Health and Medical History of President

Donald Trump

Trump's father died at 93 "after suffering from Alzheimer's disease for about five years" 3. (Obituary: 4) Trump reports longevity in his father's ancestors 2.

Trump's mother died at age 88 3, having had "debilitating bone loss" (presumably osteoporosis) for perhaps 10 years 1. She suffered also from longlasting complications 5 of a mugging and beating in 1991 6, nine years before her death. Trump reports longevity in his mother's family, too 2.

Trump said in 2011 that he "had a father who was 94 [and] a mother who was 90, so you know, I'm genetically lucky that way" 7.

Trump's older brother, Fred, "was an alcoholic. Died at a very young age, 43. ... Probably around college time he started drinking a little bit and then a little bit more and a little bit more. ... he also smoked." 2 Donald Trump has abstained from smoking and drinking throughout his life 8, a fact often ascribed to witnessing his brother's fate. Regardless of their genesis, these temperate habits have certainly benefitted him.

Per Trump: "I had my appendix out when I was 11, and that was the last time I was in a hospital. That was a one-night deal." 2

Sometimes in the spring or in the fall, I'll get a little hay fever. And that comes and goes. Actually I don't know why this would be. It used to be worse when I was young. Maybe it's given up on me. ... But when I was young, it could be pretty rough, the hay fever. But very, very little now. I don't know if that's something that you're not that surprised at, but the hay fever is not very bad.

Trump averred in 2016 that "I had a doctor that gave me a letter -- a very strong letter on the heels," continuing that the condition was temporary and that it was "not a big problem, but it was enough of a problem." He did not produce any documentation. 10

Long speculation held that the heel spur diagnosis was a ruse to avoid military service 11. In late 2018 the daughters of a New York podiatrist, Dr. Larry Braunstein, spoke to the New York Times 12:

The doctor's daughters said his role in Mr. Trump's military exemption had long been the subject of discussions among relatives and friends. "It was family lore," said Elysa Braunstein. "It was something we would always discuss."

Speculation turned to fact in early 2019 when Trump's longtime attorney testified as follows, under oath, before Congress and a large television audience:

During the campaign [in 2015-2016] Mr. Trump tasked me to handle the negative press surrounding his medical deferment from the Vietnam draft.

Mr. Trump claimed it was because of a bone spur, but when I asked for medical records, he gave me none and said there was no surgery. He told me not to answer the specific questions by reporters but rather offer simply the fact that he received a medical deferment.

He finished the conversation with the following comment. "You think I'm stupid, I wasn't going to Vietnam" 13.

Comment: None of the released medical examinations have mentioned this.

Primary documentation from government sources -- his draft card in 1964 and his drivers license in 2012 -- gives Trump's height as 6 feet 2 inches MORE. And, during debates in the 2016 presidential campaign, it was apparent that another debater, former Gov. Jeb Bush (6 feet 3 inches), is taller than Trump 15.

Thus, there is no doubt that Trump is 6 feet 2 inches tall (at most).

He has stated (2016) that "the one thing I would like to do is be able to drop 15, 20 pounds. It would be good." 2

Speculations that Trump's disclosed weight far below his actual weight were known as the "girther" conspiracy, in mocking reference to the fatuous "birther" accusations that President Obama was born outside the United States 17.

Comment: It says something when even the height and weight of the President -- which are the simplest and most straightforward parameters conceivable -- are uncertain and thought to be manipulated. Physician participation in spreading misinformation hurts the profession (at the least).

Trump has said: "I tell my kids no drugs, no alcohol, no cigarettes. But the world is so competitive that if you're stuck on drugs or alcohol, you're not going to be able to compete. It's going to be a disaster. And you know, it potentially can ruin your life." 2   Comment: This sound advice understates the medical benefits of avoiding cigarettes and alcohol -- unquestionably a positive and powerful factor in Trump's health.

It's amazing, I can't even believe it. I've been so lucky in terms of that whole world, it is a dangerous world out there. It's like Vietnam, sort of. It is my personal Vietnam. I feel like a great and very brave soldier.

You know, if you're young, and in this era, and if you have any guilt about not having gone to Vietnam, we have our own Vietnam -- it's called the dating game ... Dating is like being in Vietnam. You're the equivalent of a soldier going over to Vietnam.

