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Diabetes- Prevention and Control This presentation is based on a book written by Dr. Marudhupandian, specialist in treatment of diabetes. It mainly stresses on the importance of life style change in order to prevent and control of diabetes and its complications. It is everybody’s responsibility to spread this awareness to your friends/relatives/neighbors etc. Awareness about Diabetes Diabetes is a metabolic disorder. It is a chronic disease that arises when the pancreas does not produce enough insulin or when the body can not effectively use the insulin it produces to release energy. Prevention and curing of Pre-diabetes is possible by identifying it at correct time, while there is no cure (except at early stage) till now for established diabetes, but it can be controlled. Uncontrolled diabetes for many years leads to many health complications as the blood arteries and nerves are affected. So, Prevention is wiser than controlling. The purpose of the presentation is to spread awareness in society about Diabetes, the silent killer. Types & Cause of Diabetes Insulin is a hormone produced by Pancreas which helps move the blood glucose into cells as energy. When your pancreas makes little (type 2) or no insulin (type 1), or your body prevents the insulin you do make from working right (insulin resistance), blood glucose level increases, which is the cause of diabetes. During pregnancy also, diabetes occurs among women sometimes, which is called Gestational diabetes. While type 2 diabetes is caused due to obesity, there is no specific reason found for type 1. It is caused by genetic problem also. Risk factors causing Diabetes Heredity ( both parents having Diabetes) Unhealthy diet - Consumption of foods containing more carbohydrates ( less proteins) increases blood sugar level rapidly, particularly in the absence of hard work, causes diabetes. Body cells become weak due to lack of hard work and infected easily. Obesity (caused due to over eating, sedentary life and thyroid hormone deficiency) and overweight. Due to over weight, blood pressure increases up to 140/90 and more; Triglyceride increases up to 250 mg/dl; HDL reduces below 35 mg/dl. These indicate chance of becoming diabetic. ( dl = 100 ml ) Reduced body stamina after age of 40 or 45. Risk factors causing Diabetes…… Malnutrition and starving; Worries, body stress; infected liver and pancreas. These factors reduce insulin production in body; Eating food of high calories ( more fat, oil, sugar ). Habit of consuming food of particular nutrients only. Long term use of certain type of steroid medicines. Child getting genes of diabetes in mother’s womb due to mother’s wrong food habit during pregnancy. Women using pills regularly and undergoing abortions often. Women affected by polycystic ovarian syndrome and who gave birth to child of more than 4.5 kg weight ; Diabetes during pregnancy; women having less body stamina. Smoking and intoxication. Symptoms and treatment Type 1 occurs among children, young adults, but it can also appear in older adults. Symptoms like excessive thirst, tired and hungry more often than usual (especially at night), frequent urination, unusual weight loss, irritability of skin, blurry vision, wounds that won’t heal, numb or tingling hands or feet, lack of energy etc will develop rapidly. Treatment includes daily injections of Insulin. Type 2 occurs among obese people of age over 30 or 40. Symptoms same as for type-1 develop slowly. For some people, it may develop without symptoms. Treatment includes tablets to enhance the function of pancreas, (and additional injection as per doctor’s advice) loss of overweight. If blood sugar is beyond control, then Insulin treatment may be needed. Symptoms and treatment… Diet control, exercise/walking, ways to deal with stress, monitoring and control of blood sugar level by timely tests, medicine to control BP, cholesterol are part of the treatment in both types. Some pills help the body release more insulin; some lower the amount of sugar the liver releases; some help insulin work better in muscle and fat; some slow the breakdown of food into sugar. As the number of beta cells goes down, the pancreas makes less and less insulin or stop. As a result, the treatment also may change over time. Additional non-insulin injections or insulin may be needed. The amount of insulin taken must be balanced with how much food they eat and how active they are. Prevention and curing of Diabetes Fasting blood sugar level between 60 to 100 mg/dl