BMJ: Scarlett McNally reports that obesity is a community problem

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Adapted from BMJ 1 April 2023

Surgeon Scarlett Mc Nally writes: In the 30 and more years since I qualified, England has had 14 obesity strategies including 689 policies. In that time the prevalence of obesity has almost doubled from 15% in 1993 to 28% of the adults in the UK in 2019. This spectacular failure of policy is probably due to a misplaced focus on individual behaviours rather than social, fiscal, or regulatory policies.

High body mass index is the fourth leading risk factor for disease in the UK and a major risk factor for 13 cancers. People with obesity are 7 times more likely to develop type two diabetes, contributing to worsening health and the risk of amputations, sight loss, kidney dysfunction and complications of surgery.

Several aspects of physiology are not widely understood or applied. First, starchy carbohydrates such as bread, pasta, rice and potatoes, are rapidly converted to sugars that are preferentially stored as fat.

Release of the hormone insulin is triggered by high sugar levels, helping to store sugar as fat and leading to the post meal dip in blood sugar around two hours later. Fats, proteins and fibre cause a lower insulin spike, leaving us feeling fuller for longer. This is the basis of low carbohydrate diets.

Second, the balance of hormones means our bodies are either storing fat or using it. Any food intake reduces fat loss for some time. This is the justification for intermittent fasting routines.

Third, it takes 20 minutes to feel full after eating. Slower eating helps us to avoid overeating at meals, helps us consider portion sizes more wisely and helps us resist second helpings.

Fourth, exercise help the body to burn fat by lipolysis.

So what do we do with this knowledge? Perhaps suggesting what and when to eat is a better option than new, expensively promoted semaglutide injections, which mimic a hormone that decreases appetite.

Replacing carbohydrates means that more protein, fat, or fibre is needed. This can be difficult in a cost of living crisis, as obesity is highly related to social deprivation. A person is twice as likely to experience obesity (37%) in the most deprived areas as in the least deprived (19%).

Tackling obesity then should include social initiatives to fight deprivation such as healthy school meals.

Our environment needs to change, through improved funding and regulation. It should permit physical activity, with play parks, walkable neighbourhoods, cycle lanes, and low traffic areas.

Commercial food companies should be subject to the full weight of regulations, which should be applied to any junk food advertising. We need initiatives to improve access to affordable, high quality food, which is shamefully poor in many deprived areas.

Obesity should not be considered a “lifestyle” problem. It requires a whole community approach focused on environments, regulation, and funding.

GP apprenticeships will start in September 2023

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Adapted from BMJ 30 July 2022

The idea of GP apprentices has been discussed for a few years now, but at last the scheme is starting up in September 2023.

The new scheme hopes to solve a lot of problems with one fell swoop.

There is a great shortage of doctors in the UK and particularly in General Practice, the foundation of the NHS system. At the same time, the expense of becoming a doctor, with student debt on qualification reaching £100,000, is making it a difficult choice for students who don’t have wealthy parents.

Universities have limited places for medical students. Although a few new medical schools have opened their doors such as Buckingham University, which is entirely privately funded, this has been insufficient to maintain GP numbers which continue to fall.

For several years conversion courses for graduates from other disciplines have been running at for instance Dundee University. This results in qualified doctors after a four- year course.

Courses for physician assistants have also been taking in graduates from careers allied to medicine in for instance Aberdeen University. Yet, there are simply not enough physicians and physician assistants to fill gaps in provision, as many of our UK readers will have noticed, whether they are seeking a GP or a hospital appointment.

What is different about GP apprenticeships is that the student will earn a wage from their very first day. I don’t know what that wage will be yet. Hopefully enough to make the experience worthwhile and at least prevent them ending up in debt.

The aim is to make medicine more accessible to students from state schools and poorer backgrounds. They want to see students from diverse backgrounds rather than just the white upper middle- class students from private schools who currently predominate.

Apprentices will complete both academic and practical education and come out with a medical degree and licence to practice from the General Medical Council.

BMJ: What is junk food and what is the harm?

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Adapted from: BMJ 3 Sept 22 People need nourishing food that promotes health, not the opposite by Carlos Monteiro et al.

Everybody needs food, but nobody needs ultra- processed food with the exception of infants who are not being breast fed and need infant formula.

