Type 1 diabetes is a chronic disease which is on the rise in India. Type 1 diabetes is an autoimmune condition caused by a deficiency of insulin and resultant high blood sugars. In the last 25 years, awareness and further studies about type 1 diabetes have revealed many aspects of the condition, such as its epidemiology, genetics, disease burden and immune and B-cell phenotypes.
Ongoing research on the part of the U.S Food and Drug Administration (FDA) recently (November 2022) ended with the medication Tzeild (teplizumab-mzwv), which is being said can help delay the onset of type 1 diabetes stage 3 in adults and in children 8 years and above who have been diagnosed with type 1 (stage 2). The approval of the medication in the form of an injection is significant because it provides a new treatment method for at-risk patients.
In this article, let us understand a little more about type 1 diabetes- its causes, symptoms, its stages and how to manage it.
There are four stages of Type 1 diabetes:
Genetic analysis helps identify underlying genotypes commonly associated with type 1 diabetes. As per research, a particular region called the HLA region on Chromosome Six is responsible for up to 50% of the risk of developing the condition. A close bloodline, such as a sibling or a relative with type 1 diabetes, can also put you at greater risk.
In this stage, one diabetes-related autoantibody is detected within the blood. Since diabetes is an autoimmune (a disease wherein the immune system of the body begins to attack its healthy cells) condition, autoantibodies, at this point, have already started attacking the beta cells within the pancreas.
At this stage, two or more autoantibodies related to diabetes are present in the blood. While beta cells continue to be attacked by the immune system, insulin deficiency leads to a blood sugar level rise as a result of glucose intolerance. Beta cell dysfunction is severe at this stage but still without symptoms.
In stage 3, there is a considerable loss of beta cells due to autoimmunity. Symptoms are visible, making it easier to diagnose type 1 diabetes. Some of these symptoms include:
Ø Blurry vision
Ø Excessive hunger
Ø Constant urge to urinate
Ø Severe fatigue
Ø Sudden and unexplained weight loss
The exact cause of type 1 diabetes remains unknown to doctors. Some possible reasons can include the following:
There is no cure for type 1 diabetes; however, it needs to be managed with the help of appropriate treatment, which includes dietary changes, medications, regular blood glucose monitoring at home and specific lifestyle changes:
As with all medications, there can be a few side effects with Tzield. These can include rash, headache and lowered levels of white blood cells.
Also Read: What Level of Blood Sugar is Dangerous? A Complete, Research-Based Guide
The right way to manage your diabetes is to reach out to your doctor, who will suggest a customised treatment plan based on your overall health, medical records and age. Depending on your diagnosis, your doctor may also recommend you to other specialists, such as a dietitian, an endocrinologist and a professional diabetes care and education specialist (CDCES). You must increase your awareness about your diagnosed condition and adhere strictly to whatever treatment plan chalked out for you by your doctor to lead a happy and normal life with your loved ones. The discovery and FDA approval of the drug, Tzeild, opens up a new door for at-risk patients and gives them more time to delay its onset.
Disclaimer: The information included on this site is for educational purposes only and is not intended to be a substitute for medical treatment by a healthcare professional. Because of unique individual needs, the reader should consult their physician to determine the appropriateness of the information for the reader’s situation.
Type 1 diabetes is also known as Juvenile Diabetes. It affects children and adolescents more often but can develop in adults even in rare circumstances. Diabetes is a condition when the body becomes resistant to insulin or doesn’t produce it to metabolize sugar in the blood. It is insulin that delivers the glucose molecules to the cells for the release of energy.
There are two types of diabetes- type 1 and type 2. In type 1 diabetes, the body doesn’t produce insulin at all. In type 2 diabetes, the body becomes resistant to insulin or creates it in insufficient quantities. The exact reason why type 1 diabetes occurs is still a topic of debate. Research has proved that genetic expression, inflammation levels and in some cases, even viral infections have a considerable role to play in this type of diabetes.
It is believed that the body’s immune system turns against itself and destroys islets of Langerhans, the pancreatic cells which produce insulin. When there is no insulin in the blood, the level of glucose increases leading to severe complications if left untreated. Since most of the patients who have type 1 diabetes are children, they might not understand the signs of the disease. As parents or guardians, it is crucial to arms oneself with knowledge of symptoms of diabetes in children. In type 1 diabetes, the symptoms appear quickly, and the onset of the disease is sudden.
