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Advances in the Assessment
of Dietary Intake
Advances in the Assessment
of Dietary Intake

Edited by
Dale A. Schoeller
Margriet S. Westerterp-Plantenga
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742

© 2017 by Taylor & Francis Group, LLC

CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

Printed on acid-free paper

International Standard Book Number-13: 978-1-4987-4932-9 (Hardback)

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Library of Congress Cataloging-in-Publication Data

Names: Schoeller, Dale A. | Westerterp-Plantenga, Margriet S.

Title: Advances in the assessment of dietary intake / Dale A. Schoeller &
Margriet S. Westerterp-Plantenga.
Description: Boca Raton : CRC Press, 2017. | Includes bibliographical
references.
Identifiers: LCCN 2016053172 | ISBN 9781498749329 (hardback : alk. paper)
Subjects: LCSH: Nutrition surveys. | Nutrition. | Diet. | Biochemical markers.
Classification: LCC TX551 .S36 2017 | DDC 613.2--dc23
LC record available at https://lccn.loc.gov/2016053172

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 Dedication

This book is dedicated to Dr. Ira Wolinsky, PhD, who conceptualized the
aims of this book and then initiated the process leading to its publication.
Dr. Wolinsky passed away on November 26, 2014, after a long career as an
investigator and an editor. He earned his doctorate in biochemistry from
the University of Kansas, Lawrence, Kansas, and went on to investigate the
role of bone metabolism and human health at Pennsylvania State University,
State College, Pennsylvania. He later moved to the University of Houston,
Houston, Texas, from which he retired as Professor Emeritus in 2005. From
the very beginning of his scientific career, Dr. Wolinsky worked to apply
the advances in basic science to the improvement of clinical science with
respect to both treatment and prevention of human disease. During his
PhD training at the University of Kansas, he applied the state-of-the-art
biochemistry to increasing the health of human teeth. Later at Pennsylvania
State University, he studied the interaction of skeletal muscle and bone to
improve bone health. At the University of Houston, he examined the impact of
weightlessness during space flight in order to prevent the loss of bone density.
Dr. Wolinsky published more than 40 journal articles and selected to expand
the impact of original scientific research on the human condition by authoring
and editing of more than 148 books. This included editing the influential CRC
Series in Modern Nutrition, which he aimed toward a “scholarly audience … to
explain, review, and explore present knowledge and recent trends, developments,
and the advances in nutrition.” Although Dr. Wolinsky welcomed investigator-
initiated book proposals for this series, he went beyond and monitored
novel developments in nutrition recruiting others to create state-of-the-art
volumes that enhanced and expanded upon those key basic developments.
Although I only knew Dr. Wolinsky through our correspondence, it was he
who first engaged my efforts as a coeditor along with Dr. Helen Lane on
a book that encapsulated the breadth of knowledge on nutrition that was
necessary for spaceflight. In 2014, it was again because of Dr. Wolinsky’s
 foresight and creativity that I was recruited to coedit this book in an effort
to change the field of diet assessment. He contacted and convinced me
that recent breakthroughs in technology were such that, if focused on diet
assessment in the form of a state-of-the-art book, could help revolutionize
the methods used for dietary assessment. Unfortunately, Dr. Wolinsky passed
away before Dr. Margriet S. Westerterp-Plantenga and I, along with the many
authors of Advances in the Assessment of Dietary Intake, could complete
this book; however, because of his efforts as a creative and engaged editor,
we dedicate this book to the memory of Dr. Wolinsky’s achievements.

Dale A. Schoeller
Margriet S. Westerterp-Plantenga
Coeditors
Contents
Editors ...............................................................................................................................................ix
Contributors ......................................................................................................................................xi
Prologue ........................................................................................................................................... xv

Chapter 1 Benefits and Limitations of Traditional Self-Report Instruments ................................1

Hamid R. Farshchi, Ian Macdonald, Ameneh Madjd, and Moira A. Taylor

Chapter 2 Statistical Approaches to Mitigate Measurement Error in Dietary Intake Data

Collected Using 24-hour Recalls and Food Records/Diaries .................................... 19
Sharon I. Kirkpatrick, Amy F. Subar, and Janet A. Tooze

Chapter 3 Computer-Assisted Dietary Assessment Methods ..................................................... 45

Suzanne McNutt, Thea Palmer Zimmerman, and Brooke Colaiezzi

Chapter 4 Strategies for Improving the Validity of the 24-hour Dietary Recall and Food
Record Methods ......................................................................................................... 67
Lisa J. Harnack and Mark A. Pereira