The foods that are “ultra- processed” include: soft drinks, packaged snacks, commercial breads, cakes and biscuits, confectionery, sweetened breakfast cereals, sugared milk based and fruit drinks, margarine and pre-processed ready to eat or heat products such as burgers, pastas and pizzas.

These foods are industrial formulations made by deconstructing whole foods into chemical constituents, altering them and recombining them with additives into products that are alternatives to fresh and minimally processed foods and freshly prepared meals.

In low amounts, they wouldn’t necessarily be a problem. But most ultra- processed foods are made, sold and promoted by corporations, typically transnational, that formulate them to be convenient, ready to eat, affordable, due to low -cost ingredients, and hyperpalatable. These foods are liable to displace other foods and also to be overconsumed.

Systemic reviews of large well -designed cohort studies worldwide have shown that consumption of ultra-processed foods increase: obesity, type two diabetes, hypertension, cardiovascular and cerebrovascular diseases, depression, and all- cause mortality.

Other prospectively associated conditions include dyslipidaemias, gout, renal function decline, non-alcoholic liver disease, Crohn’s disease, breast cancer and in men colorectal cancer. They also cause multiple nutrient imbalances.

It is calculated that ingestion of these foods compared to fresh ingredients, matched for macronutients, sugar, sodium and fibre adds a typical 500kcal daily, which leads to the inevitable fat accumulation.

US investigators have found that dietary emulsifiers and some artificial sweeteners alter the gut bacteria causing greater inflammatory potential, so replacing sugar with these isn’t a good idea either.

In the UK policies to limit promotion and consumption of ultra-processed food have recently been rejected, mainly because of the belief that in our current economic situation people need access to cheap food. As no one really wants to support foods that cause illness, the obvious solution is to promote foods that are fresh and minimally processed, available, attractive and affordable. Such a strategy would improve family life, public health, the economy and environment.

Nina’s plea: Would you write to Congress and change USA food guidelines?

This is a message from Nina Teicholz, writer and low carb activist:

My highest concern about the existing USA Food Guidelines is for the people who have no choice but to eat the food that they are given, which is based on what is thought of as “a healthy diet”. There are many essentially ‘captive’ populations in schools, hospitals, and prisons. Many of these people are the most disadvantaged among us. Native Americans on reservations have no choice about the food assistance they receive.

I’ve spoken with the Native American woman who for years has been trying to change the USDA food they get, and she cannot get even the tiniest change. They desperately need the food, yet it’s more than 50% carbs, and something like 40% of the kids on these reservations have diabetes.

The same is true for poor people, education programs, and feeding programs for the elderly. These people have no choice.  No other food  is given to them. Many doctors also say they have no choice, because  they are required to teach the guidelines to patients. It is the same thing in most federally funded institutions.

Thus, my hope is, if we have to have Guidelines for the time being, that they do as little harm as possible. The Guideline is coming up for review, but the committee have already decided not to review the evidence on low carb diet studies.  We are seeking to change this, and there is already some support for our position, that these studies should be included in the evaluation. Could we get in a low-carb option? Could we force them to consider all the science on saturated fats? This next set of Guidelines will come out by the end of this year, and I think there is still time to try to force change. Our actions now would build awareness around the issue that there is something wrong with the Guidelines. There is so little awareness of the problems. And actually I’m hopeful,  because in the last few months, we’ve worked with a number of groups to raise awareness to a level it’s never been before.

Here’s what I would suggest for now.
Both my group, The Nutrition Coalition and the group Low-carb Action Network,  have webpages that make it very easy for you (if American) to write/call your Members of Congress. This is super important and I urge everyone to do this. USDA is not budging. Congress is really the only body of power interested in change, and they need to hear from people. So I would urge everyone to contact their members of Congress. It can take just a few min.

Thank you,


My comment: If the USDA food guidelines are changed, it would make it so much easier for the UK to follow. The photograph shows the breakfast given to a diabetic patient in a US hospital who had just had a heart attack. The UK also dishes out abysmal food to its patients. Wouldn’t it be great if they had a low carb option?

Public Health Collaboration conference online a great success

The Public Health collaboration online conference 2020  was very successful.  The videos are available on You Tube for free making the conference even more accessible for everyone who needs advice on what to eat to stay healthy.

If you are able to contribute to the PHC fund to keep up our good work please do so. Sam Feltham has suggested £2.00.  This is via the PHC site.

