Risk factors of stroke

Risk factors of stroke Stroke is a neurological emergency. Stroke occurs as an end result of diminished blood supply to brain. It produces significant morbidity and mortality in the society. About 20% of patients die within 1 month of stroke attack. It has both modifiable and non modifiable risk factors. Treatment of modifiable risk factors will help in reducing about 80% stroke in the community.

General risk factors for stroke

Non-Modifiable risk factors

• Age - Age more than 55
• Gender - Male 
• Race (ischemic stroke): blacks > whites > Asians 
• History of stroke or TIA.

15-30% of strokes are preceded by TIA.

35% of pts with TIA will have stroke within 5 years.

10% risk of recurrent stroke within first years of stroke.

(TIA – transient ischemic attack).

• Family history.
• Fibromuscular Dysplasia.
• Patent Foramen Ovale (PFO or hole in the heart).

Modifiable risk factors

Modifiable risk facrors are divided into medical disorders and lifestyle disorders.

Medical Risk Factors 

High Blood Pressure.

Atrial Fibrillation.

High Cholesterol. 

Diabetes.

Atherosclerosis.

Circulation Problems.

Lifestyle risk factors

Smoking.                                                                                                

Alcohol use.

Physical Inactivity.

Obesity. 

High risk factors for ischemic stroke

General population (0.6 %/yr)

Asymptomatic carotid bruit : 1.5 %/yr.

Prior myocardial infarction  : 1.5 %/yr.

Asymptomatic carotid stenosis : 2.0 %/yr.

Nonvalvular atrial fibrillation :  5.0 %/yr.

History of TIA : 6.0 %/yr.

Prior ischemic stroke : 10 %/yr.

Rare risk factors

Thrombocythaemia and  thrombophilia ( increased platelet count ) 

Polycythaemia ( Increased hemoglobin) 

Anticardiolipin and lupus anticoagulant antibodies (i.e. antiphospholipid syndrome). 

Endocarditis ( infection of heat valve) 

Low-dose oestrogen-containing oral contraceptives 

Migraine   

Vasculitis (SLE, polyarteritis nodosa, giant cell arteritis, granulomatous CNS angitis) 

Amyloidosis   

Hyperhomocysteinaemia 

CADASIL (cerebral dominant arteriopathy with subcortical infarcts and leucoencephalopathy)

Reduction of stroke risk following control of risk factors

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Risk factors for depression

Depression is the fourth leading cause of global burden of mental ill health. According to WHO it will be the second most common form of disability by 2020 after ischemic heart disease. Depression is a major cause of suicide. Nearly 1 million people die of suicide, annually. Incidence of major depressive disorder is 1 in 20 people during their entire life time. It is more common in women than men.

Depression affect compliance, immune functioning, quality of life and it will lead to unhealthy behaviours in patients. Due to depression patient experience a variety of somatic illness. Less than one half of depressed patients are identified and adequately treated by primary care physician. It is a common condition and is treatable. Hence identification of this syndrome is important.

Risk factors for depression are

1. Gender-common in females. 
2. Genetic/biological vulnerability. 
3. Stress/environmental/life events especially loss events such as bereavement. 
4. Physical illness especially chronic and painful illness.
5. Drugs.
6. Chronic and excessive alcohol intake.
7. Difficulties in interpersonal relationship.
8. Lack of social support with no confiding relationship. 

Pathways to depression

Broadly depression  can be classified as two major groups.

1. “Major” depression – Pharmacologically treated.
2. “Minor” depression – Treated mainly by psychological approaches.

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What is raynauds phenomenon ?

Raynauds phenomenon is due to episodic digital ischemia (decreased blood supply to digits). On exposure to cold there is color change to digits which change on rewarming. Emotional stress may precipitate Raynaud’s  phenomenon. Color changes are well demarcated and confined to fingers and toes.

Phases of raynauds phenomenon

Phase of  blanching/pallor - On exposure to cold there is spasm of arteries in the digits and cause diminished blood supply to digits, so that the the digit appears white. 

Phase of cyanosis - In this phase there is bluish discolouration of digits. There is dilatation of veins and small capillaries and lead to accumulation of de oxygenated blood in the vessels. In both these phases there is coldness and numbness of digits.