is normal; 100 to 126 mg/dl is called pre-diabetes stage, which can be cured (for type 2 only) by proper diet, exercise and reduction of weight. Above 126 mg/dl is considered as diabetic. Identifying and curing at the stage of pre-diabetes level is very important, as uncontrolled diabetes is not curable. Identification of pre-diabetes can be done by yearly once blood test above age of 30 or 40. For patients of controlled diabetes for many years, ( at early stage) sometimes, they will feel giddiness when taken usual drugs due to glycemia ( blood sugar level lower than normal). Such patients may be advised by doctors to stop medicine. Ways of Prevention and Control of Diabetes Awareness about diabetes Reduction of mental stress Regular exercise Determined Diet control Weight control Timely tests for diabetes ( once a month) Medicines if diagnosed as diabetic. Testing methods Above age of 30, testing for blood glucose yearly once is advisable for normal people. Fasting blood glucose level of 60 to 100 mg/dl (100 to 126 mg/dl is called pre-diabetes stage) and post brandial level of below 120 mg/dl i.e., 1.5 hour after taking food is considered as normal levels. For diabetic people, testing once in a month can be done to monitor the blood glucose level; Blood glucose level should be kept in control within the values as below: At fasting: 70 to 120 mg/dl; After 2 hours of diet: 140 to 160 mg/dl. (less than 180) Type 2 diabetics can check blood glucose 1.5 hours after diet; Type 1 diabetics can check fasting glucose level. Testing methods…. Glucose Tolerance Test (G.T.T.) is an accurate test for diagnosing whether you are diabetic or not. For diabetic people, the blood sugar level in this test exceeds 200 mg/dl after 2 hours of test. Hemoglobin A1C Test is an reliable test for diagnosing whether you are diabetic or not. Normal value: less than 5.7%; Prediabetic: 5.7 – 6.4%; Diabetic – if more than 6.5%. Diabetics can undergo this test, fructossamine test, and urine albumin test once in 3 months. Hba1 test is useful for patients having brittle diabetes ( level varying during a day ) If you have glucometer at home, it will be easy to monitor blood glucose level (and take the required quantity of insulin accordingly, especially for type 1 patients, whose blood glucose levels vary abruptly.) Other tests for diabetics Following tests shall be conducted once in a year for diabetics. Eye check up Kidney function tests Tests for legs X-ray Lipid profile ( Total cholesterol, HDL, LDL and triglycerides) Topler test Phyothesiometry test Other specified tests Complications due to uncontrolled diabetes Patients suffering from diabetes for 10 to 15 years are affected by many complications as below. Loss of eye sight ( Retinopathy). Generally, people over 40 shall undergo eye check up at least once a year. ( check Glaucoma ) Harder for blood flow to legs and feet ( Keep legs elevated on a pillow while sleeping, so that blood circulation to and from heart improves) Amputation of leg ( blood arteries get damaged and due to less supply of oxygen, tissues die; change of colour of leg’s fingers and leg pain while walking indicate the need of urgent special treatment to prevent amputation ) Coma Diabetic Ketoacidosis (life threatening) Complications…… Neuropathy Damage to Kidney and other body parts Due to uncontrolled blood glucose, blood arteries get damaged. Hence, blood pressure increases. If blood arteries of kidney are damaged then blood pressure increases rapidly. Medicine cannot control BP in this case. Due to liver becoming less effective, LDL increases. Due to reduced supply of oxygen (blood arteries affected) wastes in blood stagnates. Consequently, swelling, pain, parts damage, permanent deactivation of tissues happen. Stagnation of wastes in blood affects lungs, kidney, liver etc, which are life threatening. Complications….. Diabetes makes harder to control Blood Pressure and Cholesterol leading to development of heart diseases and ultimately heart attack/ stroke/paralysis; Due to long term effect of hypertension, there is a chance of heart failure (enlarged heart). Breathing difficulty may be a symptom of heart disease. Before any surgery to be done, blood sugar should be in control. At unavoidable situations for surgery, heavy dose of insulin is used for patients of uncontrolled sugar. In post-operative period also, blood sugar should be kept in control. Curing of wounds takes more time for diabetic patients, as body immunity is decreased by diabetes. Blood pressure Blood pressure is a symptom of an