New Diabetes Medications

Medication recommendations are changing rapidly. The usual strategy for beginning treatment of mild to moderate type 2 diabetes has been an initial trial of diet and exercise. These things remain of great importance but present-day thinking is that, unless they are completely successful, they should not be carried on very long before starting medications. Appropriate medications to get control of the diabetic condition as soon as possible appears most effective in the long run in producing good results long term and preventing diabetic complications.

 

Metformin is still the commonly accepted starting point for almost everybody. It is effective, low cost and has little serious toxicity. I like it because it directly addresses what appears to be the primary problem in type 2 diabetes, insulin resistance.

 

However, unless metformin, with diet and activity measures, is perfectly effective after 3 months or so, it's becoming standard recommended practice that one should consider adding one of the two new groups of diabetes medications, the GLP1 agents or the SGLT2 inhibitors (explanations of both of these coming). This is because both, when added on, not only reduce blood glucose but have also been found to produce significant reductions in major diabetes complications. As usual with new medications they are expensive and of course have their own side effects in some who use them.

 

GLP1 agents – We've discussed these previously. GLP1 is a hormone normally produced in the intestine that works when eating to decrease blood glucose and also to control the appetite. It is usually deficient in those with type 2 diabetes and seems to be an integral part of the diabetic problem. Multiple medications have now been developed which replace this action. Most patients, particularly those who are overweight, have significant improvement in blood glucose and lose some weight. But these medications have an additional important benefit in that several studies have now shown that they also reduce the risk of heart and vascular problems, a big issue with diabetes.

Those presently being sold are Victoza, Bydureon, Trulicity, Adlyxin and Ozempic, the last one seeming to be a little more effective than the others. All are given by injection once weekly except for Victoza which is injected daily. Most people tolerate them well but an occasional side effect is nausea.

A new development in this group is that within the last couple of months the FDA has approved an oral form of Ozempic (generic name – semaglutide), which seems to be just as effective as the injected form. It is taken daily and will be marketed under the name of Rybelsus. So those who want to avoid injections will have this alternative and I suspect it will be the way most will want to go.

 

SGLT2 inhibitors – These medications block the uptake of glucose by the kidney and cause a large output of glucose in the urine, in turn causing a lowering of glucose in the blood and some weight loss, and usually some lowering of the blood pressure. Due to the increased urine glucose there is some increase in urine output but usually not too bothersome, although the dose of other diuretic medications may have to be reduced. Also, because of the increased urine sugar, there is a problem in many women of vaginal yeast infections.

Those presently on the market are Invokana, Jardiance, and Farxiga. These are all taken orally and all of of them are also marketed in combination with metformin under different names.

The big news here is that these medications now have also been shown to significantly reduce heart problems as well as kidney complications. Most of the heart benefit has been shown to be primarily a reduction in the development of congestive heart failure (CHF), at present an increasing problem in the U.S. In fact, the improvement in CHF has now been shown to also be a benefit in non-diabetics, so that these are now being considered as an important new CHF treatment by cardiologists.

The finding that they also reduce the development and progression of kidney damage in diabetics has been a big pleasant surprise, and this benefit, along with the heart benefit is causing many experts to strongly recommend their use, particularly in those with some element of kidney involvement.

 

 

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The Trump Zelensky phone call and Mr. Schiff's impeachment hearing

The Dems hate Mr. Trump and from the moment of his election have called for his removal from office by the impeachment rather than the election process. And to this end they've continued to fish around for a suitable reason. It's sort of like the Alice in Wonderland scene in which the King of Hearts calls for the verdict first and then the evidence.

 

The most recent eruption was brought about by a "courageous" whistleblower, who however is not courageous enough to identify himself or submit to questioning, talking about Mr. Trump's traitorous behavior in a congratulatory phone call to Ukraine's newly elected president. Since then other Trump opponents have come forth who are familiar with the conversation and have reported similar impressions. However, their revelations are no longer necessary since the entire transcript of the call was declassified by Mr. Trump and is readily available to those who are interested to read for themselves.