Phase of rubor/redness - It occur on rewarming the digit.This is due to dilatation of blood vessels, spasm resolves, so there is reactive hyperemia. In this phase patient experience pain and throbbing sensation. All the three phases need not be present in a given patient. Some patient experience only pallor and cyanosis where as others have only cyanosis.

Classification 

Primary or idiopathic condition is called Raynaud’s disease. Secondary is associated with underlying disease that is known to produce vasospasm.

Raynauds disease

It is more common in females and is usually seen between the age group 20 to 40. Fingers are more commonly affected than toes. Other areas affected may be ear lobes, tip of nose, penis. This is more common in those who suffer from migraine or variant angina. Those with raynauds disease have milder form of Raynaud’s phenomenon.  

Secondary causes of Raynaud’s phenomenon

a) Collagen vascular diseases:

1. Scleroderma (80-90%)
2. Dermatomyositis, Polymyositis(30%) 
3. Rheumatoid arthritis 
4. Systemic lupus erythematosus(20%)

b) Diseases  producing arterial occlusion: 

1. Atherosclerosis of the extremities-Common in men more than 50 yrs. 
2. Thromboangiitis obliterans (TAO) more common in young males who are smokers
3. Acute arterial occlusion 
4. Thoracic outlet syndrome

c) Pulmonary  artery hypertension

d) Nervous system disorders:

1. Intervertebral disk disease
2. Syringomyelia
3. Spinal cord tumors
4. Stroke 
5. Poliomyelitis
6. Carpal tunnel syndrome

e) Disease of Blood: 

1. Cold agglutinins
2. Cryoglobulinemia
3. Cryofibrinogenemia 
4. Myeloproliferative disorders
5. Waldenström’s macroglobulinemia

f) Trauma: 

1. Vibration injury
2. Hammer hand syndrome
3. Electric shock
4. Cold injury 
5. Typing
6. Piano playing

g) Drugs: 

1. Ergot derivatives
2. Methysergide
3. β-adrenergic receptor
4. Blockers
5. Bleomycin 
6. Vinblastine 
7. Cisplatin

Complication of Raynaud’s phenomenon 

Rarely progress to digital ischemia, gangrene, ulceration and auto amputation of digits.

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Quitting smoking is difficult ,Why ?

Principal content of tobacco is nicotine. It is responsible for its addictive behavior. Tobacco smoking produce physical as well as psychological dependence. Many smoke cigarette as way to cope up with stress and depression. So it is a part of many people’s daily rituals. On quitting smoking people experience withdrawal symptoms that is, unpleasant effects. Addicted smokers control nicotine intake by adjusting the frequency and dose of tobacco intake to obtain the desired psychological effect and avoid withdrawal. Even if they know that smoking is harmful, the addictive behavior prevents them from quitting. Not only addiction is preventing cessation other factors such as peer group pressure, advertisement of cigarette companies also make the attempt of cessation difficult.

Methods for smoking cessation

Smokers who are not motivated

• Record smoking status at regular intervals
• Anti-smoking advice should be given.
• Encourage change in attitude towards smoking to improve motivation

Motivated light smokers (smoke < 10cigarette /day)

• Anti-smoking advice
• Anti-smoking support programme.

Motivated heavy smokers (10–15cigarette /day)

• As above plus nicotine replacement therapy (NRT) (minimum 8 weeks).

Motivated heavy smokers (> 15 cigarette /day)

• As above plus bupropion if NRT and behavioral support are unsuccessful and patient remains motivated. 

Placebo or will-power alone has a ~2% chance of abstinence for ≥ 6 months. This can be increased by the following

• Written self-help materials: 1%
• Opportunistic advice from doctor: 2%
• Face-to-face behavioral support from specialist: 4–7%
• Proactive telephone counseling: 2%
• NRT with limited or intensive behavioral support: 5–12%
• Bupropion with intensive behavioral support: 9%.

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Inter vertebral disc prolapse - Clinical features

Functions of Inter vertebral disc
1)     To separate two vertebral bodies and increases available motion.
2)     To transmit load from one vertebral body to the next.
3)     The disc makes up to 20% to 33% of the length of the vertebral column.
4)     Disc increase in size from cervical ( neck) to lumbar region (lower back).
Anatomy
Disc thickness is 3mm in cervical region (neck region) where weight bearing loads are minimum.
Disc thickness is 9mm in lumbar region (low back)

Risk factors for disc herniation are the following

1)     Job requiring heavy and repetitive weight  lifting.

2)     Use of machine tools.

