Start with the Annexes

I’ve not been here for a while… but enough has happened to warrant a new post, so here I go!

A long time ago (decades not weeks) I was involved in a minor court case where I was required to produce a document for submission to the court. Like the good civil servant I am (during daylight hours), I drafted a detailed document with many annexes of supporting information. Prior to the submission of my document to the court, I attended a conference with a QC where he would review it to ensure I hadn’t said anything stupid. His office was in Inner Temple, in a building that was founded by the Knights Templar during the 12th century and is now the place where barristers hang out.

It was a winter’s day in his sitting room-like office – comfy sofas facing an open coal fire, tea in china cups and Viennese whirls on a tea plate – where I proudly presented my work.

I was surprised when, instead of starting at the first page and reading my carefully drafted text from the beginning, he went straight to the back and started looking through the annexes. He looked at my puzzled expression over the rim of his teacup and explained, “I always start with the annexes. That’s where people put the interesting stuff, that they don’t want you to read.”

This was brought back to my mind when I read the latest paper on childhood obesity from those masters of obfuscation, Public Health England. The report is called Time to Solve Childhood Obesity. An Independent Report by the Chief Medical Officer, 2019 Professor Dame Sally Davies.

It’s ok, in a fairly mediocre sort of way, and it wouldn’t have made the headlines had it not contained one of the stupidest recommendations that has ever been made – that the government should ban eating on urban public transport.

Here is how one (irony defying) newspaper front page covered it:

Now, I’m no fan of people that stink out the train with their Cornish pasty or drop their Marks and Spencer sushi on the seats, but I wouldn’t want to be the person whose job it was to take away the Big Mac from the drunken banker on the 21:54 Guildford train from Waterloo!

Anyway, the report is curious from one aspect. It is almost ALL ANNEXES. The report is ten pages followed by about 80 pages of annexes, some of which are really quite rich in data and visuals. If we think back to what the QC said, its where they put the interesting stuff that they don’t want you to read, I wondered what they could have possibly hidden in there. And then I found it!

“The important biological determinants for obesity are: genetics; programming of biology that happens before birth and early in life that affects how the body responds to food; in all probability, the microbiome…

Emerging evidence suggests the microbiome, the many millions of microbes living inside a human’s gut, play an important role in health and disease. Babies are colonised as they are born from their mother’s birth canal. Recent work has shown an association between antibiotic usage and increased weight gain in childhood.”

Hold the phone!! An association between antibiotic usage and increased weight gain in childhood??? How come that didn’t make the headlines??? Cos it was buried in 80 pages of annexes maybe?

The link between antibiotic use, or over-use really, and obesity is covered in detail by Tim Spector in his recent book The Diet Myth in which he cites research by Martin Blaser.


It was Martin Blaser who produced the famous maps comparing antibiotic prescription rates and obesity in the USA. As he says, the correlation is strikingly non-random.


Given that PHE has now recognised the association too (albeit only in Annexe D), I wondered if they had produced a similar comparison and guess what? They haven’t. Quelle surprise…*

Undeterred, I wondered if I could produce my own maps given the PHE does collect data on prescription rates for antibiotics (they are trying to reduce over-use) and rates of obesity. I found maps for both, already done by others, and here they are. See if you think there is a strikingly non-random correlation in England too:

download mapantibiotics

Map on the left is overweight-ness from the Daily Telegraph … the darker red the fatter. Map on the right  is antibiotic prescription rates – the darker blue the higher the number of prescriptions. It was produced by Laura Shallcross, and Dame Sally C Davies (British Journal of General Practice 2014;64:604-605).

Whoa!! Shut the door!!! Dame Sally Davies??? The same Dame Sally Davies that wrote the obesity report?

So, she wrote the obesity report that buries the connection between antibiotics and weight gain in Annexe D of Annexes A-G and then what, she forgot that she had done the map that might demonstrate the possible connection and so it didn’t get into the report?

Or, maybe, it was just too interesting even for an annexe.


*Definition – A French phrase that means “what a surprise.” Often said sarcastically.



One comment on “Start with the Annexes

  1. CJ says:


Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s