Also Read: Difference Between Type 1 & Type 2 Diabetes
Type 1 diabetes may have the potential to damage major organs or even organ systems in the body. Keeping the blood sugar levels under control is the key to reducing the risks associated with Type 1 Diabetes in children. Below are some risk factors which may come along with Type 1 Diabetes:
Most of children with type 1 diabetes only get diagnosed when they present with Diabetic ketoacidosis, which is state in type 1 diabetes with very high sugar, vomiting ,abdominal pain and fruity smelled fast breathing.
Dr. M.G. Kartheeka, MBBS, MD
One of the prominent warning signs of type 1 diabetes is increased urination. High sugar levels lead to a toxic environment in the blood. The body tries to bring back balance by eliminating the excess sugar. The kidneys produce excessive urine, and this makes one take frequent trips to the washroom.
The body can get dehydrated due to frequent urination. To replenish the fluids, it demands more water by making the child feel thirsty. If your child is demanding water too frequently, talk to his doctor. It could be a warning sign of type 1 diabetes.
The body converts the food we eat into glucose, the smallest currency of energy. When one suffers from type 1 diabetes, the glucose cannot be used by the body as there is a lack of insulin- the hormone responsible for delivering glucose molecules to the cells. This makes one feel low in energy. So the body demands more food to stave off the hunger. It is a vicious cycle. If your child has an increased appetite, observe if he is showing other warning signs of type 1 diabetes.
The continually fluctuating blood sugar levels create havoc on the mood of a person. Children are no different. When the sugar levels are low, we feel morose and irritable. When they are high, we feel full of energy and are in a better mood. When the levels dip too low or go too high, it could make one feeling depressed or manic. Frequent and unexplained mood swings in kids could be a warning sign of type 1 diabetes.
The eye provides us with sight due to the lens which bends and stretches to help form images which are then sent as signals to the brain. Fluids nourish this lens in the eye. High sugar levels affect the flexibility of the appears. This leads to blurry vision. When the blood sugar levels come under control and the diabetes is managed, the vision returns to normal. Vision changes are an early warning sign of type 1 diabetes.
Read More: How Diabetes Affects The Eyes?
In type 1 diabetes, there may be a high amount of sugar in the blood but since it cannot be used by the cells. This makes the person feel weak and tired. Excessive and unexplained fatigue and weakness is a visible warning sign of type 1 diabetes.
While the body may demand more food and feel more hungry than usual, since the primary energy-providing mechanism is not working correctly, the patient may experience unexplained weight loss. The high sugar levels are not helping the cells which are deprived of energy leading to a decline in body mass due to loss of fat and muscle in the body.
This is commonly observed in children who haven’t been wetting the bed earlier. High sugar levels lead to frequent urination. Children cannot control their urge in the sleep leading to bedwetting, another warning sign of type 1 diabetes.
When the body uses fat to produce energy, it leads to the formation of ketones. Ketones provide a fruity-smelling scent to the breath. If left unchecked, high levels of ketones in the body lead to ketoacidosis, which is a life-threatening condition.
This is another warning sign of type 1 diabetes. High sugar levels are dangerous for the health of genital organs as they lead to an unhindered proliferation of vaginal yeast, bacteria, and fungi. This subjects the girl child to many vaginal and urinary tract infections. Controlling the blood sugar is the best way to reduce the frequency of the infections.
This is a warning sign of type 1 diabetes exclusive to this type. When the body burns fats and muscles instead of carbohydrates to release energy, it releases ketones- the waste materials of the process. In small amounts, they don’t cause much damage, but in high quantities, they can cause toxicity in the blood leading to nausea and vomiting.
Children are more prone to develop complications of type 1 diabetes like hypoglycemia or hypoglycemia or diabetic ketoacidosis and there are high chances that the symptoms for these complications are frequently missed and underdiagnosed. Timely intervention is very crucial.
Dr. Ashish Bajaj, M.B.B.S., M.D
The diagnosis of type 1 diabetes can lead make you feel overwhelmed as a parent. The responsibility of administering injections, monitoring sugar levels and taking care of the diet apart from worrying about the child will add to your woes. Remember sugar control is important to avoid harmful effects of sugar causing complications, some of which can be fatal. With consistent care and appropriate medication, the situation can be brought under control.