3)     Operation of motor vehicles.

4)     Cigarette smokers and tobacco consumers.

5)     Overtime heavy work,  poor postural habits.

6)     Degenerative changes make the disc susceptible to trauma.

Any trauma which suddenly increases the pressure will result in rupture of posterior fibres of annulus.

Repeated stresses over time cause

1)     Fatigue breakdown

2)     Traumatic rupture

Clinical features of disc prolapse

Patient is usually an adult between 20 -40 age group. Commonest complaint is low backache. It can be acute or chronic sometime pain radiate to the buttock and leg. The pain is increased by flex-ion (stooping forward) episode, straining, sneezing, coughing and relieved by rest. If there is associated, nerve root compression there will be numbness or weakness in lower limb.

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Insulin use - Practical points

Diabetes mellitus is a progressive, metabolic disorder where there are disturbances in carbohydrate, lipid and protein metabolism. It results from insulin deficiency and / or insulin resistance. As the global burden of diabetes is increasing number of patients on insulin also increases. All those who are on insulin must know the following practical points.

Storage of insulin

1. Stored in a cool and dark place, otherwise their potency is lost (Temperature dependent).
2. Do not keep in a freezer compartment. 
3. The vial in current use can be easily kept at room temperature in a dark place without losing any potency. 
4. Cold insulin if injected is painful.

Insulin injection sites

• Absorption of insulin shows regional difference
  Absorption of insulin is maximum from abdominal region followed by upper outer arms, buttocks and upper outer thighs.
• Abdominal region > upper outer arm and buttocks > upper outer thighs
• The site of injection should be rotated within the same area.
• Depth of injection – subcutaneous with insulin syringe.
• Intravenous injection (direct injection into vein), Intravenous infusion , or Intramuscular routes (direct injection into muscle ) are used only during, emergency such as  ketoacidosis or stressful conditions.
• Same site is used for at least one month and rotation is done within the same site rather than rotating to different sites.
• Using same site decreases variability in day to day absorption. 
• Rotation within the same area prevents lipodystrophy.
• Avoid a site with open wounds or blisters.

Injection technique

• If site is clean, there is no need to clean the site with alcohol or spirit. 
• In thin or averagely built person, lift or grasp a fold of skin between thumb and index finger and inject at 45° or 90°.
• In obese person, full length injection at 90° is recommended.
• Mixing – usually available as premixed form.
• Regular insulin can be mixed with all other preparations.
• Insulin glargine should not be mixed with other insulin.

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Irritable bowel syndrome - understanding clinical features

Irritable bowel syndrome (IBS) is one of the common bowel problems. Other names are spastic colon, nervous bowel, mucous colitis, functional bowel disorder, intestinal hurry. Many persons suffering from this won’t disclose it to others and their doctors because of fear. Even though the symptoms are distressing many of them can be relieved with proper medication. About 20% of general population may be suffering from the disease but only 10% seek medical attention. This can occur at any age majority experience the first attack before 45 yrs. IBS is mainly a disease of young women. Understanding and treating the condition is important because it will affect the quality of life and frequent work absenteeism .This is a functional disorder of bowel without any structural abnormality.

Clinical features of Irritable bowel syndrome

IBS is characterized by recurrent abdominal pain associated with defecation and altered bowel habits. Symptoms vary from person to person . Predominants symptoms are abdominal pain, altered bowel habits, gas and flatulence, upper gastrointestinal symptoms. Even healthy people may  have occasional stomach upset and diarrhea , IBS  patients experience it more frequently.

1. Abdominal pain

It is the most common and key symptom of IBS. It can be colicky or cramp like mainly felt in the lower abdomen and is relieved by medication. Some patients experience a constant ache in the abdomen. Severity of pain varies from patient to patient. Usually pain is present only during wakeful hours and won’t disturb the sleep. Factors that aggravate pain include eating or emotional stress and it is  improved by passage of flatus or stools. In females during premenstrual and menstrual period worsening of symptoms can occur. 

2. Alteration in bowel habits 

One of the most consistent clinical features in IBS is alteration in bowel habit. Patient may experience diarrhea (IBS-D), or constipation (IBS-C) or a mixture of these (IBS-M ).The usual  pattern is constipation alternating with diarrhea,eithr of these symptom can predominate. In constipated patients stools may be hard with narrow caliber described as marble like or pencil thin. Patients also explain incomplete evacuation this will lead to repeated defecation .In some people diarrhea predominates. This is small volume loose stool. Usually there is no diarrhea at night. Emotional stress and eating will worsen the diarrhea. Passage of mucus per rectum can occur. Usualy there is no weight loss or malabsorption. Rectal bleeding is not seen. 