imbalanced body. The tests to find out what is out of balance are: fasting insulin, hemoglobin a1c, potassium, RBC magnesium, and vitamin D. High insulin can also stimulate the kidney to produce angio tension, a substance which increases blood pressure. (Ratio of Triglycerides/HDL of less than 2 is good; more than 4 means hyper insulinemic. Fasting insulin level over 10 is high; over 15 is considered as hyper insulinemia. ) Blood pressure is increased when cholesterol deposits block the arteries anywhere in body. Blood pressure is elevated by kidney diseases. Chemicals like synthetic food colours and preservatives affect pancreas and kidneys. Above age of 70, many people have hypertension. Blood pressure…. Normal BP for adults is 120/80 to 105/70; 120/80 to 135/85 is called pre-hypertension. For children and athletes it is 100/65 to 90/60 Normal pulse rate for adult is 60 to 100 bpm.; for children 90 to 120 bpm; for infants 120 to 160 bpm Normal oxygen level in blood is 95 to 100%. Oxymeter is used to test the blood oxygen level. Lungs function is checked by spirometry test. ( air is blown by mouth into spirometer and reading is observed how much and how quickly you can move air out of lungs) Blood pressure to be recorded once in two years at least. (for normal people ) Blood pressure…. As there will be no symptoms for high blood pressure, it is called silent killer. High blood pressure more than 140/90 damages many body parts, mainly causing heart attack/heart failure. Diabetics are advised to maintain BP below 130/80. Very low blood pressure haves some symptoms like dizziness, confusion, decreased urine output etc. below 90/60 medicine needed to avoid fainting. Tests for kidneys Diabetics shall check kidney every year to prevent any major complication. GFR test. GFR shall be above 90 for a healthy kidney. GFR of below 60 indicates kidney disease. GFR can be estimated from blood creatinin level. Albumin in urine test shows that kidney is affected. Two tests of two weeks apart shall be done to diagnose. ACR (microalbumin to creatinin ratio) shall not exceed 2.5 for male and 3.5 for female BUN test (blood urea nitrogen) (10 to 20 mg/dl is normal) Tests for kidneys…. Test for creatinin level in blood ( normal level is 0.6 to 1.2 mg/dl) and urine Test for ketones level in urine (wastes) (negative result is normal). Ketones build up when the body needs to break down fats and fatty acids to use as fuel . This occurs when the body does not get enough sugar/carbohydrates. Ultrasound image of kidney to check for any growth or blockage on urinary tract. Ways of reducing Blood pressure Reduce salt in diet; Avoid taking salted foods like pickle etc. salt can be substituted by spices. Reduce blood cholesterol by exercise and if needed by medicine; Check by TMT for 70% blocks in arteries, followed by angioplasty treatment. Stop smoking, alchohol, No to coffee Reduce overweight by diet and exercise/walking. Check body mass index. Control thyroid problem if any. Ways of weight loss ( 2 to 3 kgs /month): Low calorie food, 6 small meals instead of 3 big meals, avoid high-protein food, walking minimum 45 min/day. . Ways of reducing Blood pressure Control blood sugar if you are diabetic. ( High BP is the cause of heart enlargement for diabetics); Above BP of 135/85 or 140/90 medicine is prescribed Decrease carbohydrate intake to avoid gain of excessive weight and LDL. Remove all saturated fats, trans fats, partially hydrogenated oils etc. Take salad of green vegetables and fruits consisting of potassium and magnesium. Stress free ( body and mind) life; Good sleep If you have continuous uncontrolled BP, change of treatment method is advisable under a doctor’s consultation. Ways of reducing Cholesterol Avoid food of high fat, and oil content, fast food, meat, organ meat, chicken with skin, egg (yellow part), fried food, full fat dairy products, nuts, dry fruits etc. Saturated fat increases total cholesterol and LDL. Body stores the excessive calories converting as fat, thereby increasing body weight. Food containing trans fats such as partially hydrogenated oils, margarines, creams etc raise LDL and lower HDL. Processed foods and foods high in carbohydrates increase LDL. Reduce overweight by diet and exercise. Over weight increases LDL and lowers HDL. Exercise can increase HDL. HDL helps to remove LDL from blood. Monitor and control diabetes, if you have, especially pre-stage diabetes. For thyroid (if any) problem, treatment needed to prevent obese. Ways of reducing Cholesterol… Eat two hours before going to