This year there were contributions from mainly the UK but also the USA.

Visitors to this site will be very pleased to know that keeping your weight in the normal range, keeping your blood sugars tightly controlled, keeping your vitamin D levels up, and keeping fit from activity and exercise, are all important factors in having a good result if you are unfortunate enough to be affected by Covid-19. We have been promoting these factors in our book and website for several years now, mainly with the view to making life more enjoyable, especially for people with diabetes, now and in the future. The reduction in the severity  to the effects of   coronavirus is a side effect of these healthy living practices.

Several talks went into the factors and reasons for this, but in a nutshell, if you are in a pro-inflammatory state already, you will have a much more pronounced cytokine inflammatory response to the virus than is useful for clearing the virus, and you end up with inflammed lung tissue which leaks fluid thereby impairing your blood oxygen levels.

A talk that I found particularly apt was the talk from a GP who had had a heart attack at the age of 44 despite a lack of risk factors except for massive stress. He gives a list of self care practices that helped him. I would also include playing with your animals. Emma and I are cat lovers and can vouch for this!

My talk is about VR Fitness, which was the only talk this year which was specifically exercise related. The Oculus Quest has only been out a year and has been sold out since shortly after New Year. I was fortunate enough to buy one in anticipation of my imminent retirement, and it has been great as an exercise tool over the long, cold, dark winter and more useful than I had ever anticipated over the lockdown as a social tool.

There were several very professional cooking and baking demonstrations on the conference this year, and indeed, this could not have otherwise happened on a traditional stage format.  We had low carb “rice”, bread, pancakes and pizza demonstrations which may well help you if you prefer to see how it is done step by step or if you want to broaden your repertoire.

I was particularly taken with the pizza base idea from Emma Porter and I will follow up with this in a later post.  The whole video is available from the PHC  site which takes you to all the videos on You Tube.




BMJ stands by Nina Teicholz despite demands for a retraction

18334616380_d884da17d4_bFeature Nutrition

The scientific report guiding the US dietary guidelines: is it scientific?

BMJ 2015; 351 doi: (Published 23 September 2015) Cite this as: BMJ 2015;351:h4962

Response by Nina Teicholz

I’m delighted that The BMJ has stood by this article and decided against retraction. Two outside reviewers judged that the criticisms of the piece did not merit its retraction, and in the end, the corrections made by The BMJ do not, in my view, materially undermine any of the article’s key claims. This article therefore stands as one of the most serious ever, peer-reviewed critiques of the expert report for the US Dietary Guidelines for Americans (DGAs).

The importance of the DGAs, and therefore of this article, should not be understated (and indeed was recognized by many in the mainstream media when the article was published). The DGAs have long been considered the “gold standard,” informing the US food supply, military rations, US government feeding assistance programs such as the National School Lunch Program which are, altogether, consumed by 1 in 4 Americans each month, as well as the guidelines of professional societies and governments around the world, and eating habits generally.

Yet rates of obesity began to shoot upwards in the very year, 1980, that the DGAs were introduced, and the diabetes epidemic began soon thereafter. A critically important yet little understood issue is why the DGAs have failed, so spectacularly, to safeguard health from the very nutrition-related diseases that they were supposed to prevent.

In documenting fundamental failures in the science behind the DGAs, this article offers new insights; It establishes that a vast amount of nutrition science funded by the National Institutes of Health and other governments worldwide has, for decades, been systematically ignored or dismissed, and that therefore, that the DGAs are not based on a comprehensive reviews of the most rigorous science. Incorporating this long-ignored relevant science would likely lead to fundamentally different DGAs and could very well be an important step in infusing them with the power to better fight the nutrition-related diseases.

A fundamental question is why 170+ researchers (including all the 2015 DGA committee members, or “DGAC”), organized by the advocacy group, the Center for Science in the Public Interest (CSPI), would sign a letter asking for retraction. After all, in the weeks following publication, any person had the opportunity to submit a “Rapid Response” to the article, and both CSPI and the DGAC did so, alleging many errors. I responded to them all in my Rapid Response. This is the normal post-publication process.