Chapter 5 The Assessment of Food Intake with Digital Photography ....................................... 85

Keely R. Hawkins, John W. Apolzan, Candice A. Myers, and Corby K. Martin

Chapter 6 Meal Patterns, Physical Activity, Sleep, and Circadian Rhythm ............................. 113
Margriet S. Westerterp-Plantenga and Marta Garaulet

Chapter 7 Assessment of Ingestion by Chewing and Swallowing Sensors .............................. 129

Edward Sazonov, Muhammad Farooq, and Edward Melanson

Chapter 8 Bites as a Unit of Measurement................................................................................ 149

Adam Hoover, Ryan Mattfeld, and Eric Muth

Chapter 9 Direct and Indirect Measures of Dietary Intake: Use of Sensors and Modern
Technologies ............................................................................................................. 163
Holly L. McClung, Joseph J. Kehayias, Gary P. Zientara, and Reed W. Hoyt

vii
viii Contents

Chapter 10 Use of Doubly-Labeled Water Measured Energy Expenditure as a Biomarker

of Self-Reported Energy Intake ............................................................................... 185
Dale A. Schoeller and David B. Allison

Chapter 11 Biomarker for Energy Intake: Resting Energy Expenditure and Physical
Activity ................................................................................................................ 199
Klaas R. Westerterp

Chapter 12 Dynamic Modeling of Energy Expenditure to Estimate Dietary Energy Intake..... 211
Diana Thomas and Vincent W. Antonetti

Chapter 13 Use of Intake Biomarkers in Nutritional Epidemiology .......................................... 221

Ross L. Prentice

Chapter 14 Stable Isotopic Biomarkers of Diet .......................................................................... 235

Sarah H. Nash and Diane M. O’Brien

Chapter 15 The Food Metabolome and Dietary Biomarkers...................................................... 259

Augustin Scalbert, Joseph A. Rothwell, Pekka Keski-Rahkonen,
and Vanessa Neveu

Chapter 16 Metabolomic Techniques to Discover Food Biomarkers ......................................... 283

Pekka Keski-Rahkonen, Joseph A. Rothwell, and Augustin Scalbert

Chapter 17 The Validation of Dietary Biomarkers ..................................................................... 301

Pietro Ferrari

Chapter 18 Targeted and Untargeted Metabolomics for Specific Food Intake Assessment:
Whole Grains as an Example ................................................................................... 315
Carl Brunius, Huaxing Wu, and Rikard Landberg

Chapter 19 Strengths and Limitations of Food Composition Databases .................................... 337

Phyllis Stumbo and Gary Beecher

Index .............................................................................................................................................. 353

Editors
Dr. Dale A. Schoeller is a director of the Isotope Ratio Laboratory in the Biotechnology Center
and is the professor emeritus in Nutritional Sciences and the University of Wisconsin-Madison,
Madison, Wisconsin. He was the first investigator to use the doubly labeled water method to measure
total energy expenditure in humans, which led to the observation that self-reported dietary assess-
ment instruments systematically underestimated dietary energy intake compared to the amount of
energy that individuals were actually expending. This work by him and many others resulted in
paradigm shift in validating and modeling the error structure in dietary assessment instruments.
More recently, he collaborated with leading nutrition epidemiologists to use the doubly labeled
water method as a biomarker of habitual energy intake to quantify systematic errors in dietary
energy intake instruments forming the basis of his work that resulted in this book.
He earned his undergraduate degree from the University of Wisconsin-Milwaukee, Milwaukee,
Wisconsin and his PhD in Chemistry from Indiana University, Bloomington, Indiana. He was
trained as a post-doctoral fellow in Biomedical Sciences at the Argonne National Laboratory,
Lemont, Illinois and joined the faculty of Medicine at the University of Chicago (Illinois, Chicago),
where he directed the Stable Isotope Core Laboratory as part of the Clinical Nutrition Research
Unit. For the last 20 years, he continued his research on the energetics of obesity at the University
of Wisconsin-Madison. His research has been recognized through multiple awards including the
Herman Award for Clinical Research from the American Society for Clinical Nutrition, the O.W.
Atwater Award for Research from Agricultural Research Service, and the Friends of Mickey
Stunkard Lifetime Achievement Award from the Obesity Society.