Also Read: 10 Harmful Effects of Sugar
Disclaimer: The information provided here is for educational/awareness purposes only and is not intended to be a substitute for medical treatment by a healthcare professional and should not be relied upon to diagnose or treat any medical condition. The reader should consult a registered medical practitioner to determine the appropriateness of the information and before consuming any medication. PharmEasy does not provide any guarantee or warranty (express or implied) regarding the accuracy, adequacy, completeness, legality, reliability or usefulness of the information; and disclaims any liability arising thereof.
Links and product recommendations in the information provided here are advertisements of third-party products available on the website. PharmEasy does not make any representation on the accuracy or suitability of such products/services. Advertisements do not influence the editorial decisions or content. The information in this blog is subject to change without notice. The authors and administrators reserve the right to modify, add, or remove content without notification. It is your responsibility to review this disclaimer regularly for any changes.
Diabetes is a metabolic disease that is characterised by a high level of blood sugar because the body cannot process it efficiently. There are two kinds of diabetes- Type 1 and Type 2. Each is different from the other but the underlying fact is that they affect how the body processes glucose. If you are confused about which type you have, it is better to consult your doctor and undergo tests.
Both Type 1 and Type 2 are similar in the fact that they are both are chronic and cannot be cured. There are some common points of difference between the two kinds of Diabetes.
Type 1 diabetes is usually diagnosed in childhood while Type 2 is usually diagnosed after 30 years of age. There are a few exceptions wherein Type 1 diabetes gets diagnosed in adulthood.
Type 1 diabetes is not associated with the patient’s body weight as it is a genetic disorder. Type 2 diabetes is related to being overweight or obese. However, there are patients who are thin and have type 2.
Type 1 has high levels of Ketones during diagnosis while Type 2 is related to high blood pressure and high cholesterol levels.
Type 1 diabetes is treated with insulin injections or the insulin pump whereas Type 2 diabetes is treated without medicines in the initial stages or with tablets.
In type 1, the patient has to depend on insulin, no matter what. On the other hand, in Type 2, the patient has a possibility to reduce his dependence on medication and live holistically without much medical intervention.
The major difference between type 1 and type 2 diabetes is that in type 1 there is insulin deficiency and in type 2 there is insulin resistance.
Dr. M.G. Kartheeka, MBBS, MD
Type 1 is an autoimmune disease. The immune system of the body attacks itself, mistaking its own body cells as antigens. The beta cells of the pancreas get attacked by it. They are responsible for producing insulin in the body. In Type 2 diabetes, the body becomes resistant to insulin and in a bid to balance things out, tries to produce more but cannot keep up with the demand.
While symptoms of Type 1 develop quickly. They typically manifest themselves over a matter of a few weeks. In Type 2, the symptoms take a long time to develop and many people do not discover the disease until they suffer a few complications.
Most individuals with type 1 or type 2 diabetes need more insulin during pregnancy, especially during the last one-third of pregnancy (approximately 26 to 40 weeks of pregnancy) because the body becomes resistant to insulin as the pregnancy progresses. Caution is advised when the diagnosis of diabetes happens during or before pregnancy.
Dr. Ashish Bajaj, M.B.B.S., M.D.
People suffering from Type 1 are usually children and adolescents. Type 2 diabetics are usually older people.
The only way to stay safe when it comes to diabetes is to adopt a healthy lifestyle. While genetic factors cannot be controlled, we can take charge of our lifestyle. Eating healthy- less sugary, processed food and more natural, fresh food, exercising regularly, not stressing over things and maintaining a healthy weight go a long way in reducing the risks of developing diabetes.
Why some people develop Type 1 diabetes and others do not is unknown. It’s most likely due to a mix of genetics and environmental factors. You are more likely to get Type 1 diabetes if you have a close relative who has it. However, there are several risk factors of type 2 diabetes. Middle aged people and senior citizens, and even those who suffer from obesity or high blood pressure are at an added risk of developing type 2 diabetes. Those who suffer from PCOS, exercise minimally, or even those belonging to ethnic backgrounds have a higher risk of having typ2 diabetes.