Yet after all this, CSPI returned for a second round of criticisms, recycling two of the issues (CSPI points #3 and #10) that I had already addressed in my Rapid Response (and which had required no correction), adding another 9 (one of which, #4, contained no challenge of fact), and demanding that based on these alleged errors, the article be retracted. CSPI then circulated this letter widely to colleagues and asked them to sign on.

This lack of substance in the retraction effort seems to point to the reality that it was first and foremost an act of advocacy—a heavy handed attempt to silence arguments with which CSPI, a longtime supporter of the Dietary Guidelines and its allies disagree.[ footnote 1] And this applies not just to the retraction letter but to other CSPI efforts to stifle alternative viewpoints. Earlier this year, for example, I was dis-invited from the National Food Policy Conference after CSPI, together with the USDA official in charge of the Dietary Guidelines, threatened to withdraw if I were included, details of which are reported here and which a Spiked columnist called an act of “censorship.”

It’s important to note that I am not the only person disturbed by the lack of rigorous science underpinning our dietary guidelines. Numerous scientists around the world have expressed concern about the science. And indeed, this consternation is shared by no less than the US Congress, which held a hearing on Oct 7, 2015 to address its serious doubts about the DGAs. Such was this concern that last year that Congress mandated the first-ever major peer-review of the DGAs, by the National Academy of Medicine. Congress appropriated $1 million for this review, and it additionally stipulated that all members of the 2015 DGA committee recuse themselves from the process.

What is the dangerous information challenging the DGAs that cannot be heard on a conference panel nor published in a peer-reviewed journal?

The major findings of this article are that:
1. The DGAC’s finding that the evidence of a “strong” link between saturated fats and heart disease was not clearly supported by the evidence cited. (Note that as of last year, the Heart and Stroke Foundation of Canada no longer limits saturated fats. Note, also, that Frank Hu, the Harvard epidemiologist in charge of the DGAC review on saturated fats, was an energetic promoter of the retraction letter against my article that critiqued his review, according to emails obtained through FOIA requests);
2. Successive DGA committees have for decades ignored or dismissed a large body of rigorous (randomized controlled trial) literature on the low-fat diet, on more than 50K subjects, collectively finding that this diet is ineffective for fighting obesity, diabetes, heart disease or any kind of cancer;
3. Although the DGAs have for decades recommended avoiding saturated fats and cholesterol to prevent heart disease, no DGA committee has ever directly reviewed the enormous body of rigorous (government-funded, randomized controlled trials) evidence, testing more than 25,000 people, on this hypothesis. Many reviews of this data have concluded that saturated fats have no effect on cardiovascular mortality;
4. The DGAC ignored a large body of scientific literature on low-carbohydrate diets (including several “long term” trials, of 2-years duration) demonstrating that these diets are safe and highly effective for combatting obesity, diabetes, and heart disease;
5. The Nutrition Evidence Library (NEL) set up by USDA to do systematic reviews of the science did not meet its own standards for its review of saturated fats in 2010;
6. Although the DGAC is supposed to consult the NEL to conduct systematic reviews of the science, the 2015 DGAC did so for only 67% of the questions that required systematic reviews;
7. For a number of key reviews, the 2015 DGAC relied on work done in part by the American Heart Association and the American College of Cardiology, which are private associations supported by industry and therefore have a potential conflict of interest;
8. The DGAs, for the first time, introduce the “vegetarian diet” as one of its three, recommended “Dietary Patterns,” yet a NEL review of this diet concluded that the evidence for this its disease-fighting powers is only “limited,” which is the lowest rank of evidence assigned for available data;
9. The DGA’s three recommended “Dietary Patterns” are supported by only limited evidence. The NEL review found only “limited” or “insufficient” evidence that the diets could combat diabetes and only “moderate” evidence that the diets can help people lose weight. The report also gave a strong rating to the evidence that its recommended diets can fight heart disease, yet here, several studies are presented, but none unambiguously supports this claim. In conclusion, the quantity of recommended diets are supported by a small quantity of rigorous evidence that only marginally supports claims that these diets can promote better health than alternatives;
10. The DGA process does not require committee members to disclose conflicts of interest and also that, for the first time, the committee chair came not from a university but from industry;
11. The 2015 DGAC conducted a number of reviews in ways that were not systematic. This allowed for the potential introduction of bias (e.g., cherry picking of the evidence).