Dr. Margriet S. Westerterp-Plantenga is a professor of Food Intake Regulation in Humans, at

Maastricht University Faculty of Health, Medicine and Life Sciences, School of Nutrim, Department
of Human Biology, Maastricht, the Netherlands. In her productive career in human research, she has
focused on the mechanisms of energy and reward homeostasis. This has involved diverse research
on satiety and the role of orexigenic and anorexigenic hormones and glucose; the physiology of diet-
induced thermogenesis and body-temperature regulation; circadian rhythm and sleep; and energy
balance, macronutrient balance, and substrate oxidation. These studies have made major contribu-
tions to the understanding of food reward and related brain-signaling pathways and have done so
with a strong perspective in their roles in the regulation of body weight and body composition.
She earned her undergraduate degree in Biology from the University of Groningen, Groningen,
the Netherlands and her PhD degree in Biomedical Sciences from Maastricht University. She was
a member of the Faculty Board of the Faculty of Health Sciences at Maastricht University and was
responsible for the Research portfolio. She is currently an associate editor of the International Journal
of Obesity and a member of the Editorial Board of Physiology and Behavior. She has been a project
leader at the Leading Technological Institute of Food and Nutrition in the Netherlands and one of the
leaders of several European projects, such as Diogenes, Full4Health, and at present PREVIEW. She
has published about 240 papers in internationally peer-reviewed journals and authored and edited
several books on food intake and energy expenditure.

ix
Contributors
David B. Allison Hamid R. Farshchi
Department of Nutrition Sciences, Nutrition School of Life Sciences
Obesity Research Center Queen’s Medical Centre
University of Alabama at Birmingham University of Nottingham
Birmingham, Alabama Nottingham, United Kingdom

Vincent W. Antonetti Pietro Ferrari

Department of Mechanical Engineering Nutritional Methodology and
Manhattan College Biostatistics Group
Riverdale, New York International Agency for Research on
Cancer (IARC)
John W. Apolzan Lyon, France
Clinical Nutrition and Metabolism
Pennington Biomedical Research Center Marta Garaulet
Baton Rouge, Louisiana Department of Physiology
Faculty of Biology
Gary Beecher Biomedical Research Institute of Murcia
Beltsville Human Nutrition Research Center (IMIB-Arrixaca)
Agricultural Research Service University of Murcia
United States Department of Agriculture Murcia, Spain
Beltsville, Maryland
Lisa J. Harnack
Carl Brunius Division of Epidemiology and Community
Department of Food Science Health
Swedish University of Agricultural Sciences School of Public Health
Uppsala, Sweden University of Minnesota
Minneapolis, Minnesota
and
Department of Biology and Biological Keely R. Hawkins
Engineering Ingestive Behavior and Metabolism
Chalmers University of Technology Pennington Biomedical Research Center
Göteborg, Sweden Baton Rouge, Louisiana

Brooke Colaiezzi Adam Hoover

Friedman School of Nutrition Science Department of Electrical and Computer
and Policy Engineering
Tufts University Clemson University
Medford, Massachusetts Clemson, South Carolina

Muhammad Farooq Reed W. Hoyt

Department of Electrical and Computer Biophysics and Biomedical Modeling Division
Engineering U.S. Army Research Institute of Environmental
The University of Alabama Medicine
Tuscaloosa, Alabama Natick, Massachusetts

xi
xii Contributors

Joseph J. Kehayias Ryan Mattfeld

Biophysics and Biomedical Modeling Division Department of Electrical and Computer
U.S. Army Research Institute of Environmental Engineering
Medicine Clemson University
Natick, Massachusetts Clemson, South Carolina

Pekka Keski-Rahkonen Holly L. McClung

Nutrition and Metabolism Section, Biomarkers Biophysics and Biomedical Modeling Division
Group U.S. Army Research Institute of Environmental
International Agency for Research on Cancer Medicine
Lyon, France Natick, Massachusetts

Sharon I. Kirkpatrick
Suzanne McNutt
School of Public Health and Health Systems
Health Studies Sector
University of Waterloo
Westat, Inc.
Ontario, Canada
Rockville, Maryland
Rikard Landberg
Department of Food Science Edward Melanson
Swedish University of Agricultural Sciences Division of Endocrinology, Metabolism, and
Uppsala, Sweden Diabetes/Division of Geriatric Medicine
University of Colorado
and Aurora, Colorado
Department of Biology and Biological
Engineering Eric Muth
Chalmers University of Technology Department of Psychology
Göteborg, Sweden Clemson University
Clemson, South Carolina
and
Department of Medical Epidemiology and Candice A. Myers
Biostatistics Pennington Biomedical Research Center
Karolinska Institutet Baton Rouge, Louisiana
Stockholm, Sweden
Sarah H. Nash
Ian Macdonald
Alaska Native Tumor Registry
School of Life Sciences
Alaska Native Epidemiology Center
Queen’s Medical Centre
Anchorage, Alaska
University of Nottingham
Nottingham, United Kingdom
Vanessa Neveu
Ameneh Madjd Nutrition and Metabolism Section, Biomarkers
School of Life Sciences Group
Queen’s Medical Centre International Agency for Research on Cancer
University of Nottingham Lyon, France
Nottingham, United Kingdom
Diane M. O’Brien
Corby K. Martin Institute of Arctic Biology
Pennington Biomedical Research Center University of Alaska–Fairbanks
Baton Rouge, Louisiana Fairbanks, Alaska
Contributors xiii