Disclaimer: The information provided here is for educational/awareness purposes only and is not intended to be a substitute for medical treatment by a healthcare professional and should not be relied upon to diagnose or treat any medical condition. The reader should consult a registered medical practitioner to determine the appropriateness of the information and before consuming any medication. PharmEasy does not provide any guarantee or warranty (express or implied) regarding the accuracy, adequacy, completeness, legality, reliability or usefulness of the information; and disclaims any liability arising thereof.
Links and product recommendations in the information provided here are advertisements of third-party products available on the website. PharmEasy does not make any representation on the accuracy or suitability of such products/services. Advertisements do not influence the editorial decisions or content. The information in this blog is subject to change without notice. The authors and administrators reserve the right to modify, add, or remove content without notification. It is your responsibility to review this disclaimer regularly for any changes.
Diabetes can be classified into two categories: Diabetes insipidus and diabetes mellitus. Both have serious consequences, though they are entirely different from each other. Let’s take a look at both of them and understand the differences.
Diabetes Insipidus is a rare disease. It is caused when there are problems related to ADH (Anti Diuretic Hormone). Someone with diabetes insipidus suffers from excessive urination. There is no increase in the blood glucose levels, unlike diabetes mellitus. A series of tests are needed to diagnose the condition. If left untreated, the condition can cause kidney damage and chronic kidney disease.
Due to excessive urination, the person feels an increased thirst leading to excessive fluid consumption. Patients are at risk of suffering from dehydration. It is of four types:
Diabetes mellitus is the more common form of diabetes. It causes elevated sugar levels in the blood. The body breaks down food into glucose that is the fuel for the cells for carrying out regular metabolic processes. When the body cannot process this glucose efficiently, it leads to high sugar levels that have serious health complications like kidney failure, vision loss, and amputations.
Diabetes mellitus is of two types.
Read More: Difference Between Type 1 & Type 2 Diabetes
The symptoms of diabetes mellitus include increased thirst and hunger, excessive urination, frequent vaginal yeast infections, slow healing of cuts and scrapes, and tingling and numbness in the feet. The disease is treated by medications that control the sugar levels and by providing synthetic insulin in the body. A healthy diet, regular exercise, weight loss and timely administration of medication are the recommended course of treatment.
Diabetes Insipidus | Diabetes Mellitus |
Caused by problems in hypothalamus | Caused by problems in the pancreas |
Caused by deficiency of ADH | Caused by a deficiency of insulin hormone |
Glucose levels are not elevated | glucose levels are elevated |
Urine doesn’t have glucose present | Urine has glucose present |
Urine is much diluted. It has no odour | Urine of normal concentration |
Excessive urination | Urination much lesser than in diabetes insipidus |
No increase in blood cholesterol | Increase in blood cholesterol |
Eating patterns do not change | Eating patterns change with excessive hunger |
Negative results when tested for ketone bodies in urine | Positive results when tested for ketone bodies in urine |
Both, diabetes mellitus and diabetes insipidus need urgent medical intervention. Consult your doctor if you suffer from any of these symptoms.
Diabetes insipidus is quite rare compared to diabetes mellitus. Diabetes insipidus commonly seen post head injury , brain surgery and brain cancer.
Dr. M.G. Kartheeka, MBBS, MD
A diabetes diet plan includes healthy food items in moderate items during regular meal times. The food items included in this diet should be naturally rich in nutrients, and low in fat and calories.
The key elements that go into making a proper diet plan for diabetes are vegetables, fruits and whole grains. In fact, people with borderline diabetes or who have a family history should follow this diet as a part of a healthy meal plan.
Poorly controlled or uncontrolled diabetes insipidus may lead to dehydration and electrolyte imbalance and this might specifically be harmful if it happens during pregnancy. Keep a caution and visit your gynecologist for any associated symptoms
Dr. Ashish Bajaj, M.B.B.S., M.D.
Diabetes may increase the chances of heart-related ailments and stroke by accelerating the development of hardened artillery or blocking them. Foods containing the following can work against your goal of having a proper, balanced diabetes meal plan:
Disclaimer: The information provided here is for educational/awareness purposes only and is not intended to be a substitute for medical treatment by a healthcare professional and should not be relied upon to diagnose or treat any medical condition. The reader should consult a registered medical practitioner to determine the appropriateness of the information and before consuming any medication. PharmEasy does not provide any guarantee or warranty (express or implied) regarding the accuracy, adequacy, completeness, legality, reliability or usefulness of the information; and disclaims any liability arising thereof.