This last claim, on the systematic nature of the DGAC reviews, is the subject of the corrections published in The BMJ this week, and refer to CSPI points #1, #2, #7, and #8 (two of which are statements in the text and two of which are in the supporting tables). I am grateful to have had the opportunity to work with The BMJ on developing this notice.

The BMJ has placed a word limit on my response. For the rest of this comment, please see:

Footnote 1
CSPI has fought for decades to eliminate saturated fats from the American food supply (so much so, that throughout the late 1980s, CSPI advocated for replacing saturated fats with trans fats and succeeded in driving up consumption of trans fats to historic levels, as described in The Big Fat Surprise, pp.227-228). CSPI has also long advocated for shifting away from animal foods containing saturated fats, towards a plant-based diet based on grains and industrial vegetable oils. The researchers who joined CSPI in signing the letter are largely adherents to this view; many have participated in generating the science that has been used to support the hypothesis that fat and cholesterol cause heart disease, and it is upon this hypothesis that the Guidelines have been based.

Competing interests: I have read and understood BMJ policy on declaration of interests and declare that I am the author of The Big Fat Surprise (Simon & Schuster, 2014), on the history, science, and politics of dietary fat recommendations. I have received modest honorariums for presenting my research findings presented in the book to a variety of groups related to the medical, restaurant, financial, meat, and dairy industries. I am also a board member of a non-profit organization, the Nutrition Coalition, dedicated to ensuring that nutrition policy is based on rigorous science.

Orthopaedic surgeon who wants to reduce amputations silenced by regulatory body


It would be funny if it wasn’t so tragic. Gary Fettke, a Tasmanian orthopaedic surgeon has been banned from talking to patients about the nutritional changes they can make to prevent amputations.

His wife, a nurse, tells his story here:


Gary’s presentation on you tube is here:





Academy of Nutrition and Dietetics ask for changes in nutrition advice


The USA  based Academy of Nutrition and Dietetics submitted comments supporting the scientific process used by the Dietary Guidelines Advisory Committee in drafting its recommendations for the 2015 Dietary Guidelines for Americans. The Academy’s recommendations to the Departments of Agriculture and Health and Human Services include:
1) Supporting the DGAC in its decision to drop dietary cholesterol from the nutrients of concern list and recommending it similarly drop saturated fat from nutrients of concern, given lack of evidence connecting it with cardiovascular disease;

2) Expressing concern over blanket sodium restriction recommendations in light of recent evidence of potential harm to the larger population;

3) Supporting an increased focus on reduction of added sugars as a key public health concern; and

4) Asserting that enhanced nutrition education is critical to any effective implementation.

The final 2015 Dietary Guidelines for Americans are expected to be released at the end of this year.

Can we humanise doctors’ working lives and all be safer?

NHS Hand-in: Department of Health
38 Degrees members deliver a petition of over 410,000 names to the NHS. Their message: Save Our NHS

The Kings Fund, new GMC chairman and Canadian researchers hope so. So do many practising doctors. With the workload pressures, lack of extra resources and retention and recruitment crisis doing nothing is no longer an option. We are very strong on patient education on our site, but no matter how smart we can be about managing our diabetes and associated conditions, there are inevitably times that we will need to see a doctor and go into hospital for some procedure. The better the whole system is running the better it is for patients.

John Toussaint, CEO of the USA ThedaCare Center for Healthcare Value, says that freeing frontline clinicians to solve problems rather than controlling or blaming them could yield major improvements in three years. Organisations should radically change their leadership behaviour, make respect for people a guiding principle and ensure that productivity improvements did not lead to employee lay-offs.”

“Redesigning care to take wasteful steps out of processes improve quality and lower costs at the same time. Leaders must act with humility, take a sincere interest in what their staff  are telling them, and build a culture of trust and systems geared to continuous improvement. Senior executives should scrap surplus strategic initiatives that are contributing to staff burn-out, focus on a few core goals, and give proper authority to clinical teams.  He said that Western Sussex Hospitals had adopted elements of his system and achieved an outstanding rating from the Quality and Care Commission. He said that the hardest part was eliminating waste in non-clinical areas such as administration, IT, human resources and finance.”