3. Gas and flatulence

Patients also complain of abdominal distension and flatulence, many patients complain of increasing gas, but that need not be present, there is alteration in bowel transit of intestinal gas and intolerance to gas. Those patients with bloating and abdominal distension experience less abdominal pain.

4. Upper gastrointestinal symptoms

About 25-50% of patients with IBS also experience dyspepsia, heartburn, nausea, and vomiting. The prevalence of IBS is more among patients with dyspepsia. 

Other coexisting conditions are fibromyalgia, non ulcer dyspepsia, chronic fatigue syndrome, headache, backache and dysmenorrhea in females. 

Stress  and IBS

Emotional factors are linked to IBS. Anger, anxiety may increase the bowel movements and produce diarrhea. Upto 50% of people may experience anxiety, depression, obsessive-compulsive disorder .Some patients also gives history of prior physical or sexual abuse.

Rome III criteria for diagnosis of irritable bowel syndrome

Recurrent abdominal pain or discomfort at least 3 days/month in the last 3 months, associated with two or more of the following:

• Improvement with defecation.

• Onset associated with a change in frequency of stool.

• Onset associated with a change in form (appearance) of stool.

Features supporting IBS

• Symptoms for more than 6 months.

• Frequent medical visits for non-gastrointestinal problems.

• Prior symptoms which are medically unexplained.

• Worsening of symptoms by stress.

Alarming features of IBS, if present immediately consult physician 

• Age more than 50 yrs.

• Male gender

• Weight loss

• Nocturnal symptoms ( Symptoms at night ) 

• Family history of colon cancer

• Anaemia – Decreased heamoglobin

• Rectal bleeding

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Causes of hypoglycemia in diabetic patients

Hypoglycemia is common problem seen in diabetic patients on insulin. It is due to imbalance between insulin requirement and administration. Highest risk is just before meals and during night. All patients on insulin and oral hypoglycemic agents should be aware of the causes  of hypoglycemia and try to avoid them.

Causes of hypoglycemia in diabetes 

Relative or absolute insulin excess.

Increased dose of insulin or insulin secretagogue (agents that help to increase insulin secretion) such as sulfonylureas and meglitinides which stimulate insulin secretion.

Intake of glucose is reduced.

• Missed or delayed meals.
• Insufficient carbohydrate in meals.

Increased glucose utilization.

• Vigorous exercises.

Increased sensitivity to insulin.              

• With improved glycemic control, late after exercise, in the middle of the night, weight loss. All this situation causes increased sensitivity to insulin.

Deceased glucose production.

• Alcohol intake.

Reduced clearance of insulin.

Renal failure.

Poorly decoded insulin regimen.

Lipohypertrohy at injection sites - Erratic insulin absorption from areas of fat

Gastroparesis

Malabsorption diseases

Risk  factors of hypoglycemia in diabetic patients

1. Impaired awareness of hypoglycemia-Patient fail to recognize the clinical features of hypoglycemia.
2. Strict glycemic control.
3. Extremes of age group.
4. Long duration of dm.
5. Type 2 DM treated with sulfonylureas, insulin.
6. Somogyi phenomenon.

Early morning hypoglycemia (at 3 am) followed by hyperglycemia resulting in elevated fasting blood glucose. This phenomenon is due to increased night dose of insulin.

Management of hypoglycemia

1. Primary prevention
2. Patient education
3. Frequent self monitoring
4. Use flexible drug regimens
5. Professional guidance

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Clinical feature of gout

Gout is a disease in which body uric acid pool is increased. This will lead to deposition of urate crystals in the joints. Most people with hyperuricemia are asymptomatic. Gout is typically seen in middle aged men. Attacks may be precipitated by excessive food, alcohol, dehydration and diuretic therapy.

Clinical syndrome caused by hyperuricemia

1. Acute urate synovitis –acute gout.
2. Chronic urate polyarticular gout.
3. Chronic tophaceous gout. 
4. Urate renal stone formation.

Commonest clinical presentation is sudden onset pain in a single joint. Common sites affected are the following. In 50% of cases it involves big toe (metatarsophalangeal joint) as shown in figure.