 

It's hard to avoid the constant commentary about the significance of the phone call, but I'm almost ashamed to say that I never actually read the transcript until today. I'd recommend you do it and judge for yourself whether it's contents should call for impeachment. I don't. To me it's not even a close call. Here it is if you're interested. It takes less than 5 minutes to read:

 

https://drive.google.com/file/d/1uyWKAGgHIqDEORgjOyo0uq7JOXzhxOQf/preview

 

On the contrary, it seems to me that Mr. Schiff should lose his office for the "parody" hoax of the phone call, just after the transcript had been released, that he read in his committee hearing. I happened to be listening to the hearing at the time and with most others was fooled into thinking he was reading the actual text until part way through it became obvious that it was a bizarre fantasy which sounded like a script from one of his movie producer friends. Judge for yourself:

 

Schiff, Sept. 26: It reads like a classic organized crime shakedown. Shorn of its rambling character and in not so many words, this is the essence of what the president communicates. We've been very good to your country, very good. No other country has done as much as we have. But you know what? I don't see much reciprocity here. I hear what you want. I have a favor I want from you though. And I'm going to say this only seven times so you better listen good. I want you to make up dirt on my political opponent, understand. Lots of it. On this and on that. I'm going to put you in touch with people, not just any people, I am going to put you in touch with the attorney general of the United States, my Attorney General Bill Barr. He's got the whole weight of the American law enforcement behind him. And I'm going to put you in touch with Rudy. You're going to love him. Trust me. You know what I'm asking. And so I'm only going to say this a few more times. In a few more ways. And by the way, don't call me again. I'll call you when you've done what I asked.

 

 

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The Syrian Pullout

It's hard to know what to make of the troop pullout in Syria. I discount automatically the uproar of the Democrats and the liberal media who reflexively oppose Mr. Trump whatever he does. After all, these are the people who fairly consistently oppose military action and restrict military funding as much as possible, and who supported President Obama's abrupt pullout of 10,000 troops from Iraq.

 

But the response from moderates and many prominent Trump supporters has also been negative. They predict that the U.S. will lose influence in the region, that ISIS may reconstitute, and that abandoning our help for our Kurdish allies against the Turks will not only cause them grief but will also serve as a sign of undependability to our other allies around the world.

 

But not all Republicans and conservatives oppose the move, and of course Mr. Trump has been forthcoming in his own defense of his decision. The action should be no surprise. Non-intervention in remote conflicts which have no direct impact on the U.S. was a major campaign promise and, in contrast to most other politicians, he has been relentless in his attention to fulfilling his promises. And in fact, for most ordinary citizens, avoiding such military action seems to be a worthy goal and how to go about it is the crux of the problem.

 

The resistance by some advisers to avoiding involvement in timeless Middle East conflicts has perplexed Mr. Trump. In fact for instance, the intention to pull out from Syria seems to have been the breaking point for General Mattis. Nevertheless, there seems to be a tendency for small conflicts to escalate uncontrollably. Korea started as a police action. Vietnam started with a small contingent of military advisors. Both started with the purpose of aiding small beleaguered countries and with only the most peripheral threat to our own interests. Both turned into major bloodbaths under Democrat administrations, generally the opponents of military ventures. Once in place there seems to be a tendency keep our military without end wherever they are involved. Here we still are in Germany and Japan 70 years after the end of WWII. So is that just a general reluctance to change from the status quo or is there truly unacceptable risk in leaving.

 

The Democrat's characterization of Mr. Trump as a fool is absurd. He is a disrupter which was a major reason that he was elected. He has obviously thought through the consequences of his actions relative to his goals, with the help of a great deal of intelligence to which we are not privy. I have listened to his arguments. The Kurds and the Turks have been at each other's throats for centuries. The Kurds have been our allies in the fight against ISIS, largely in their own interest as well. Are we thereby obligated to take on the task of supporting one component of this never-ending conflict? The Kurds are tribal and have often been at war with each other. Some of the Kurd groups actually have been using terrorism techniques in Turkey. On the other hand, the Turks, despite being a NATO member, must be restrained from their own terrorism and killing of civilians and economic and diplomatic constraints against them are being put in place. Turkey and Syria are in constant conflict over their border and the Kurds are now turning to Mr. Assad for protection which the President sees as a good thing.

 

So is the President making the same deadly mistake that President Obama did in abruptly leaving Iraq, or on the other hand is he trying to avoid the similarly deadly mistakes of President Bush in his involvement in Iraq. Clearly Trump and Obama are worlds apart. In stark contrast to Mr. Obama, Mr. Trump has made it his mission, also a campaign promise, of rebuilding the military so that it can be used effectively where appropriate. The primary reason for our involvement in the Syrian civil war to begin with was to pursue and disband the remnants of ISIS which has been accomplished, and Mr. Trump has stated his intention to watch them carefully from a short distance to intervene if they seem to be reconstituting.

 

For the outside observer with limited knowledge the situation is confusing but still of vital interest to all of us so we should be paying attention. For now, I'm trusting to the President's judgement. As he so often says, we'll see what happens.