When it comes to eliminating wasteful practice,  the Quality and Outcomes framework is a good example. Payment by performance in British General Practice was a massively expensive experiment set up in 2004. In Scotland it has just been abandoned. Almost all GPs hit the desired targets for chronic disease health care identification and monitoring. 25% of GP income was tied to the targets, often of dubious value. Many GPs left or retired and it is believed that the strain of delivering QOF has put many young doctors off being GPs. A study in the Lancet however showed all this was for nothing. There was no benefit to total mortality for any of the diseases covered compared to usual care.

Terrence Stephenson is the current chairman of the General Medical Council in the UK. He delivered a lecture to the Royal Society of Medicine in which he expressed the desire that the GMC shake off the “policeman” image that they have.

“For most doctors, the GMC is known for tackling bad practice and striking doctors off the register. The GMC get 10,000 complaints a year, most of which come from the general public. Making complaints is free, easy and you can even do it online. Unfortunately it can be used in highly inappropriate ways. For instance someone complained that trees from a practice’s garden were blocking their sunlight. Of these complaints 250 are directed to a tribunal and of these 55 doctors were struck off the register.”

“ I think we need reforms to this procedure. Many complaints are erroneous. Many could be dealt with locally. Many patients would be better satisfied if they went through local complaints procedures or the ombudsman.  It is my ambition to make the GMC more focussed on patient safety. The sad truth is that medicine is a high risk profession. It is safety critical industry and people are harmed by healthcare. In any human business there will be human error that can never be eradicated but I think it behoves us to try and fix it”.

When it comes to human errors we all know that lack of sleep, overwork, interruptions, boredom, unfamiliarity with the work can all contribute. Being hungry and thirsty also impair us.

Canadian researchers suggest regular meal breaks for doctors. Many work long shifts with no guaranteed breaks. Healthy food should be available. (Not just sandwiches and crisps I hope!). Food outlets should be open 24 hours to accommodate shift workers. Staff should be able to store and eat food near to where they actually work. They also suggest that professional bodies increase awareness of doctors’ nutrition and their well-being and promote self-care for doctors.


Based on several articles in the BMJ 4 June 16

Ending blame culture would improve NHS care in three years by Matthew Limb freelance journalist

QOF and mortality Richard Lehman Lancet 2016 doi:10.1016/SO140-6736(16)00276-2

Fitness to practice process must change by Abi Rimmer

Five ways to help doctors eat healthily at work doi:10.1136/postgradmedj-2016-134131


The UK Has A New PM – One Who Has Diabetes

theresa mayAs of today, the UK has a new prime minister – Theresa May.

Theresa May has type 1 diabetes. She was diagnosed later in life than is usual with type 1 – and she was misdiagnosed with type 2 initially.

I’ve never harboured political ambitions. I’ve no idea how you would go about devising the best practices and policies for running the country. And Ms May’s biggest job at the moment is negotiating the exit from the EU.

But her appointment did get me thinking. How on earth do you cope with diabetes and the heavy responsibility of country leadership? Fair enough, she’s had a senior political role for some time so the transition probably isn’t that much of a leap, but even so… How do you do it?

What happens if you have a hypo in the middle of Prime Minister’s Question Time? My brain starts to go slightly mushy and I get easily confused when I’m hypo. Mushy brains don’t lend themselves to debate.

How do you cope with the interruption of routine? My diabetes is best controlled when routines stay constant – the same time for meals, the same levels of activity, the same sorts of foods and the same time to bed. Life at any kind of senior level doesn’t lend itself to regular routines.

How do you fit in hospital appointments? At the very least, she should be attending clinics every six months and also having regular retinal screening appointments. If you’re a very senior politician, I imagine hospital appointments often have to be cancelled at very short notice.

Blood pressure. As a diabetic, you are more likely to suffer high blood pressure than most people. Is being prime minister at all good for your blood pressure?

How do you manage with all the eating out? Good blood sugar management means you need to know the carbohydrate values of what you are eating, which is tricky when you are eating out.

Anyway, I don’t agree with her politics, but I don’t – and wouldn’t question – her ability to do the job. It’s interesting to reflect on the impact of a chronic condition on someone working at that kind of level. Diabetes often requires huge efforts of will power – overcoming the tiredness, forcing yourself to be organised enough to remember all your equipment and carry spare food and sweets just in case etc. Sometimes, all you want to do is sleep, the prospect of even a conversation too exhausting to cope with.

When you’re working at Theresa May’s level, you must need vast quantities of that will power and determination. Ms May, I salute you.