Mark A. Pereira Moira A. Taylor

Division of Epidemiology and Community School of Life Sciences
Health Queen’s Medical Centre
School of Public Health University of Nottingham
University of Minnesota Nottingham, United Kingdom
Minneapolis, Minnesota
Diana Thomas
Ross L. Prentice Department of Mathematical Sciences
Fred Hutchinson Cancer Research Center United States Military Academy
University of Washington West Point, New York
Seattle, Washington
Janet A. Tooze
Joseph A. Rothwell Department of Biostatistical Sciences
Nutrition and Metabolism Section, Biomarkers Wake Forest School of Medicine
Group Winston-Salem, North Carolina
International Agency for Research on Cancer
Lyon, France Klaas R. Westerterp
Department of Human Biology
Edward Sazonov Maastricht University
Department of Electrical and Computer Maastricht, the Netherlands
Engineering
The University of Alabama Margriet S. Westerterp-Plantenga
Tuscaloosa, Alabama Department of Human Biology
NUTRIM, FHML, MUMC+,
Augustin Scalbert Maastricht University
Nutrition and Metabolism Section, Biomarkers Maastricht, the Netherlands
Group
International Agency for Research on Cancer Huaxing Wu
Lyon, France Department of Food Science
Swedish University of Agricultural Sciences
Dale A. Schoeller Uppsala, Sweden
Nutritional Sciences and Biotechnology Center
University of Wisconsin–Madison Gary P. Zientara
Madison, Wisconsin Biophysics and Biomedical Modeling Division
U.S. Army Research Institute of Environmental
Phyllis Stumbo Medicine
Institute for Clinical and Translational Science Natick, Massachusetts
University of Iowa
Iowa City, Iowa Thea Palmer Zimmerman
Health Studies Sector
Amy F. Subar Westat, Inc.
Division of Cancer Control and Population Rockville, Maryland
Sciences
National Cancer Institute
Bethesda, Maryland
Prologue
Margriet S. Westerterp-Plantenga and Dale A. Schoeller

WHY IS DIETARY ASSESSMENT NECESSARY?