Using a bronze cast of his hands made in 1997 (and kept on public display through at least 2016), the length of his right hand has been accurately measured as 7.25 inches 19.

According to data from Ergonomics Center of North Carolina, the average American male's hand is 7.61 inches long. Trump's hand sits at the 15th percentile mark. That is, 85 percent of American men have larger hands than Trump. As do a third of women. 20

Note, however, that the comparison above refers to all American men. At 6'2'' Trump is almost half a foot taller than the average American man 21. If Trump were compared to men of his height rather than all men, his hands would be comparatively smaller still. Of note, compared to firefighters, truck drivers, and EMTs, Trump's hands are at the 10th percentile or less MORE.

The smallness of his hands clearly nettles Trump, beginning with a magazine article calling him a "short-fingered vulgarian" in the 1980s -- to which Trump wrote rebuttals for more than 25 years 22 -- and extending beyond the 2016 presidential campaign, during which Trump felt it necessary to characterize the size of his genitals after an opponent mocked his small hands. MORE

Trump is known to use "bronzer" -- "a powder or cream designed to give a tanned look" -- sometimes in a thick layer. A line of oxidized bronzer has been seen around his hairline. Trump prefers to apply his make-up himself, in private, but the line is evidence of poor technique. 24

Whether Trump undergoes artificial tanning is unknown. Some accounts say yes, but sources say the White House has no tanning booth nor tanning bed. However, some Trump-owned properties offer spray-on tans. 24

Photographers have noticed that the white balance in Trump's 2017 official photograph is "too cold" but cannot be corrected without making him look orange-ish 25.

Before 2017 Trump was on a long-acting tetracycline for the condition 26, e.g. doxycycline or minocycline. By February 2018 he was on ivermectin cream 27. No reason for the change has been disclosed. Comment: Two possible reasons would be: (a) a desire to limit the number of systemic medications the President takes, and/or (b) tetracyclines (not so much minocycline) cause sensitivity to the sun in some people, which would be a factor if Trump does do artificial tanning.

• Germs -- Trump has called himself a "germaphobe," as discussed below, to a degree that it affects his behavior daily.
• Poisoning -- It has been widely reported that Trump is afraid of being poisoned, and that this is one of the reasons he likes to get food from McDonald's, where he can be reasonably sure no one in the kitchen is plotting to do him in 28. Comment: This may be a perfectly valid fear for a highly unpopular person, but if it is the main reason he consumes a high fat diet, then he is merely trading the possibility of acute poisoning for the certain slow poisoning of his arteries.
• Toothbrush tampering -- Moving into the White House "he imposed a set of new rules: Nobody touch anything, especially not his toothbrush" 28. (Unclear if this is a true fear, perhaps related to poisoning, or just a pet peeve.)
• Senility -- "Trump, a man whose many neuroses included a horror of senility" 28. This unsourced report is plausible given the Alzheimer disease Trump would have witnessed in his father.
• Substances [?] -- Trump speaks with a mixture of pride and vehemence about his avoidance of substances, including coffee. (And yet his daily caffeine intake is substantial.) Nevertheless, as a wealthy young man in New York City during the cocaine-fueled 1980s, his avoidance remains notable. Certainly, watching the decline of his older brother has formed his attitudes, which may border on fear.
• Sexually transmitted disease -- Trump has likened the risks of sexually transmitted disease to the risks of combat, as noted elsewhere. The frequency with which he refers to this suggests it is an idée fixe for him. Yet, it appears not to affect his personal decisions about safer sex.
• Sharks -- He is reported as being obsessed and terrified of sharks, and of saying: "I donate to all these charities and I would never donate to any charity that helps sharks. I hope all the sharks die." 29 (Comment: It's hard to know how much truth is in that quote.)
• Military service -- Trump's fear of military service during the Viet Nam war was wholly rational, but it led him to take unethical (at the least) steps.

He, of course, describes impressive stamina, saying, while campaigning in 2016, "I feel as good today as I did when I was 30" 2.