bed; Walking after dinner is helpful. Consume vegetables of fiber nature. Garlic, fenugreek, ginger, turmeric, basil, beans, broccoli, cabbage, cauliflower, apple, pears, leafy vegetables, oats can reduce cholesterol. Use stairs instead of lift and escalator. Diabetics are advised to keep LDL below 100 mg/dl ( 70 mg/dl for heart patients); triglyceride below 150 mg/dl; HDL above 40 mg/dl. ( 50 mg/dl for women). Total cholesterol to be less than 200 mg/dl, but less than 160mg/dl is desirable. No smoking and intoxication. Foods consisting of magnesium can lower cholesterol. Some aurvedic medicines lower cholesterol. After all the effort of diet and exercise fail, “statin” tablet is prescribed. Insulin resistance and hyper insulinemea When the body’s cells are resistant to the action of the insulin, it is called Insulin resistance. As a result, pancreas produces much more insulin than normal In a normal person, 1 unit of insulin may be needed to help 10 mg of glucose go into the cell, but in a hyperinsulinemic person, 10 units of insulin may be needed. Fasting insulin level of 5 is healthy; over 10 is high; over 15 is considered as hyperinsulinemea. Ratio of Triglycerides/HDL (of less than 2 is good;) more than 4 means hyperinsulinemic. Consequences of hyperinsulinemea High triglycerides; Low HDL. (Triglycerides shall not exceed 150 mg/dl, but less than 120 mg/dl is desirable.) High plasminogen activator inhibitor activity (PAI-Fx) causing risk of clotting High uric acid Polycystic ovary syndrome, infertility, obesity, high leptin levels. Type 2 diabetes Elevated blood pressure Symptoms & Consequence of Low blood glucose (Hypoglycemia) Blood glucose reduces below 60 mg/dl. It is a life threatening condition. Generally happens among type-1 patients. But it is rare among type-2 patients. Symptoms include cold sweating, tiredness, fast heart beat, nervous; consequently, head pain, blurry eye vision, loss of consciousness, fainting, coma happens. Low quantity of food intake, too much exercise and high quantity of insulin injected may be the reasons of fainting. Symptoms & Consequence of Low blood glucose (Hypoglycemia)…. During the symptoms, or if you think blood sugar is low but you cannot check it at that time, dissolve two teaspoon of sugar or glucose in water and drink immediately. If problem still exists (15 min), use more sugar or glucose. Keeping always some sugar in pocket is advisable. Once your blood sugar returns to normal, eat a meal or snack. Some people may not feel any signs of low blood sugar. Untreated low blood sugar can be life threatening. On the onset of the symptoms, get away from work, machines, or driving, to avoid accidents. Symptoms & Consequence of high blood glucose (Hyperglycemia) It takes days or weeks to develop hyperglycemia. Causes: Over eating; wrong food habit; mind stress; illness due to infection; accident; pregnancy; skipping medicine, less exercise, Insulin level lower than requirement. Symptoms: Initially the symptoms of diabetes will be there; Then, stomach pain, body pain, sense of vomiting, vomiting, loss of appetite, dry skin. Consequences: difficult and fast breathing with an organic ( fruity) odour, giddiness, fainting, dull senses. Treatment: In initial stage, planned diet, Insulin quantity as per doctor’s advise. Test for ketones in blood and urine. Symptoms & Consequence of high blood glucose (Hyperglycemia) During sickness: Blood sugar may increase or decrease. Even if you don’t eat, body produces blood sugar and hence insulin is needed. Along with the usual medicine, Insulin may be needed as per doctor’s advise, in case of rise in blood sugar. Take liquid food once a hour. Test blood sugar and ketones in urine every 4 to 6 hours. If blood sugar exceeds 300 mg/dl or ketones in urine is medium or high, then consult doctor. (ketones in blood or urine are a sign of low insulin level and that the body is using fat for energy instead of sugar) During diarrhea, or vomiting, take soup or orange juice every 10 to 15 minutes. If food is not digested or the sickness prolongs for more than 24 hours, consult doctor. Diet control Select a diet with low G.I. (Glycemic Index) like whole grains, fiber rich foods, salads of green vegetable, sprouts etc which add glucose to blood slowly. Avoid carbohydrates and sugars of high G.I. to reduce triglycerides in blood. Diabetics shall avoid bananas, mangoes, jack fruit, dates, resins, papaya, large quantity of rice, honey, sugar, sweets, coconut, potato, beet root, fruit juices, ice cream, grapes, foods consisting of