The survival time of chocolates on hospital wards: covert observational studyBMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f7198 (Published 14 December 2013) Cite this as: BMJ 2013;347:f7198
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This study replicates what we have in the civil service. I have seen a medium sized box of chocolates being demolished in less than 8 hours.
I would state that in my experience the speed of eating is inversely proportional to the number of boxes and choice available.
How were confounding factors such as the presence of biscuits allowed for?
Competing interests: No competing interests
In common with other correspondents, I am concerned about two issues:
1) the high "lost to follow up" rate is worrying and I would suggest the authors reassess their data by an "Intention to eat" analysis;
2) that the choice of chocolate may have led to bias. In my (admittedly subjective) experience, everyone likes all the Roses, but there are some "pretty dodgy" Quality Street in the box. The Kaplan-Meyer plot shows a distinct plateau in the Quality Street decay pattern which doesn't exist in the Roses pattern. I believe this is related to the "only-nasty-ones-left standoff" that anecdotally occurs with Quality Street and not Roses, in which the hopes of expectant chocolate eaters are dashed by the presence of only the toffee coins and the strawberry creams, and they decide that no chocolate is better than those chocoates, and walk away. However, the temptation and salivation stays with them and they return later to partake.
Further research is needed.
Competing interests: I have received chocolates as gifts from patients in the past. I prefer Roses over Quality Street, but Celebrations are the best, aren't they?
15% consumption by doctors potentially represents a massive over-consumption by that group, given the relative scarcity of doctors on hospital wards.
Competing interests: No competing interests
This study provides an excellent preliminary report of an at-present under-researched issue.
We feel that future studies should investigate the handwashing habits of each professional group prior to selection of the chocolate from the box, insertion into the mouth, and most importantly post-consumption prior to patient contact. With so many individuals from different disciplines inserting their ungloved hands into a communal space within a short time period, it may only be a matter of time before local protocols force withdrawal of these valuable morale boosters, as we have already witnessed with white coats, neckties, and dare we suggest, French-cuff shirts.
Such research will probably require a national multi-centre study. This would also remove any bias arising from current special offers at WRVS shops depending on geographical location.
Competing interests: Bias towards Cadbury Milk Tray
Dr Gajendragadkar and his colleagues are to be commended for the important contribution to understanding the chocolate consumption across three hospitals.1 Although a rigorous, multi-site, exploratory study, the full impact of the findings may not have been recognised by the authors.
Chocolate intake in many healthcare settings seems far too ad hoc given the relationship between per capita consumption (kg/person/year) and the number of Nobel laureates per 10 million population.2 This has been overlooked by the investigators.
Given the seminal findings of Messerli, there is now a need to replicate the work of Gajendragadkar et al in other health systems followed by a prospective, multi-site, phase III study to see if increasing the chocolate consumption increases the rate of being awarded a Nobel Prize. Although this will be a large study given the paucity of Nobel prizes, difficulties with loss to follow-up and an ever-present risk of ‘contamination’ from chocolate intake from sources other than the trial, it would seem urgently needed. Alternatively, perhaps chocolate should be more routinely available to health professionals?
1.Gajendragadkar PR, Moualed D, Nicolson P. et al. The survival time of chocolates on hospital wards: covert observational study. BMJ 2013;347:f7198 doi: 10.1136/bmj.f7198 (Published 14 December 2013)
2.Messerli, F. H. Chocolate consumption, cognitive function, and Nobel laureates. N Engl J Med 2012; 367(16): 1562-1564.
Competing interests: No competing interests
I read the article with great interest and congratulate the authors for providing evidence to support the commonly held perception that "allied health professionals scoff all of the choccies!"
I do however feel that in the interests of harmonious team working and to provide irrefutable evidence, a follow on study could be performed comparing the half life of chocolates left in the doctors mess vs those left in the nurses staff room.