Objectively, Trump's only form of exercise is golf, but he habitually rides in a golf cart, even driving the cart onto the green (a major violation of golf etiquette) in 2017 to save walking a few feet 33. Trump's physician has encouraged more exercise 34, but Trump has demurred 35 36.

In January 2018 he underwent a treadmill exercise test as part of his annual physical examination. Quantitative results were not disclosed, but his physician reported "above average exercise capacity based on age and sex" 27. (Trump gave an exaggerated account 35.) Given that Trump was at or close to exhaustion on an international trip in May 2017, this statement from the presidential physician in January 2018 is seen to be an exaggeration, too 34:

One of the things, being with the President on a day-to-day basis, that has been impressive to me is he has a lot of energy -- a lot of energy and a lot of stamina.

And I think I first noticed that -- we traveled, did some overseas travel last year. And I was really surprised because I didn't know the President early on. And the days -- we'd get these 14-, 16-hour days, and the staff is just spent after a while. And you're just like, man, when are we going to the hotel? When are we going down? Because you have all the issues of different time zones and things of that nature, too.

And I'll tell you, out of everybody there, the President had more stamina and more energy than just about anybody there. He was the one that was always like, we're not going to skip this event, we're going to do this, we're going to do that, and stuck to the schedule despite the urging of some of us to let's just forget the rest of the day.

"A noted homebody, who apart from the White House, seldom sleeps away from Trump properties or dines outside Trump restaurants," Trump flew out from Washington, DC around 2:20 pm on May 18 aboard Air Force 1, on his first international trip as President. Having worked during most of the 12 hour 20 minute flight to Saudi Arabia, sleeping "barley a wink," he landed in Saudi Arabia at 9:42 am local time on May 20 ... just in time for a full day's work. 37

Day 2: "He stifles yawns. His eyes narrow. And ultimately, when he garbles part of his speech [May 21], an aide explains that President Donald Trump is `just an exhausted guy.'" 37 (The garbling was actually rather substantive.) After the speech, he cancels an appearance at a Twitter forum in Riyadh 37.

Day 3: Now in Israel, "he was blinking through an appearance with Prime Minister Benjamin Netanyahu" 37. On short notice Trump cancels a speech at Masada when he learns access must be by cable-car, not by helicopter 39.

Day 8: At the G7 meeting in Taormina, Sicily, on May 27 he rode a golfcart 700 yards to a photo-shoot while the other leaders all walked 40 3. (Six years earlier, two of Dr. Zebra's friends, then aged 91 and 86, easily walked the entire length of Taormina.)

May 31: Shortly after midnight Trump makes his famous "covfefe" [sic] gaffe in a tweet, which is quickly deleted 38.

Even into June he appeared to be conserving energy, by driving a golf cart onto the green (a major violation of golf etiquette) to save walking a few feet 33.

Two years later, Trump's status in summer 2019 was described by a sympathizer as: "He's exhausted ... He's very tired. [His opponents] have worn him down." 41

Comment: The important take-away here is that, although Trump always looks high-energy during his brief moments in front of the camera, he is still subject to becoming over-taxed.

• Sparsity -- Male pattern baldness is, of course, extremely common in men with normal levels of testosterone. To block the action of testosterone on hair (and, coincidentally, the prostate) and thereby prevent further hair loss, Trump has been taking a widely-prescribed medication called finasteride since at least 2016 26. (This disclosure ruptured the 36-year relationship between Trump and his private physician 42.)
• Styling -- Trump detailed his morning hair-care routine in 2011 7. His daughter has described different mechanics to friends 28: "an absolutely clean pate -- a contained island after scalp-reduction surgery -- surrounded by a furry circle of hair around the sides and front, from which all ends are drawn up to meet in the center and then swept back and secured by a stiffening spray." Trump's first wife, Ivana, testified in a sworn deposition during their divorce proceedings in the early 1990s that Trump had scalp reduction surgery, which he has denied 3.
• Color -- Trump's daughter also related that the color arose "from a product called Just for Men -- the longer it was left on, the darker it got. Impatience resulted in Trump's orange-blond hair color." 28
• Acceptance -- Because hair transplants can produce such stellar results, it is reasonable to ask why Trump has not elected to have one. He can certainly afford it, and certainly cares about the appearance of his hair. One acquaintance has stated: "He said that he thought that if he cut his hair or changed it, that he would lose his power and his wealth" 29. Comment: Does scalp reduction surgery somehow prevent a later transplant?