more carbohydrates, fried foods, salty foods, soybeans, almonds, pistachio etc. Instead of 3 big meals, 6 small meals are advisable. Daily calories requirement: 2600 calories for slim people; 2200 calories for average weighing people; 1800 calories for obese people. Diet control…. Cucumber, mushroom, apple, radish, cinnamon powder, fenugreek etc are good for health. Potassium rich foods are: melons, orange, pears, spinach, tomato, low fat milk, low fat yogurt etc. Magnesium rich foods: beans, broccoli, okra, spinach etc. Take 2 liters of water daily Don’t skip breakfast. Overeating high-protein foods leads to weight gain, leading to diabetes. Glycemic Index examples Drinking 200 ml of water will not change blood glucose. Foods increasing blood glucose of about 10 to 20 mg/dl: 100 gms of many fibrous vegetables, leafs, 200 ml of low fat butter milk etc. Take plenty of foods in this category. Foods increasing of about 30 to 60 mg/dl: 100 gms of vegetables (except plantain), dhal, gram, wheat, rice, cucumber, papaya, apple, orange, 200ml of milk, coffee, tea without sugar, salted lemon or tomato juice, coconut’s water etc. Limited quantity of this category is advised. Avoid foods increasing of more than 60 to 100 mg/dl like: Carrot, Glycemic Index examples…. Taking foods increasing of more than 100 mg/dl, will not help to control blood sugar, but it will get worst. Ex: 100 gms of Dates, grapes, mango, banana, jack fruit, raisins, chickkoo, potato, beet root, 200ml of fruit juices, Pepsi, honey etc. 100 gms of sweets, dates, grapes or 200 ml of fruit juices with sugar will increase blood sugar of 150 to 250 mg/dl. Sugar should not be added in coffee/tea/milk. Calories of foods Milk 150 ml gives 200 cal; Tea 150 ml gives 60 cal.; 4 biscuits give 100 cal; 1 chapati (15 g) gives 40 cal; 1 paroto (70 g) gives 250 cal; 1 cup (180 g) of dhal gives 200 cal; 1 cup of vegetables give 75 cal; 1 idly (75 g) gives 75 cal; 1 Dosa (50 g) gives 110 cal; 1 teaspoon of (15 g) of peanuts give 90 cal; 1 cup of rice (210 g) gives 250 cal; 100 g fruits give 60 cal; Nature of foods Ideally, our blood’s pH should stay on the alkaline side: between 7.35 and 7.45. Common acid-forming foods include processed junk foods, meat and egg. Common symptoms of an unbalanced pH include heartburn (a burning sensation in the stomach and acid-tasting burps), bloating, belching, and feeling full after eating small amounts of food. Other symptoms could include insomnia, water retention, migraines, constipation with diarrhea, fatigue, a burning sensation on the tongue and in the mouth, and halitosis. over-acidity in the body tissues, is one of the basic causes of diseases, especially the arthritic and rheumatic diseases." To maintain health, the diet should consist of 60% alkaline forming foods and 40% acid forming foods. To restore health, (to loose weight) the diet should consist of 80% alkaline forming foods and 20% acid forming foods. "ACID-FORMING" Foods Acid forming foods include: asparagus, barley, beans (dried), BREAD, BUTTER, cashew nuts, Cereals, CHEESE, chestnuts, CHOCOLATE, cod liver oil, Cottage Cheese, Cornmeal, cottonseed meal, cream, FLOUR, hazelnuts, HONEY, lentils, Macaroni, Margarine, Mushrooms, OATS, pasta, peanuts, Peas, pistachios, pomegranate, Rice, SUGAR, syrups, tapioca, walnuts, WHEAT. in the blood Alkaline forming foods include: agar, sprouts, almonds, APPLES(apple cider), apricots, BANANAS, beets, berries, BROCCOLI, cabbage, CARROTS, cauliflower, cherries, coconut, cucumbers, DATES, figs (dried), flaxseed, GARLIC, GRAPES, Grapefruit, green beans (fresh), guava, LEMONS, lettuce, mango, MELONS, mint, mustard greens, nectarines, okra, Olives, olive oil, ONIONS, ORANGES, papaya, parsley, Peaches, Pears, PINEAPPLE, plums, Pumpkin, radishes, RAISINS, Soybeans, Spinach, Strawberries, turnips, watermelon. Facts of food Body cannot produce 8 Essential Amino acids which are essential for body maintenance and to be got from food. Low quantity of EA acids like lysine and methionine are found in grains and dhals but when consumed with vegetables and curd, the requirement is fulfilled. Body’s requirement of vitamins is very less; but they cure diseases and delay the process of ageing. Vitamin A, D, E, K dissolve in fat. Anti-oxidants are precursors of vitamins. Vitamins and antioxidants resist the ill-effects caused by free radicals. Free radicals are produced in human body as byproducts of oxidation. When fats and oils are heated to high degree temperature, free radicals are released. Facts of food… Saturated, polyunsaturated