Competing interests: Desperately in need of a publication
I welcome this important study by Gajendragadkar et al, but feel the authors did not go far enough in their analysis. A key variable that goes unexamined in this otherwise fine study is the impact of the identity/role of the person who breaks the seal on the box of chocolates on its subsequent consumption. I posit that the rate of consumption by different groups of hospital employees is directly correlated with whether a member of their own group was seen to open the box, conferring unspoken chocolate ownership/primacy by that group.
Furthermore, it would be interesting to record how any observers present impacted on consumption patterns - I hypothesize that some junior doctors (particularly those covering multiple wards, and especially the shyer locums), despite deeply coveting a large, glorious handful of chocolates, may have been cowed by ward nurse/healthcare assistant observation of their actions into only taking one chocolate or none at all. However in an unobserved situation, that same doctor might delightedly gorge on those same chocolates.
Finally, on a related note, rather than allowing the final unconsumed chocolates to become 'lost to follow up' (a decision with suspect motivation), I would be interested in an analysis of the profile of those people most likely to take the last chocolate (and the way this courageous group handles the dilemma of disposing of the box versus leaving it on the counter - and their interactions with witnesses during this delicate time). I look forward to follow up studies.
Competing interests: LM has spent long, hungry days eyeing up unopened boxes of chocolates on the wards, too cowed by complex protocol to personally break the seal. She has also spent hours with her ward colleagues, all silently dreaming of taking that last Quality Street in the box (she very much wanted to, but never did).
Gajendragadkar et al provide a timely examination of chocolate survival, given we are now entering the period when traditionally seasonal generosity leads to enormous winter pressure on ward chocolate supplies. The number of boxes donated to medical wards often make it difficult if not impossible to have all chocolates eaten within four hours of arrival on the ward, especially when considering classic 'box-blocker' chocs such as strawberry cream.
My own hospital has been able to make use of government funding to employ a 'winter pressure registrar'. Their true value is seen when they are willing to eat the coconut ones. Communication and co-ordination of arrival time and location is another important element, and only a truly MDT approach to chocolates can stop them falling through the cracks and into matron's office,
Competing interests: I regularly eat donated chocolates
It is unfortunate that Gajendragadkar et al did not do a detailed subgroup analysis on the types of chocolates that decayed most rapidly and which types had longer half-lives. They missed a wonderful opportunity to send a message to Nestle that there are too many of the hard chewy ones and not enough of the orange crèmes in Quality Street.
Also the authors state "it is likely that excessive consumption will lead to deleterious effects on population health, outweighing any potential benefits". Perhaps they are not aware of the seminal paper by Messerli published last year in the New England Journal of Medicine showing a very strong correlation between national per capita chocolate consumption and winning Nobel prizes.
1: Messerli FH. Chocolate consumption, cognitive function, and Nobel laureates. N Engl J Med. 2012 Oct 18;367(16):1562-4.
Competing interests: Preference for Terry's dark chocolate oranges
This is clearly a very important work in a much neglected area. Despite the power calculations, the relatively small sample size allows only limited conclusions to be reached. I look forward to seeing a larger study in the future.
One possibility to explore, given such a greater sample size, would be whether the pattern of consumption is truly one of exponential decay, or whether there is a consistent pattern of certain individual chocolate types languishing in the box for a disproportionate time period. Extensive clinical experience suggests that the distorting effect of slightly variant proportions of "the round gold wrapped toffee one" in Quality Street boxes, anecdotally frequently declined "because of my fillings" could be an issue. The seminal work of Cooke and Morse could suggest that the presence of coffee creams in the Roses collection could have a similar effect. Perhaps a collaborative approach between these 2 research groups would be fruitful, although I would not speculate as to whether in a strawberry or orange cream fashion.
Cooke F and Morse R. Do you know your chocolates? recognition survey among medical staff of various grades. BMJ. 1997 December 20; 315(7123): 1655–1656
Competing interests: A strong prediliction for Hotel Chocolat products.