• From 3:

  A recent book by former campaign manager Corey Lewandowski and former aide David Bossie, Let Trump Be Trump 43, said the presidential candidate would often eat one McDonald's meal a day consisting of two Big Macs, two Filet-O-Fish sandwiches and a chocolate shake -- a menu that would total at least 2,400 calories and more than 3,400 milligrams of sodium.

• From 44, referencing the same book:

  Trump's fast-food diet is a theme. "On Trump Force One there were four major food groups: McDonald's, Kentucky Fried Chicken, pizza and Diet Coke," the authors write. The plane's cupboards were stacked with Vienna Fingers, potato chips, pretzels and many packages of Oreos because Trump, a renowned germaphobe, would not eat from a previously opened package. The book notes that "the orchestrating and timing of Mr. Trump's meals was as important as any other aspect of his march to the presidency," and it describes the elaborate efforts that Lewandowski and other top aides went through to carefully time their delivery of hot fast food to Trump's plane as he was departing his rallies.

• Despite having tweeted in 2012 "I have never seen a thin person drinking Diet Coke" 45 and calling the beverage "garbage" 46, Trump drinks a dozen of them each day 47. By pressing a button on his Oval Office desk, he summons a White House butler to bring him one 48. In 2011 said that he likes a "little caffeine" and that, while he likes tomato juice and orange juice, "Coke or Pepsi boosts you up a little" 7.
  Comment: This is a considerable caffeine intake. It is safe to say that Trump has a physical addiction to the substance, i.e. would suffer withdrawal symptoms if the substance were withdrawn. One would also not be surprised if the underlying drive to consume that much caffeine arose from a need to counteract daytime somnolence, given that Trump (a) does not sleep much, and (b) by virtue of his obesity is at elevated risk for obstructive sleep apnea, which is a cause of daytime somnolence. (And in a vicious cycle, the caffeine may of course prevent him from sleeping more.)

At Trump's first presidential physical (2018), his physician prescribed a change in diet MORE. Trump was non-compliant 49. Comment: The fundamental mistake of aging is to presume (or hope) that the body can tolerate in later life what it could tolerate with impunity earlier in life, or that the future is even as predictable later as it is earlier 50. Trump is making precisely this mistake, perhaps misled by the longevity of his parents, who did not pursue the same physiological path as him. Bacchus has already started sending in his bills, which will inevitably become due in full.

Comment: President Trump, like every human past middle age, has presbyopia -- difficulty focusing visually on a nearby objects, as when reading. (George Washington's reading presbyopia may have saved the United States.) It's completely normal, and is especially troublesome in poor light, when the pupil dilates and loses its depth-of-field effect. Adding illumination can restore depth of field, making letters clear enough to read without glasses.

This was quickly reported as a potential security hazard, because adversaries could have hacked the waiters' mobile phones to gather image data (the documents being reviewed) or audio data (the conversation) while the phones were in proximity to the president 51.

Comment: This episode is most notable for what it says about the complexity of the presidency, i.e. the fact that White House aides must, at least indirectly, worry about the national security implications of the lens of the president's eyes! (It reminds Dr. Zebra of the similar wonderment of a U-boat medic in World War 2 who was discussing a sailor's case of gonorrhea with his surprisingly knowledgeable captain. The captain believed that the resolution of the sailor's urethral discharge was likely due to encapsulation of the gonococci. "The things that a U-boat commander had to know!" 52a) One must wonder, however, whether mobile phones are routinely removed from anyone who gets in conversational range of the president, given that they could be used for eavesdropping at any time.

In January 2018 Trump's "visual acuity" without glasses was 20/30 in both eyes 34, but the report did not specify if this was distance vision or near vision (deliberate ambiguity?). Based on the universality of presbyopia, it is certain that 20/30 represents distance vision and that his near-vision acuity is publicly unknown.