oils release free radicals faster than mono unsaturated oils like olive oil. Air pollution and ultra violet rays (also cigarat) produce free radicals naturally. Air pollution destroys vitamins in fruits and vegetables. Muscles, cells, nerves are made of proteins. Milk and dairy products are good source of proteins. ( skimmed products are advisable for heart patients) Minerals ( Calcium, sodium, pottasium etc) create bones, hemoglobins and help metabolism. Fruits and vegetables are full of minerals. Minerals balance acids and alkalines; help for elasticity of muscles and blood clotting. Water constitutes more than 50% of our body. It helps for detoxification through kidneys; controls body temperature; transfers oxygen to all body parts. Facts of food…. Vitamins, minerals and water give vitality to body. Fibre content in fruits and vegetables helps to solve constipation, reduce cholesterol absorption, prevents cancer, reduces weight, controls diabetes. Soluble fibre present in oats, grapes, apple, broccoli, leafy vegetables etc reduces cholesterol and LDL in blood. Vitamin C improves immunity of body against infections. It is destroyed by cooking. Vitamin E acts as anti-oxidant; helps for immune system. It is present on cell membranes. Sprouts are good source of vitamin E. Food facts…. Vitamin A is present as Retinol in meat, milk, fish liver oil and as beta carotene in fruits and vegetables. Beta carotene resists against free radicals. It is not destroyed by cooking or ultra violet rays from sun. It is converted as vitamin A in body. Only 30 to 50% of beta carotene is absorbed by body. It acts as an anti-oxidant. It is present in red, orange coloured fruits and vegetables and dark green coloured vegetables. Exercise Due to lack of hard work/exercise, fat accumulates in body; body cells become weak and become prone to diseases. Simple way of exercise is walking. During exercise, Insulin is induced in body, and body’s capacity to use insulin increases. Exercise reduces weight; spends calories and blood glucose from body. Due to exercise, heart muscles get stronger and elasticity of arteries improve; Blood pressure is normalized; LDL and triglycerides which are the causes of obese, are reduced and HDL is increased. Exercise makes one’s mind stress free and gives more enthusiasm and confidence. Exercise…. Exercise helps to prevent bone softening ( after age of 35) and to retain elasticity of muscles. Drink water before and after exercise for better heart’s function and blood pressure. During exercise, if you feel symptoms like fainting, chest pain/pressure, fast breath etc, consult doctor for medical check up/tests. Exercise reduces body’s resistance to insulin, which in turn reduces hypertension, and hence heart is saved from the effect of hypertension. Exercise improves dissolving capacity of blood clots and plaque deposits in coronaries. Exercise…. Before exercise if you have blood glucose above 250 mg/dl or keetones are found in urine, avoid exercise. If blood sugar before exercise is below 100 mg/dl, then, it is better to have some snacks. Yoga is a best exercise. ( Avoid “Sarvanga Asana” if you have hypertension). Certain body parts benefited by certain yoga. It is ideal to have normal hemoglobin level to increase your exercise capacity. Exercising hands and legs increases muscles; Muscles help to burn calories and for fitness. Wear a medical identification during walking. Gestational Diabetes High blood sugar during pregnancy can cause miscarriages, birth defects, born too early, weighing too much/less (or) even loss of baby or risk to mother’s life. Most mothers get rid of this form of diabetes shortly after the delivery. But sometimes, the risk prolongs. There is a chance of the baby becoming diabetic in latter age. Pregnant mothers shall undergo test for high blood sugar during sixteenth week, twenty fourth week, thirty second week. Hba1 test is useful to check blood glucose level. Training to children Train them to develop healthy balanced food and exercise habit so as to maintain weight control. Training in yoga, swimming, sports, music and arts shall be given from young age. Limit TV and computer watching time for children. Train them to develop good characters and to avoid unnecessary desires. Encourage to develop social attitude. Encourage self-dependence, self defense and to eliminate any psychological problems in them. Above mentioned training becomes essential especially if you have family history of diabetes / heart diseases, so as to protect your children in future.