 

 

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The Tariff War, China and Mr. Trump

Our China problem has been developing for decades. President Nixon opened relations with the communist government in 1972, to a large extent as a counterbalance to the Soviet Union. Thereafter it was the common wisdom that, as their contact with the free world increased, they would eventually fall into line with the behavior of the rest of the developed nations. Indeed, this seemed to be coming true in the 1980's when Deng Xiaoping liberalized their economy, opening it up to the outside world. Nevertheless, their leadership has remained steadfastly Communist and, instead of accommodating, is ominously determined to become the world's prime super-power. To this end they are steadily expanding their military and have established a strong presence in the developing countries of Africa, Latin America and Asia. The main engine of this activity has been their dramatically expanding economy, fueled by an almost limitless number of formerly impoverished peasants turned into new diligent factory workers but in addition more traditional Communist tactics of stealing secrets and prohibiting outside competition.

Previous U.S. administrations, from Nixon on down, have largely ignored this developing situation but Mr. Trump campaigned on the idea that it is critical to our country's welfare to at last confront China's expansionism and in his can-do manner he is attempting to carry out his promise. The major weapon he is using is the strength of the U.S. consumer economy, which has in the past been providing the largest portion of the increasing Chinese wealth.

I am not an economist, but I have read a lot of the works of the traditional liberal economists and strongly accept the great importance of the traditional liberal idea of the free market and free trade, as does I believe Mr. Trump. However even Adam Smith, the great founder of the modern economic ideas of the Enlightenment period, who pointed out the bad economic effects of trade interference by the English government of his time, admitted that tariffs are sometimes necessary for public protection in times of potential conflict. So, for now, I have bought into Mr. Trump's use of tariffs as a weapon and, as he frequently comments, will wait and see what happens. Because of the large imbalance of trade between our countries, largely the result of their restrictive policies, it seems that the tariffs should have a great deal more impact on them than us. Indeed, this seems to be playing out in a declining Chinese economy and their recent tactic of currency devaluation, which maintains the competitive price of their exports but at the same time reduces the buying power of their own citizens. Furthermore, China has, in the many emerging economies of the world, competitors for the U.S. market which have started to replace it as a source of low-priced consumer goods.

Nevertheless, some fear that China's unitary, authoritarian government, which allows for more long-term planning, must inevitably be the winner. But herein I believe lies our greatest and most potent weapon, that of individual freedom. China has for millennia been, and continues to be, an authoritarian country. Their government has allowed a measure of economic freedom, with good results, but it remains oppressive, both in the political area and even in its economic structure. Major businesses continue to be subject to Party observers and regulators. There are secret police, control of the news media and internet, as well as suppression of religion, minority groups and political dissent. Our country was founded on the principles of individual rights and a government that exists and operates by the consent of the people rather than the other way around. It is the resulting vitality and innovativeness of our citizens that has produced our economic success, and not the control and planning of a central authority.

The ongoing unrest in Hong Kong is an interesting test of the Chinese Communist party. How will they handle the demands of the Hong Kong people to maintain their political sovereignty? If too lenient, there is risk, as happened with the Soviet Union, of incentivizing other dissidents. If too severe, they will demonstrate to the rest of the world, and especially to the developing countries with which they have made inroads, what they are really made of.

 

 

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Harris, Biden and School Busing

In the recent Democrat primary debates Senator Kamila Harris chastised Senator Biden over his anti-school busing stance back in the 70's and has thereby gained significant ground in the polling. Ms. Harris gave an emotional speech, pretty clearly pre-arranged, about how much being bused to an alternative school changed her life. Ms. Harris is the daughter of a Jamaican father and an Indian mother, both well paid academic scientists, and grew up in an upper middle-class family in Berkeley, California, probably the most "progressive" city in the country. It seems unlikely that in her childhood she ever suffered significant racial animosity. Mr. Biden's response was that in the past he was agreeable to the concept of busing, but not when it was imposed by federal court order, probably an untrue statement when you look at the record, but the best he could do. The subject of court ordered school busing is interesting to me because it is one of the foundations of my conversion from a youthful liberal to a mature conservative.

School busing started in San Francisco right when my son was entering first grade. When all the buses came on the first day there were only a handful of kids, most families having found other alternatives. I resolutely convinced a reluctant Emily to let him go, that it was all for the good, and that "there was nothing to fear but fear itself". So off he went every day to Hunter's Point, a predominantly black area, without incident. In fact, down the line he was put in a "gifted" program which was shifted from one school to another and so wound up being bused to 3 different schools.