As a candidate, Trump issued three statements about his medical health:

• 2015: (December)   MORE 8 (Physician statement #1)
• 2016: (September)  MORE 9 (Physician statement #2)
• 2016: (September)  MORE 2 (Interviews: Dr. Oz, Fox)

• 2017: (January)  Takes office.
• 2018: (January)  MORE 27 Press briefing: MORE 34
• 2019: (February) MORE 49
• 2019: (November) MORE 53

Comment: Incredibly, these physical examinations, which one would expect to be routine, staid affairs, took on circus-like characteristics:

• The 2015 report had ridiculous, unprofessional hyperbole that made Trump's physician a national laughingstock. It later emerged that Trump wrote this report himself.
• The 2018 report was delivered during a press conference in which the President's physician made good-humored and properly caveated remarks that commentators unfairly inflated to ridiculousness.
• The first 2019 report, though more subdued (and, sadly, far less complete), still contained unsupportable prognostications from the new presidential physician.
• The second 2019 report, for Trump's "interim checkup" if that's what it really was, is a shambles. Subtexts of the nonsensical statements from the White House and the President's physician strongly suggest it was not a routine examination at all, but a hurried, abrupt consultation at Walter Reed for undisclosed medical reasons.

Hence, three times in two years confidence in the office of the President's physician was undermined -- a low ebb in its history. Even with a perhaps unwarranted acceptance that the President's medical team has been completely and honestly forthcoming, all this sturm und drang is itself dangerous, as it can easily detract from substantive medical issues -- as it already seems to have done with Trump's sleep.

The diagnosis is not a surprise. Although Trump does good things for his arteries by avoiding tobacco and maintaining a low blood pressure, anyone living in the modern world is at risk for atherosclerotic arterial disease, of which coronary disease is the deadliest type. Thus, news outlets intone that Trump "has a common form of heart disease" 54 55, but of course it is more complicated than that.

First, a little background:

Coronary artery disease causes symptoms when pathological narrowings in an artery limit blood flow through that artery. Based on the laws of hydraulics, a single lesion in a coronary artery has to obstruct about 60% of the arterial diameter in order to cause symptoms. When obstruction is 100% or nearly so, a heart attack will occur.

Coronary artery disease is a concern because it can lead to heart attack, heart failure, effort intolerance, and arrhythmias including sudden death. It can also can herald disease in other important arteries, such as those in the brain.

1. A calcium score between 100 and 300 raises the risk of heart attack or coronary death by a factor of 7.7 as compared to people having no coronary calcium 56. Comment: That sounds grim, but this is only a relative risk. The next item discusses absolute risk, which is more important.
2. For Trump as an individual, his calcium score, blood pressure, cholesterol level, etc. translate to a predicted 9.5% chance of a "CHD event" in the next 10 years, using the MESA model 57. (See screenshot at bottom of this page→ MORE) In the MESA model, a "CHD event" (coronary heart disease event) is defined as any of: myocardial infarction (heart attack); resuscitated cardiac arrest; death from coronary heart disease; or, in persons with angina, coronary revascularization ("revascularization" = bypass/angioplasty/stent) 58. A different, unnamed model has been reported to yield a 17% risk 59. Comment: The difference between the models could be explained if they use different endpoints. For example, the MESA model does not consider angina pectoris as a "CHD event," but another model might, and so its predicted "risk" would be a higher number. Other models for persons aged 70+ generally do not factor in coronary calcium levels. The MESA output for Trump MORE shows that considering his calcium score does not markedly change his risk prediction.
3. At the level of single obstructions in the coronary arteries, it can be said, on the basis of one study 60, that Trump has a 95% chance of being free from a coronary obstruction of more than 50%. Comment: There is no question, however, that Trump should continue to take a statin, as figure 1 in another study shows 61.
4. Compared to the typical 17% annual increase in calcium score 62, Trump's increase in annually compounded calcium score was quite high from 2009 to 2013 (went from 34 to 98 = 188% rise in 4 years = 30% increase per year), but has been slow from 2013 to 2018 (went from 98 to 133 = 35% rise in 5 years = 6% increase per year). Comment: This is hard to interpret. The recent slow-down could be good, or it could be bad (because one benefit of statins seems to be conversion of dangerous non-calcified atherosclerosis into less dangerous calcified atherosclerosis). Such uncertainty highlights limitations of the coronary calcium score as it is understood today. New scanning techniques are available, but are not as well studied.

