a generation of more active seniors, older presidential candidates are no surprise. But older age also raises concern about the risk of Alzheimer’s disease. Reagan, who turned 70 shortly after his first inauguration, was diagnosed with Alzheimer’s several years after leaving office.

Olshansky’s research found many presidents outlived the life expectancy of their time, likely thanks to wealth and access to top medical care that Clinton and Trump also have. Hey, what happened to the excellent health care that we are supposed to get with the Affordable Care Act?

Possibly the factor most promising for longevity is that both candidates’ parents lived into their 80s and 90s, Olshansky noted. “We have sufficient information to believe the two of them are both likely to be healthy long enough to survive eight years in office,” Olshansky said.

Even with Dr. Caplan’s suggestion for a 2 day examination, etc….is this solution going to happen? We all know that it isn’t because while discussions of Clinton’s pneumonia and Trump’s weight make for employment for media TV idiots and help fill the empty air time on cable news channels, you really don’t need to be all that healthy to be president, much less a politician and more importantly…… the voters really don’t care.                                                                                                                      Caplan went on to point out that we have had people in or near the White House with bad hearts, consider President Eisenhower and Dick Cheney who both had heart attacks while in office. We have had presidents who have abused alcohol and pain medications, such as John Kennedy and Richard Nixon, and before he took office, George Bush. And at least one president surpassed any missteps exhibited by Clinton, frequently stumbling, tripping or banging his head, Gerald Ford.

I think that we all can agree that most if not all politicians are crazy and as Americans have health concerns. But as I have said earlier, we should be focusing on real policy- economic, health care, educational and social issues and more importantly the health of the average American, who is obese, rides motorcycles and bicycles without helmets, doesn’t exercise regularly, eat billions of dollars of junk foods and doesn’t follow the “suggestions” of their own doctors.

So, how much do we know — and should we know — about how physically fit Donald Trump and Hillary Clinton are for the job?

Maybe we should be more concerned about the V.P. candidates (Republican vice presidential candidate Mike Pence released a letter by his campaign, Saturday from his doctor Saturday stating that he is in “excellent general and cardiovascular health,”) or more importantly our own health and more importantly, how our health will be effected by a Single Payer Health Care System?????