As it turned out we made the difficult decision to return home to Scranton after 14 years in California. Making the decision involved a temporary stay in Scranton, and on returning to San Francisco, we enrolled my 2 kids for a couple of years in a Catholic school a few blocks from our house. My liberal eyes were opened! Now they walked to school. And when they came home, they played around with schoolmates who lived nearby. We got involved with neighbors for fund raising events for the school. What busing did was to rob my kids of the blessing that I had experienced of growing up going to a neighborhood school. Racism had nothing to do with it. There was no way to live in San Francisco, even back in the 1970's, without mixing with people of other cultures. The Catholic school enrollment was largely Hispanic, and my son's best friends were Pancho and Miguel, who lived down the street.

This was one of many experiences that taught me that society was the way it was for many complex reasons and that simplistic ideas for change, introduced abruptly without thinking through the consequences, often did more harm than good. Liberals have a tendency toward what Thomas Sowell calls one stage thinking. They perceive a problem and agitate to apply a direct solution without more than a superficial analysis of cause and effect. If you do not agree with what seems to them to be obvious it is either that you are ignorant or have some nefarious motive. I understand that way of thinking well, having indulged in it when I knew no better. Most who reason that way are I think well intentioned, but some are merely opportunists, taking advantage of their more sincere comrades for personal benefit. I can't read anyone's mind, so I'll leave it to you to decide in which category Senators Harris and Biden belong.

 

 

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The Media, Trump and Independence Day

I had to chuckle when I read the reports on Independence Day celebrations in this morning's Times. The coverage of the national celebration in Washington, arranged for the first time in decades by Mr. Trump, was from an Associated Press article. The President gave a patriotic speech with no political references, celebrating our heroes of space exploration, civil rights, and so on, with a significant tribute to our military. Each branch was singled out, recounting their history and various heroic achievements, and was accompanied by patriotic renditions by the Army band and chorus along with military displays, primarily warplane flyovers.

 

This seemed to me when I listened to large parts of the President's speech that it was pretty standard Independence Day fare expressed by our nation's leader. But where Mr. Trump is concerned the press is the press. I would judge the article to have been about 75% negative. After the first paragraph it described the confusion of the staff and the concern over possible poor turnout. In fact, there was a large enthusiastic crowd but the article's implication was that a significant portion of it was manufactured, and that many of the attendees were there simply because of curiosity or custom. About half the article was devoted to the inevitable protestors and their activities with interviews recounting their complaints. The report I heard was that there were a tiny handful but you sure couldn't tell that from what was reported.

 

Compare that with the following article about the local annual Mayor's Independence Day celebration which was given substantial space and 2 photos. The attendance was meager, and the celebration was all military. It was organized by a retired military officer, the keynote speaker was the Commander of the local VFW, there were representatives from veterans of various wars and a traditional American flag was blessed and then raised. In the article there was nary a disparaging word.

 

So, in Mr. Trump's case the celebration was primarily for personal aggrandizement, was received with a lukewarm contrived response, and was excessively militaristic. The local celebration was a big deal, despite its attendance by 50 people, and appropriately honored our military heroes and flag.

 

So, the major media congratulate themselves for "speaking truth to power" and can't understand the skepticism of us folks in flyover country. We get the picture folks. 

 

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The Census and Citizenship, Legal and Illegal

 

 

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I don't get the problem with asking about citizenship in the census. The question was asked to everyone in every census until 1950 and then thereafter in the "long form" which was given to every 6th person until 2000. The question was stopped under President Obama.

I have checked the census forms for my grandfather in 1930 and 1940 and his answer to the citizenship question was in the negative. No problem with that. Many people are in the country legitimately who are not citizens. The Dems who are dead set against the question fear that it will inhibit people who are here illegally from responding to the question. I'm not sure why that would be since there would be no inquiry into legal status, just citizenship. They would just answer like my grandfather.

But the whole controversy brings up the issue of whether we should be counting people who are here illegally in the census in the first place. The census count is used to determine each state's number of congressional representatives whose most important task is to determine where federal funds should go and how we should be taxed to pay for them. And if states which encourage illegals and have large numbers of them have more influence in congress than those who don't I see an obvious problem with that.

Furthermore the numbers of each state's electors in the Electoral College is based primarily on the number of it's congressional representatives. This in turn means that people here illegally are essentially voting in our elections for President and Vice President.

Bottom line is that I do think it's important that we make an actual determination of the proportion of our population who are citizens. But much more critical to me is knowing the actual numbers and general whereabouts of people who are here illegally since, if they are counted, they can have a significant impact on the decisions made in our House of Representatives and Presidential election. How we could ever accomplish that task is hard to say since some are fighting tooth and nail even to prevent asking the citizenship question.