Although putting numbers on serious events can be comforting, it is important to remember that the predictions are not really individual predictions, and that arterial disease has a large, unpredictable component. No physician would be surprised if Trump had a heart attack or stroke tomorrow. Comment: It's this unpredictability, plus Trump's age, that make the effusive prognoses of the White House physicians unsupportable. For example, arterial narrowings much less than 100% often cause heart attacks, not because they limit blood flow, but because they are metabolically active or physically unstable and thereby incite formation of a blood clot at that spot (which then causes 100% obstruction). It is precisely these types of plaques -- non-calcified -- that are missed by coronary calcium scanning. Also, even minimal amounts of coronary disease may enable spasm of the artery, with all the consequences of obstructed blood flow. The most sobering statistic is that sudden death is the first symptom of coronary artery disease in 20% of patients. That said, many people do well in the long term with coronary disease. But all in all, it is better not to have it!

• Age            = [worse every year] But not amenable to treatment!
• Tobacco usage  = [good] Lifelong non-user
• Diabetes       = [good] Does not have diabetes mellitus
• Blood pressure = [good] Lifelong healthy pressure (apparently)
• Family history = [good] No heart attacks or strokes in close blood kin
• "Cholesterol"  = [bad→good] Blood lipids are under treatment
• Obesity        = [bad] Unsuccessful treatment
• Exercise       = [bad] Unsuccessful treatment

Trump takes a cholesterol-lowering "statin" medication and reported in September 2016: "And actually I've experimented with three statins. And one seems, for me, to work the best. And it's really brought my cholesterol down into a good range." Asked how long he's been on it: "Couple of years, I would say. Couple of years" 2. Doctors quadrupled the dose of Trump's statin during his second year in office after a marked rise in his cholesterol levels. The dose of his statin (rosuvastatin / Crestor) is now at the maximum normally allowed... assuming the patient has been compliant in taking the pills.

Blood pressure is more important than cholesterol in determining arterial disease. Trump's blood pressure is suprisingly low, assuming the reported numbers are accurate. MORE Trump echoes this: "I actually have very low blood pressure, which is shocking to people" 7, also noting "I've always been lucky with blood pressure. I've always had very good blood pressure." 2

Prevention becomes more important given the established coronary disease evidenced by coronary calcium.

Comment: The House of Representatives impeached Trump on December 18, 2019, thereby solidifying "Dr. Zebra's Law" which states: "Any president whose genital morphology becomes a topic of public discussion will be impeached." See the page for William Clinton.

Journalistic accounts describe him waking around 5:30 am, after 5 to 6 hours of sleep, watching television, tweeting, then going to work 47. "Trump normally set his own schedule on when to start the day and often had flexibility when he returned to the residence" 23b. "During Trump's first six months in the White House ... [he] didn't show up for work until 11:00 in the morning" 23c. His chief of staff tried, "with only modest success," to "accelerate the start of [Trump's] workday" to arrive in the office by 9:00 or 9:30 am 47. His nightly dinner in the White House residence begins at 6:30 or 7 p.m. 47, though he prefers by that time to be in bed with a cheeseburger 28. Before the presidency: "he goes to bed late, gets up early" 7.

There is little description of his sleep quality. As a mark of bravado, he said "I slept like a rock" the day after a long practice session preparing for an interview with the Mueller investigators 23d (the interview never occurred). One source of sleep disruption can be ruled out: Trump and his wife maintain separate rooms in the White House -- the first presidential couple since the Kennedys to do so 28.

Without deliberately searching, Dr. Zebra has encountered several descriptions of overt daytime somnolence in Trump:

• While a presidential candidate, an aide sent to brief him on the Constitution reported: "I got as far as the Fourth Amendment before his finger is pulling down on his lip and his eyes are rolling back in his head" 28.
• After a night with no sleep in May 2017, during a week of exhaustion: "He stifles yawns. His eyes narrow. And ultimately, when he garbles part of his speech, an aide explains that President Donald Trump is `just an exhausted guy.'" 38
• At a meeting of the G7 in June 2018, the New York Times delicately reported: "At some points, Mr. Trump closed his eyes in what people in the room took to mean he was dozing off" 67.