Every day individuals are faced with multiple choices about what and how much to eat. Some of
these choices are known to be associated with undernutrition, overfeeding, or chronic disease. How
much these choices increase the dietary risk factors or lead to the potential beneficial factors in an
individual or in populations has been revealed through dietary assessment, often in large-scale epi-
demiologic studies. Examples are numerous, and nutritionists employing dietary assessment have
repeatedly demonstrated the importance of these choices.
Dietary research has reveled the impact of saturated fatty acids on low-density lipoprotein (LDL)
cholesterol (Groen et al. 1952; Kinsell et al. 1952; Keys et al. 1965); in addition, the LDL cholesterol
raising the effect of trans fatty acids was identified (Mensink and Katan 1990). These insights resulted
in the producers reducing trans fatty acids in margarine. For the role of fatty acid consumption in car-
diovascular diseases, dietary analysis was accompanied by newly developed objective measurements
of intake such as the incorporation of fatty acids into blood cholesteryl esters, red blood cells, and fat
tissue (Beynen and Katan 1985; Van Staveren et al. 1986; Katan et al. 1986, 1997). For the dietary
bioactive phytochemical flavonoid, the assessment of intake led to insights in their role in the risk
for coronary heart disease (Hertog et al. 1992, 1993a, 1993b, 1995; Rimm et al. 1996). Going into
detail regarding fiber intake, determination of dietary fiber was developed, and among others, well-
controlled intervention studies have shown that four major water-soluble fiber types (beta-glucan,
psyllium, pectin, and guar gum) effectively lower serum LDL cholesterol concentrations, without
affecting high-density lipoprotein (HDL) cholesterol or triacylglycerol concentrations. These find-
ings underlie the current dietary recommendations to increase water-soluble fiber intake (Theuwissen
and Mensink 2008). Foods containing plant sterol or stanol esters were shown to be useful for mildly
hypercholesterolemic subjects (de Jong et al. 2003). Dietary assessments including comparisons
between countries revealed differences in total cholesterol and HDL cholesterol levels in populations
differing in fat and carbohydrate intake (Knuiman et al. 1987). Quite recently, among 9- to 11-year-
old children in 12 countries, the home environment appeared to be more significant than the school
environment for a healthy dietary pattern (Vepsäläinen et al. 2015).
Further research focused on the growing concern over excess body weight. Dietary studies
have been performed, which found that high-fat diets in humans induced short-term hyperphagia
and were associated with a higher adiposity (Tremblay et al. 1989). The fat content of the diet has
an effect on body fat as a function of the effect of dietary fat on energy intake (Westerterp et al.
1996a), whereas dietary fat oxidation is a function of body fat (Westerterp et al. 2008). Although
a low-glycemic index (GI) diet seems to modestly improve long-term glycemic control in subjects
with type 2 diabetes (Brand et al. 1991), at present there is no evidence that low-GI foods are supe-
rior to high-GI foods in regard to long-term body weight control (Raben 2002). The applicability
of the GI in the context of mixed meals and diets is still debatable, because the outcomes depend
on the method used (Flint et al. 2004). Overweight individuals consuming artificial sweeteners
instead of fairly large amounts of sucrose mostly as beverages did not increase their energy intake,
body weight, fat mass, and blood pressure over 10 weeks, as their counterparts did, who consumed
fairly large amounts of sucrose (Raben et al. 2002). In addition to general population studies,
research questions aimed at promoting the performance in elite athletes by fine-tuning energy
balance. Under extremely high-energy expenditures, such as in the Tour de France or Whitbread
race around the world, it is actually difficult to ingest enough energy to prevent a negative energy

xv
xvi Prologue

balance, which would be disastrous for performance. High-energy drinks, consumed during the
race, contribute significantly to daily intake (Westerterp et al. 1986). Sailors, during offshore races
of several days or weeks, often fail to maintain energy balance due to their work on the deck,
changing and trimming the sails, the continuous need to counterbalance movements of the boat,
the watch system not allowing for a full night’s sleep or a normal frequency, and the order of
meals and activities (Branth et al. 1996). At high-altitude expeditions, it seems to be impossible to
maintain the energy balance above 5000–5500 m. Maintenance of energy balance determines the
success of these expeditions. Experienced negative energy balances are largely due to insufficient
energy intake (Westerterp et al. 1992, 1994, 1996b, 2000). Hypoxia induces a negative energy
balance by reduction of energy intake due to a more rapid increase in satiety and a decrease of
hunger, probably caused by higher hypoxia-induced ventilation and diet-induced thermogenesis
(Westerterp-Plantenga et al. 1999).
As evidenced previously, many of the advances in nutritional science have come from studies
in which dietary assessment was central to the study. It should be noted, however, that epidemio-
logic studies of diet provided only part of the scientific story. Sometimes, the first notion came
from the population dietary assessment data, which could be the last step in generalizing the
findings.

WHY ARE NEW METHODS FOR DIETARY ASSESSMENT NECESSARY?

Although early methods for dietary assessment have evolved and improved since the 1930s, they
still suffer from a lack of accuracy in reporting due to memory failure, response bias, and the daily
variability in diet. The large meal-to-meal, day-to-day, and seasonal variations in food intake make
it difficult to capture usual intake. Dietary reporting is inconvenient, and individual biases such as
body image, weight consciousness, dietary restraint, and social expectations, may influence dietary
reporting. Do the investigators help or hinder? Have they unwittingly contributed to the problem of
misreporting? Do techniques such as the use of guided imagery or reminiscing, coercion, expect-
ant looks, suggestive and repeated questioning, and conviction of importance of the survey further
influence reporting accuracy?
On the positive side, accurate reporting of dietary intake has not been impossible to attain.
Dieticians gave accurate reports of food intake of the Swedish Olympic cross-country skiing team
during a training camp (Sjödin et al. 1994). After the first failing, dieticians learned to report their
own food intake with full accuracy (Goris and Westerterp 1999, 2000). On the negative side, even
in the hands of the most experienced nutritional epidemiologists, inaccuracies in dietary assessment
remain (Freedman et al. 2014). Furthermore, even if reports were accurate, some research questions
have been too specific to be approached using traditional dietary epidemiological methods. For
instance, when the range of intakes of fatty acid distributions is small, and large-scale studies prob-
ably cannot find diet–health associations.
In the beginning of the 1980s, the emergence of biomarkers has been a major development
for efforts to understand and increase the reliability of dietary assessment. Examples include
24 h urinary nitrogen (Huse et al. 1974; Isaksson 1980; Bingham and Cummings 1985) to
validate protein intake, the PABA technique (Bingham and Cummings 1983) for recovery of
intervention-induced changes of specific food items, fat biopsies (Dayton et al. 1966; Plakké
et al. 1983) for determining the incorporation of fatty acids, and doubly-labeled water (Schoeller
and van Santen 1982; Westerterp et al. 1986) for validating the energy intake under conditions
of energy balance. With regard to the latter, major insights came through doubly-labeled water
energy expenditure studies that have revealed that underreporting was endemic in dietary sur-
veys (Livingstone et al. 1990), not method specific (Livingstone and Black 2003), mainly related
to dietary fat intake in Western societies (Goris et al. 2000), and getting worse over time (Goris
et al. 2001). Conversely, overreporting was identified, when caretakers reported on the patient’s
food intake (Simmons and Reuben 2000).
Prologue xvii