Podagra. Acute gout with  swelling and erythema

Other sites affected are 

1. Ankle
2. Midfoot
3. Knee
4. Small joints of hands
5. Wrist
6. Elbow

Large joints of limbs and axial skeleton (spinal joints) are rarely affected.

Acute gout

Characteristic features of pain in acute gout are given below

1. Sudden onset of pain, which reach maximum severity in 2 to 6 hours, it may wake up the patient in early morning.
2. Patients describe the pain as very severe and ‘worst pain ever’.
3. On touching the area severe tenderness occur, patient cannot even wear a sock or let bedding rest on the joint.
4. There can be marked swelling with overlying skin become red and shiny.
5. The disease is self-limiting, pain resolves over 5 to 14 days, with complete resolution.
6. Once the attack subsides, pruritus (itching) and desquamation of skin is seen.
7. Along with the above features there can be fever, malaise and confusion particularly if large joints are affected.
8. Some patients experience only milder attack. More than one joint may be affected. Cluster attack can occur ,in such case other joint is affected after a few days. But polyarticular involvement is unusual.

Chronic gout

Chronic pain and damage to joints occur which may lead to severe disability and functional impairment. If the hyperuricemia is uncontrolled repeated attack can occur  and progress to chronic gout. 

Tophus with white monosodium urate monohydrate

Chronic poly articular gout is rare, it is seen in elderly on long duration of diuretic therapy and chronic renal failure. 

Chronic tophaceous gout - Urate crystal may be deposited in joints and soft tissues to produce tophi, which appear as irregular firm nodule white in colour. Common sites affected are extensor surfaces of fingers, hands, forearm, elbows, Achilles tendons (back of the ankle joint) and the helix of the ear. Tophi may undergo ulceration and infection.

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Fibromyalgia clinical features

Fibromyalgia, common clinical condition in which there is widespread musculoskeletal pain and tenderness. It is also called as CWP  (chronic widespread pain). Although it is primarily a pain syndrome it may be associated with neuropsychiatric manifestations. This is more commonly seen in women with a female to male sex ratio 9:1. It can occur at any age  but incidence increase with increase in age. Fibromyalgia produces negative impact on social and psychological functioning.

Risk factors of fibromyalgia 

1. Psychosocial stress such as marital disharmony.
2. Alcoholism in the family.
3. Injury or assault.
4. Law income.
5. Self reported childhood abuse. 

Clinical features

Clinical features include wide spread pain and neuropsychiatric manifestation. Patient usually complain of pain in one region of body initially, later pain becomes widespread.

Characteristics of pain

1. Poorly localized.
2. Can’t ignore.
3. Severe in intensity.
4. Reduce the functional capacity.
5. Worsened by physiotherapy.
6. Unresponsive to NSAIDS (Analgesic).

Duration of pain

Pain is present almost through out the day on most days for at least 3 months.

Site of pain

1. Pain is present above and below the waist.
2. Pain is present on both side of body.
3. It involve the axial skeleton (neck, chest, back). 

Patients also complain about headache. Facial and jaw pain, abdominal and pelvic pain.

Neuropsychiatric manifestations are the following

Fatigue - It is very common, more  severe in the morning. There will be severe disability, so the patient experience difficulty in doing house work, shopping etc although they can dress, feed and groom themselves.

Stiffness 

Sleep disturbances 

Anxiety

Depression

Cognitive dysfunction - Difficulty in concentration, short term memory loss.

Clinical features

Usual symptoms

1. Multiple regional pain
2. Marked fatigability
3. Marked disability
4. Broken,non-restorative steep
5. Low affect, irritability,weepiness
6. Poor concentration,forgetfulness

Variable locomotor symptoms

1. Early morning stiffness      
2. Numbness, tingling of all fingers 
3. Swelling of hands, fingers

Additional, variable, non-locomotor symptom

1. Non-throbbing bifrontal headache (tension headache)
2. Colicky abdominal pain, bloating, variable bowel habit (irritable bowel syndrome)
3. Bladder fullness, nocturnal frequency (irritable bladder)
4. Hyperacusis,dyspareunia, dtecomfort when touched (allodynia)
5. Frequent side-effects with drugs (chemical sensitivity) 

Comorbid conditions associated with fibromyalgia include other musculoskeletal pain, infectious disease, metabolic and psychiatric disorders. Twenty percentages (20%) of patients have associated degenerative or inflammatory rheumatoid disease.