Although his physician had sought fit to give Trump a sleeping aid (pill) during travel across time zones 34, as of early 2018 he had not taken a sleep history at all, was unaware of even the most basic sleep parameters of the President, and based his medical judgments on speculation. When asked in January 2018 how much Trump sleeps, Dr. Jackson replied 34:

He doesn't sleep much. I mean, I would say that — you know, this is just my guess based on being around him. I didn't ask him this question, so I could be wrong on this, but I would say he sleeps four to five hours a night. And I think he’s probably been that way his whole life. That’s probably one of the reasons why he’s been successful, I don't know. ... But he’s just one of those people, I think, that just does not require a lot of sleep.

Comment: As the saying goes, this is 10 kinds of bad.
    The patient sleeps 5 hours a day and, although he calls it "garbage," drinks 12 servings of Diet Coke a day because he likes the caffeine "boost." He has even rigged a system where he can get the drug "stat." All of this should have prompted the physician to take a sleep history, not the least because the patient's caffeine consumption is approaching toxic levels, and, indeed, may already be having a toxic effect (the caffeine may be causing the short sleep time). Instead, the physician assumes that the patient has always been this way -- which is not the question at hand.
    (Note: it is unlikely that the President is a physiological short sleeper. Although many people in the USA now sleep less than six hours nightly, historical records show that this is a recent development, i.e. it is due to population sleep-habit changes, not biology. Most so-called "short-sleepers" are, therefore, really just "brief-bedders" because of work pressure, and statistically Trump is more likely to fall into that category.)
    But even if we assume that Trump's inborn physiology truly does need only 4-5 sleep hours per night, why does he need so much caffeine and why does he doze in public meetings? He is assuredly not ok with public dozing. This president cares greatly for anything that might connote weakness, and he knows that daytime somnolence caught on camera would lead to snide remarks about Grandpa, age 73, needing a blankie for his afternoon nap.
    The possibility must be considered that he has a sleep disorder such as obstructive sleep apnea (OSA). He is a set-up for it. He is a thick-necked older man with truncal obesity who, on the basis of his caffeine intake, appears to be fighting somnolence every day, all day. (Does he snore? That would be a reason his wife sleeps separately.) Though OSA patients typically like to spend more time in bed, it is easy to posit a hyperactive Trump willing himself not to do that. Or, he may actually be spending far more than 5 hours daily in bed: He spends lots of time in the residence, and reportedly likes to be in bed by 6:30 with a cheeseburger 28.
    Trump's apparent high-energy conduct does not rule out OSA. Dr. Zebra has seen strikingly high-energy people with severe sleep apnea, who burn the energy as a way to counter the sleepiness 68 69, much as a tired child becomes frenetic.
    Overall, therefore, no matter how it's dissected, there are so many abnormal factors at play in Trump's sleep physiology that a mere sleep history is unlikely to fully clarify his clinical state. Therefore, he should be tested for a sleep disorder, which we know had not happened as of January 2018. Although national guidelines do not recommend screening the general adult population for OSA, those guidelines apply only to asymptomatic patients. As we have seen, with even the limited data available now, it can easily be construed that he is symptomatically somnolent. Moreover, his actions that some observers call "dementia" are more likely signs of sleep deprivation, as well could be some negative aspects of his personality.
    Regardless of who is in office, sleep should always be among the top clinical considerations for the President's physician. One presidency has already been destroyed by sleep apnea. Presidential physicians should receive enhanced training in sleep medicine. They need to know that OSA is an insidious attacker of anyone involved in daily brain-work -- so subtle that it was not even discovered as a disease until the 1970s. Now everyone knows someone who has it. Why not the President? If Trump does have a sleep disorder -- or if he has bad sleep habits, or if caffeine is disrupting his sleep -- treatment is likely to be successful, and it can be life-changing (for the better).
    It is even odds that this patient, if asked by the press about his sleep, will say he is the best sleeper in the history of mankind. Only the President's physician, sitting down with the patient in a confidential setting and building on the patient's confidence in their relationship, can obtain the information to help this man -- who may not even know he needs help.