In the face of these shortcomings, experts still diverge in their opinions on dietary assessment
and its traditional tools. Some advocate that “Something is not better than nothing” (Dhurandhar
et al. 2015). Specifically with respect to the energy intake, they argue that “it is time to move
away from the use of self-reports of energy intake as a research tool. They base this on the
evidence that self-reports of energy intake are so poor that they are wholly unacceptable for
scientific research on energy balance and that researchers and sponsors should develop objective
measures of energy intake.”
Other researchers admit that accuracy of reported or recalled absolute intakes fails, yet they
believe that dietary patterns can be recognized, and thus, traditional dietary assessment should still
be employed. It is added, however, that even if dietary assessment is imprinted by some inherent
weaknesses, it should not be discredited and rejected for research purposes. Indeed, the information
should be used with caution, should not be overinterpreted, and would be advantageously used with
other supporting techniques. (Tremblay pers. comm. 2016). Many conclude that a multistep process
should be used to reinforce the outcome of a traditional dietary assessment. Biomarkers and sen-
sors are projected to add useful information that would compensate for shortcomings of traditional
dietary assessment.

HOW PROMISING ARE THE NEW METHODS FOR DIETARY ASSESSMENT?

Expectations are that these shortcomings can be partly or completely circumvented during the
twenty-first century. Biomarkers, improved sensors, and portable electronic technology are all
under investigation. Photography may help to add information about ingredients, food prepara-
tion, and food consumption environment, including sociological and psychological aspects of eat-
ing. Three-dimensional scanning of foods may be obtained in canteens, restaurants, and shops to
improve estimates of serving sizes, and a chip to measure nutrients in the blood is on the technical
wish list. At the same time, updates of food composition databases (Murphy et al. 2016) and harmo-
nization across cultures for international studies receive attention.
Reduction of the burden of the subjects, increase of acceptability and compliance, reduction of
costs for the researchers, applicability to diverse population groups, higher data quality, consistency,
completeness, and as such higher reliability of the outcome of dietary assessment are expected to
lead to greater success in the assessment of dietary intake.

HOW RELEVANT IS ADVANCED DIETARY ASSESSMENT FOR CURRENT

RESEARCH QUESTIONS?
With increasing health awareness, and numerous health-related advices, the question remains as
to how detailed dietary assessment still can become more relevant. Current research questions are
asked in the perspective of the leading causes of death: risks for cardiovascular diseases, chronic
metabolic disorders, and cancer. Attention regarding the assessment of single nutrients seems to
be shifting to attention on food patterns (Jacobs and Steffen 2003), regularity of meals (Pot et al.
2016), and a Mediterranean diet (Waijers et al. 2007; Knoops et al. 2004; Estruch et al. 2013;
Berendsen et al. 2013; Santoro et al. 2014). Personalized nutrition is also a focus, with dietary
assessment methods that are swift and on the spot, in an accessible attractive looking format, and
with appropriate feedback and advice that are tailored to the individual’s situation (Zeevi et al. 2015;
Livingstone et al. 2016). To these ends, investigators are beginning to combine dietary assessment
with a person’s genetic profile, so that individuals may reduce their risk of dietary diseases as part
of personalized medicine.
Dietary assessment, as currently performed, however, remains imperfect. Risk reduction for
early mortality due to the leading chronic diseases in mainly Westernized societies remains a
xviii Prologue

major focus for dietary assessment studies. Some success has been made, but further progress will
require a wider perspective. Investigations have shown that not only food patterns but also the
complete lifestyle are related to health and well-being. Thus, habitual physical activity is promoted
along with regular timing of meals, activity, and sleep, and all are in line with the individual’s cir-
cadian rhythm (Westerterp-Plantenga 2016); but exactly what food and exercise and how much of
each remain controversial. To answer this, we need to learn to improve the accuracy and reliability
of dietary assessment, and then how to disentangle that from other confounding lifestyle factors.
Novel methods of dietary assessment are needed to augment the traditional dietary assessment
methods.