On examining the patient there wont be any evidence of synovitis or joint damage, neurologic deficit or wasting. Some time evidence of osteoarthritis may be present. On touching certain body part people complain of increased pain.

Why people develop fibromyalgia?

Possible causative mechanisms in fibromyalgia.

The exact mechanism is not known. There is alteration in pain processing in brain and patients have increased sensitivity to pain. There is decreased threshold to pain perception and tolerance at certain sites throughout the body. Certain peripheral pain generators act as trigger such as arthritis, bursitis, neuropathy and other degenerative and inflammatory conditions.

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How to diagnose depression and what are the criteria for major depression

Five or more of the following symptoms can happen during two week.

Period representing a change from normal functioning. 
At least one of the symptoms is either depressed mood or decreased interest or pleasure. Do not include symptoms due to medical conditions, delusion or hallucination. 

1. Depressed mood*.
2. Substantial weight loss or weight Gain.
3. Insomnia/lack of sleep or hypersomnia.
4. Feelings of worthlessness or inappropriate guilt.
5. Recurrent thoughts of death or suicide or suicide attempt.
6. Decreased interest or pleasure*.
7. Psychomotor retardation or agitation.
8. Fatigue or loss of energy
9. Diminished ability to think or concentrate

*From Diagnostic and Statistical Manual of Mental Disorders, fourth edition

*One of these symptoms must be present 

• Symptom should not meet the criteria for mixed episode.
• There  is  clinically significant distress in social, occupational, or other important areas of functioning.
• These symptoms are not due to the direct physiologic effects of a substance (e.g. drug of abuse, medication) or a general medical condition (e.g. hypothyroidism)
• The symptoms are not better accounted for by bereavement (i.e. after the loss of a loved one).

The episodes are diagnosed as mild, moderate and severe depending on the number of symptoms and intensity. Minimum duration of the whole episode is expected to be about two weeks.

Screening questions for depression

1. How have you been feeling recently?
2. Have you been low in spirits?
3. Have you been able to enjoy the things you usually enjoy?
4. Have you had your usual level of energy, or have you been feeling tired?
5. How has your sleep been?
6. Have you been able to concentrate on newspaper articles or your favourite television or radio programmers? 

Following are the difficulties for a non psychiatrist in diagnosing depression

1. Making sense of the emotional experience of the patient.
2. Pinning down the predominant mood state.
3. Assumptions /attributions to a physical or external factor.
4. Difficult questions to explore deeply.
5. Either normalising or interpreting any sadness as depression.

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Obesity a rising problem

Obesity is a chronic metabolic disorder with excessive fat deposition in the body .WHO defines obesity as body mass index more than  30 kg/m². Incidence of obesity is increasing worldwide, also in developing countries. As the people get older they accumulate more fat. Obesity indicate an excess fat storage, and looking at the undressed patient it can be easily identified. The term  overweight (rather than obese) indicate individuals with BMI between 25 and 30. It is medically significant and worthy of therapeutic intervention, especially in persons with  risk factors such as hypertension and glucose intolerance.

The distribution of adipose tissue in the body is important and has implications for morbidity. Intra-abdominal and abdominal subcutaneous fat have more significance compared to subcutaneous fat in the buttocks and lower extremities. This is clinically  detected  by the waist-to-hip ratio, with a ratio > 0.9 in women and >1.0 in men being abnormal. This may be because intra-abdominal adipocytes are more lipolytically active than those from other sites. 

Incidence of obesity is increasing  because of the following 

1. Increased availability of energy rich drinks and foods.
2. Increase in labour-saving devices (e.g. lifts and remote controls).
3. Increase in passive transport(cars as opposed to walking)

Obesity can be simple obesity or it can be associated with other conditions. Most  patients have simple obesity, Even when it is associated with other conditions, excess calories consumed in the diet  than expenditure through exercise and body functions, is the main cause of obesity.

Energy balance

1. 1 kg body weight gained has energy of approx 7000 kcal.
2. 10 kg weight gain over 5 years -70000/5*365=_ _38 kcal/day.
3. This is a daily error of energy balance of _1.5%.
4. OR 10 minutes’ walk.
5. OR one square (1/8) of a 2oz milk chocolate bar.
6. OR half a digestive biscuit.

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