Dr. Zebra also notes a dire pathway: excessive caffeine + untreated sleep apnea --> intermittent atrial fibrillation --> embolic stroke --> Crisis over the 25th Amendment, section 4.

Frequent contact between doctor and patient has also been described by members of the White House Medical Unit 34.

Here is the main problem. Officials want us to believe a series of events occurred that would have been pitched to President Trump with a conversation like this:

"Sir, we're going to take 5 hours of your day to bring you to Walter Reed for an hour of consultation, despite the fact that you'll be coming back for another multi-hour visit two months later. And, while you're at Walter Reed, we won't do any specialized evaluations, in fact we won't do anything we couldn't do at the White House. We'll even drive you so it takes longer than flying by helicopter.

"Yes, sir, we know that you really hate germs and that hospitals are filled with the worst germs there are. That's why we want to keep you there for longer than necessary, for a tour, even though discussions of medical treatments are distasteful to you and even though, if you had to make a hospital tour, you could at any time visit a military hospital overseas which is better P.R.

"Yes, sir, we know you like to play golf on weekends. But we think you'll also enjoy talking with the family of a servicemember who is physically damaged as a result of obeying orders that came from your administration. Yes, sir, we know that if the servicemember's children are there that will be a particularly difficult thing for you emotionally, but we will have plenty of Purell and hand-wipes for you after you give them an endearing touch.

"Yes, sir, we think this is the right way to handle your preventive health care. True, we are bringing you back sooner than any other President has ever been brought back for routine preventive health care, but it won't look bad and besides, you are, after all, older than all of the others were, except for that one who had Alzheimer disease. Pardon? Uh, no, sir, of course you have great genes and have nothing wrong with you like Alzheimer disease. We just think that this will keep your name in front of the public due to the fact that it won't be pre-announced and so the press will go hyper and have a reason to write stories about you on an otherwise quiet weekend. And this novel course will also give us the chance to educate the public that routine preventative care occurs continuously throughout the year, and is not just a single annual event. It's a win-win!"

So what actually did happen? Alas, we have little to go on beyond the official statement from the President's physician. This is problematic, however, because its most crucial sentences appear to be as carefully engineered as a jet engine, to sound reassuring while technically allowing great wiggle room and deniability.

From the full text of the physician's note MORE, here are the critical sentences that require careful parsing:

The President has not had any chest pain, nor was he evaluated or treated for any urgent or acute issues. Specifically, he did not undergo any specialized cardiac or neurologic evaluations.

The most informative question to ponder about this event is: What is available at Walter Reed that is not available at the White House medical facility?

During a radio interview in 1993 76 Trump admitted "It could be a psychological problem" and host Howard Stern diagnosed: "He's very wealthy and yet he's a prisoner of obsessive-compulsive disorder."

[Trump] also said he liked to drink through a straw rather than straight out of a glass. "I'd prefer drinking through a straw if I'm going to a restroom," he said. Stern asked: "Because you are afraid that the glasses can be contaminated?" "They certainly can be," Trump replied. ...

"I like it. I like cleanliness. Cleanliness is a nice thing. Not only hands, body, everything," Trump added, telling Stern he had never sought professional help for his compulsive behavior.

A magazine interview in 2011 reported:

He's got a big thing about germs, so he's a frequent hand-washer and goes everywhere with packets of hand sanitizer stuffed into his suit jacket. He pulls one out now, dangling it in the air. It's a Super Sani-Cloth Germicidal Disposable Wipe ("The two-minute germicidal wipe") -- which isn't exactly the kind of market-share leader you might expect Trump to favor. He rubs his palms together. "I don't use Purell, Purell is too sticky, but this other stuff is great. I always carry a couple of them." 7

As president, Trump has many times chased from his presence aides who seem to have a cold 74.

Comment: Dr. Zebra offers no opinion on whether Trump has an obsessive compulsive disorder. As a wealthy and powerful person, Trump is in a position to indulge himself when it comes to the very reasonable goal of avoiding illness. Some of his actions may be considered eccentric, as a minimum, but Trump is certainly no Howard Hughes. His physician has covered for him on the hand-washing habit 34.