Links and product recommendations in the information provided here are advertisements of third-party products available on the website. PharmEasy does not make any representation on the accuracy or suitability of such products/services. Advertisements do not influence the editorial decisions or content. The information in this blog is subject to change without notice. The authors and administrators reserve the right to modify, add, or remove content without notification. It is your responsibility to review this disclaimer regularly for any changes.
Links and product recommendations in the information provided here are advertisements of third-party products available on the website. PharmEasy does not make any representation on the accuracy or suitability of such products/services. Advertisements do not influence the editorial decisions or content. The information in this blog is subject to change without notice. The authors and administrators reserve the right to modify, add, or remove content without notification. It is your responsibility to review this disclaimer regularly for any changes.
Diabetes mellitus is a metabolic disease that affects the pancreas. In this, the body is unable to properly process the energy released from the food leading to high sugar levels. When this happens over a period, it causes organ damage and other serious complications. There are no apparent reasons why people get diabetes, but many factors in their genes and lifestyle increase their odds of suffering from this disease. Diabetes mellitus can occur because of two reasons. Either the pancreas does not produce a sufficient amount of insulin, a hormone essential for using sugar in the body (Type 1) or because the body develops resistance to the insulin coursing through the system (Type 2). A third kind is known as Gestational Diabetes which occurs when a pregnant woman without a previous history of diabetes develops high sugar levels.
Diabetes mellitus (DM) is a chronic metabolic disorder characterized by persistent hyperglycemia. It may be due to impaired insulin secretion, resistance to peripheral actions of insulin, or both. Chronic hyperglycemia in synergy with the other metabolic aberrations in patients with diabetes mellitus can cause damage to various organ systems, leading to the development of disabling and life-threatening health complications, most prominent of which are microvascular (retinopathy, nephropathy, and neuropathy) and macrovascular complications leading to a 2-fold to 4-fold increased risk of cardiovascular diseases.
Dr. M.G. Kartheeka, MBBS, MD
Following are the most common symptoms:
Diabetes mellitus has no cure. It is a chronic disease that can be best managed by keeping the blood sugar levels under control. However, care must be taken that the sugar levels don’t get too low as that is more harmful and can even be fatal.
Most importantly, this condition requires medical intervention, therefore, do not self-diagnose or take medications without proper consultation.People can live healthy lives with diabetes provided they keep their sugar levels in check. With a proper lifestyle and medications, many live long, quality lives.
Also Read: Desserts For Diabetics: An Expert’s Guide To Enjoying Sweet Treats Safely
Disclaimer: The information provided here is for educational/awareness purposes only and is not intended to be a substitute for medical treatment by a healthcare professional and should not be relied upon to diagnose or treat any medical condition. The reader should consult a registered medical practitioner to determine the appropriateness of the information and before consuming any medication. PharmEasy does not provide any guarantee or warranty (express or implied) regarding the accuracy, adequacy, completeness, legality, reliability or usefulness of the information; and disclaims any liability arising thereof.
Links and product recommendations in the information provided here are advertisements of third-party products available on the website. PharmEasy does not make any representation on the accuracy or suitability of such products/services. Advertisements do not influence the editorial decisions or content. The information in this blog is subject to change without notice. The authors and administrators reserve the right to modify, add, or remove content without notification. It is your responsibility to review this disclaimer regularly for any changes.
I still have a clear memory of her taking insulin after every meal and the way she used to keep some chocolates handy for her hypoglycemic episodes. I always knew that diabetes is a genetic problem and there are chances that I may also get this disease. Understanding the risk, I used to take special care of myself by eating right and exercise daily. But who could escape the problem that is in the blood!
I was 27 when I got diagnosed with diabetes. Before I tell you my story, let me introduce myself.
My name is Preet Karan. I am 28 years old, male, living in a small town in Chhattisgarh province. I am an MBA graduate and currently employed in a leading multinational bank.
I was working as a relationship manager hence travelling and meeting clients was my daily routine. Everything was working well until I realized that I was making frequent visits to the toilet. I didn’t pay any attention to it as it was the summer season and I thought maybe it was because of drinking too much water. But these were only the initial symptoms. My condition worsened in the following weeks. I was losing weight. I lost almost ten kgs in a week. My muscles softened to the extent that I could feel my hip bone while sitting in the office. My trips to the loo became more frequent.
