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Research Christmas 2013: Research

The survival time of chocolates on hospital wards: covert observational study

BMJ 2013; 347 doi: (Published 14 December 2013) Cite this as: BMJ 2013;347:f7198

Re: The survival time of chocolates on hospital wards: covert observational study

Dear Editors

I realise, as a latecomer to the discussion, my comments may already been voiced by other readers but I see no evidence of this based on published rapid responses so far as they go.

As a responsible clinician and teacher, I must vigorously protest the misleading nature of the title of the paper as it is obvious to me (as to any self-respecting connoisseur of quality chocolate) that the researchers are not aware of the basic difference in the contents of study matter namely Quality Street and Roses product as sold in UK.

In spite of regional difference in the confectionery makeup of boxed product, I can declare with certainty the following facts:

1. In UK (as in the world), Quality Street products contains BOTH chocolate-based and toffee based sweets (12 varieties in total with about 25% toffee content).
2. Rose chocolate sweets (10 varieties in a box) in UK are all chocolate coated with only one sweet has toffee as the main content
3. 1 out of 12 Quality sweets uses dark chocolate, for Roses (in UK format) it is 1 out of 10.
4. The serving size for Quality Street sweets is 29g which account for 3 sweets.
5. Serving size for Rose sweets (UK) is 25g which is listed as 2 sweets.
6. As a result each sweet is estimated at 9.6g for Quality Street, 12.5g for Rose (UK).

Furthermore I would also point out in the usual work pattern in a surgical unit differs significantly from a medical-based ward care as follows:

1. Surgical ward round generally start earlier than medical round, as the surgeons will need to attend operating theatre and/or clinics which invariably start in normal local working hours.
2. Time exposed to doctors in ward for surgical unit is less than for medical units (as usually the surgical team is likely to complete their rounds in a shorter time).
3. The 10am start time for the study almost certainly means that for acute units (like surgical and acute medical ward) staff are involved in direct personal health care at that time (including cleaning/showering, clinical procedures like drain removals/ dressing changes etc)

This, without doubt, compromises the value of data as analysed by the authors. I shall list my concerns about their conclusions as followed:

1. The authors did not recognise the inherent difference in the content of the study products, that not all Quality Street sweet are chocolate cover and Quality Streets sweets does not contain as much chocolate as Rose.
2. Quality Street sweets come in smaller size as compared to Rose
3. Clearly the nursing and healthcare assistant cohort knew which product to consume as reflected by their obvious bias to Rose sweets (larger, higher chocolate content)
4. Comparison of the decay and half-life of each product clearly reflects the popularity of the Rose product
5. The authors fail to recognise the difference in consumption between wards as a result of the difference in workflow of units.
6. Australasian experience (unpublished data: 2000 – 2004, single surgical (28 bed) ward in a tertiary hospital, 6 months Jan –July observational study annually, 750g blocks of Cabrury™ and Nestle™ chocolate, 9.30 am start time per working weekday) suggest that it is an statistical impossibility for any chocolate to survive beyond 45 minute except for Easter and Christmas season.

In conclusion I submit that the title of the article is misleading and the authors had failed to account for the inherent self-selection bias in spite of the exploratory nature of the study.

Competing interests: I was a regular supplier of Chocolate to my ward staff in my younger days and only stopped the practice after an inadvertent episode of direct observation of ugly feeding frenzy by ward nurses, akin to both substance dependence and conditioned response.

29 December 2013
Shyan Goh
Orthopaedic Surgeon
Sydney, Australia