ACKNOWLEDGMENTS
We thank Drs. Edith Feskens, Wageningen University, Wageningen, the Netherlands; Barbara
Livingstone, Ulster University, Ulster, Ireland; Martijn Katan, Free University, Amsterdam,
the Netherlands; Ronald Mensink and Klaas Westerterp, Maastricht University, Maastricht, the
Netherlands; Angelo Tremblay, University of Laval, Quebec, Canada; Mikael Fogelholm, University
of Helsinki, Helsinki, Finland; Anne Raben, University of Copenhagen, Copenhagen, Denmark;
Nikhil Dhurandhar, Texas Tech University, Lubbock, Texas; Sally Poppit, University of Auckland,
Auckland, New Zealand; Jennie Brand-Miller, University of Sydney, Sydney, Australia; Margarita
Santiago Torrez, University of New Mexico, Albuquerque, New Mexico; Michele Mendez,
University of North Carolina, Chapel Hill, North Carolina; Jean Jacques, Tufts University, Medford,
Massachusetts; and Natalie M. Racine, University of Wisconsin-Madison, Wisconsin, for their valu-
able contributions.

REFERENCES
Berendsen, A., A. Santoro, E. Pini et al. 2013. A parallel randomized trial on the effect of a healthful diet on
inflammageing and its consequences in European elderly people: Design of the NU-AGE dietary inter-
vention study. Mech Ageing Dev 134(11–12):523–530.
Beynen, A. C. and M. B. Katan. 1985. Rapid sampling and long-term storage of subcutaneous adipose tissue
biopsies for determination of fatty acid composition. Am J Clin Nutr 42:317–322.
Bingham, S. and J. H. Cummings. 1983. The use of 4-aminobenzoic acid as a marker to validate the complete-
ness of 24 h urine collections in man. Clin Sci 64(6):629–635.
Bingham, S. A. and J. H. Cummings. 1985. Urine nitrogen as an independent validatory measure of dietary
intake: A study of nitrogen balance in individuals consuming their normal diet. Am J Clin Nutr 42:1276.
Brand, J. C., S. Colagiuri, S. Crossman et al. 1991. Low-glycemic index foods improve long-term glycemic
control in NIDDM. Diabetes Care 14(2):95–101.
Branth, S., L. Hanbraeus, K. Westerterp et al. 1996. Energy turnover during offshore sailing racing as studied
by food inventories, doubly labeled water and anthropometry. Med Sci Sports Exerc 28:1272–1276.
Dayton, S., S. Hashimoto, W. J. Dixon et al. 1966. Composition of lipids in human serum and adipose tissue
during prolonged feeding of a diet high in unsaturated fat. J Lipid Res 7:103.
Dhurandhar, N. V., D. Schoeller, A. W. Brown et al. 2015. Energy balance measurement: When something is
not better than nothing. Int J Obes 39(7):1109–1113.
Estruch, R., E. Ros, J. Salas-Salvado et al. 2013. Primary prevention of cardiovascular disease with a
Mediterranean diet. N Engl J Med 368(14):1279–1290.
Flint, A., B. K. Møller, A. Raben et al. 2004. The use of glycaemic index tables to predict glycaemic index of
composite breakfast meals. Br J Nutr 91(6):979–989.
Freedman, L. S., J. M. Commins, J. E. Moler et al. 2014. Pooled results from 5 validation studies of dietary
self-report instruments using recovery biomarkers for energy and protein intake. Am J Epidemiol
15:172–188.
Goris, A. H. and K. R. Westerterp. 1999. Underreporting of habitual food intake is explained by undereating
in highly motivated lean women. J Nutr 129(4):878–882.
Goris, A. H. and K. R. Westerterp. 2000. Improved reporting of habitual food intake after confrontation with
earlier results on food reporting. Br J Nutr 83(4):363–369.
Prologue xix