I distinctly remember one incident when I was at an eatery located on the outskirts of the city. During our 1 hour stay in that restaurant, I may have gone to urinate at least 6-7 times.
My friends suspected something amiss, but I still blamed it on the hot summer.
However, the most challenging situation for me was to get dressed for the job. It was too exhausting to get out of bed and go all the way to meet clients.
This routine continued for a month until my grandmother observed ants in the toilet area. She asked me to test my urine and blood sugar, as the sugar in the urine may be attracting ants.
At that time, I also started feeling something wrong with my body, so I immediately complied. I went to the nearest medical laboratory and gave my blood sample. After work, I went to the laboratory to check my report.
And BOOM! My blood sugar reading was around 550 mg/dl. I immediately went to my family doctor, who asked me to do a retest in the morning. I still remember how painful that night was.
I couldn’t sleep the whole night; I was blaming myself for not taking enough care of my body.
The thought of injecting the needles scared the hell out of me. I had already seen my mother struggling with this problem and I certainly did not want to suffer the same. It was an emotional rollercoaster ride for me. I felt anger, anguish, anxiety and pity all at the same time through the night.
After the long night, I went to another laboratory. ”There was something wrong with the previous laboratory,” I thought. I gave my blood samples and waited eagerly for the report.
Each second that I waited felt like a lifetime. The report came, and to my horror, I was labelled a ‘diabetic.’
At that time, I felt like I had lost everything. The efforts that I had put in for my studies, for the job and everything else, seemed to be all wasted. I realized that it was more important to keep your body fit.
All types of thoughts were coming to my mind.
Could I still do my job?
Did I have other diabetic complications?
Would I need to take injections or medicines only?
With all these questions, I went to the endocrinologist. He comforted me and performed all kind of tests to see if I had any other diabetes-related health issues.
The reports came, and I found that I had been a diabetic for the past three months.
I was lucky as there was no organ damage.
The doctor asked me to follow a regular balanced diet and take insulin twice a day. I was following his instructions, but something was wrong. I was not able to control my blood sugar levels. I was taking ten units of insulin twice, but the blood sugar levels were always haywire. Unable to understand what is happening I decided to research online.
I read lots of diabetic research papers and came to know about the carb counting mechanism. It’s a simple mechanism that states the number of carbohydrates in every meal. I found that diabetes is a problem of carbohydrate metabolism, the more carbohydrate you put into the body, the more insulin will be needed for metabolism.
After learning this strategy, I reduced my carbohydrate intake and relied on foods that are rich in good fats. This mechanism helped me to get off from insulin injections for a year.
I found that my body is still making some amount of insulin, which is sufficient if I eat foods that are low in carbohydrates.
But as I was Type 1 diabetic, I knew that a time would come when the leftover insulin-making-cells will get destroyed, and then I will have to rely on an external source of insulin.
Also Read: What Level of Blood Sugar is Dangerous? A Complete, Research-Based Guide
After one year, that time came. My blood sugar went above 200mg/dl even if I didn’t eat anything.
I got the signal that my insulin-producing cells were destroyed, and I had to now rely on an external source of insulin for the rest of my life. Currently, I am using short-acting insulin after every meal and a dose of long-acting at night before going to bed. I still follow a carb counting mechanism, which helps in managing my diabetes better. Being selective in your diet not only helps in better blood sugar control, but it also helps you to keep your body fit and healthy.
I have also created yogicult.com, a website that shares diabetes management tips.
After a year of living with diabetes, I can now say that it is not the type of condition that is going to limit your abilities. If you are diagnosed, please don’t stop dreaming, there are politicians, actors and even sports personalities who have touched the pinnacle of success after diagnosed with diabetes
So focus on eating right, and I am sure you will do great.
About Me:
Preet Karan is the administrator of yogicult.com. The site publishes articles about effective diabetes and health management. The focus of the author is to understand the technical research and present to the readers in a simplified manner.
Disclaimer: Please note that the above information is prepared by the author and states his/her point of view and may not represent practices that are followed universally. It states facts about his/her life and maps their journey of disease-diagnosis-treatment. Because every patient is unique, you are advised to consult your doctor before trying out or acting on this information. PharmEasy has only facilitated the distribution of this information in the interest of patient journey and welfare.