Goris, A. H., E. P. Meijer, K. R. Westerterp. 2001. Repeated measurement of habitual food intake increases
under-reporting and induces selective under-reporting. Br J Nutr 85(5):629–634.
Goris, A. H., M. S. Westerterp-Plantenga, K. R. Westerterp. 2000. Undereating and underrecording of habit-
ual food intake in obese men: Selective underreporting of fat intake. Am J Clin Nutr 71(1):130–134.
Groen, J. J., B. K. Tjiong, C. E. Kamminga et al. 1952. The influence of nutrition, individuality and some other
factors including various forms of stress, on the serum cholesterol: An experiment of nine months dura-
tion in 60 normal human volunteers. Voeding 13:556.
Hertog, M. G. L., P. C. H. Hollman, M. B. Katan. 1992. The content of potentially anticarcinogenic flavonoids
of 28 vegetables and 9 fruits commonly consumed in the Netherlands. J Agr Food Chem 40:2379–2383.
Hertog, M. G. L., E. J. M. Feskens, P. C. H. Hollman et al. 1993a. Dietary antioxidant flavonoids and risk of
coronary heart disease. The Zutphen elderly study. Lancet 342:1007–1011.
Hertog, M. G. L., P. C. H. Hollman, M. B. Katan et al. 1993b. Intake of potentially anticarcinogenic flavonoids
and their determinants in adults in the Netherlands. Nutr Cancer 20:21–29.
Hertog, M. G., D. Kromhout, C. Aravanis et al. 1995. Flavonoid intake and long-term risk of coronary heart
disease and cancer in the seven countries study. Arch Intern Med 155(4):381–386.
Huse, D. M., R. A. Nelson, E. R. Briones et al. 1974. Urinary nitrogen excretion as objective measure of
dietary intake. Am J Clin Nutr 27:771–773.
Isaksson, B. 1980. Urinary nitrogen output as a validity test in dietary surveys. Am J Clin Nutr 33:4–5.
Jacobs, D. R., Jr. and L. M. Steffen. 2003. Nutrients, foods, and dietary patterns as exposures in research:
A framework for food synergy. Am J Clin Nutr 78:508S–513S.
de Jong, A., J. Plat, R. P. Mensink. 2003. Metabolic effects of plant sterols and stanols (Review). J Nutr
Biochem 14(7):362–369.
Katan, M. B., J. P. Deslypere, A. P. J. M. Van Birgelen et al. 1997. Kinetics of the incorporation of dietary N-3
fatty acids into cholesteryl esters, erythrocyte membranes and fat tissue—an 18-month controlled trial
in man. J Lipid Res 38:2012–2022.
Katan, M. B., W. A. Van Staveren, P. Deurenberg et al. 1986. Linoleic and trans-unsaturated fatty acid content
of adipose tissue biopsies as objective indicators of the dietary habits of individuals. Prog Lipid Res
25:193–195.
Keys, A., J. T. Anderson, F. Grande. 1965. Serum cholesterol response to changes in the diet: IV. Particular
saturated fatty acids in the diet. Metabolism 14(7):776–787.
Kinsell, L. W., J. Partridge, L. Boling et al. 1952. Dietary modification of serum cholesterol and phospholipid
levels. J Clin Endocrinol Metab 12(7):909–913.
Knoops, K. T., L. C. de Groot, D. Kromhout et al. 2004. Mediterranean diet, lifestyle factors, and 10-year
mortality in elderly European men and women: The HALE project. JAMA 292(12):1433–1439.
Knuiman, J. T., C. E. West, M. B. Katan et al. 1987. Total cholesterol and high density lipoprotein cholesterol
levels in populations differing in fat and carbohydrate intake. Arteriosclerosis 7:612–619.
Livingstone, M. B. and A. E. Black. 2003. Markers of the validity of reported energy intake. J Nutr
133:895S–920S.
Livingstone, K. M., C. Celis-Morales, S. Navas-Carretero et al. 2016. Effect of an Internet-based, personalized
nutrition randomized trial on dietary changes associated with the Mediterranean diet: The Food4Me
Study. Am J Clin Nutr 104(2):288–297.
Livingstone, M. B., A. M. Prentice, J. J. Strain et al. 1990. Accuracy of weighed dietary records in studies of
diet and health. BMJ 300(6726):708–712.
Mensink, R. P. and M. B. Katan. 1990. Effect of dietary trans fatty acids on high-density and low-density
lipoprotein cholesterol levels in healthy subjects. N Engl J Med 323(7):439–445.
Murphy, S. P., U. R. Charrondiere, B. Burlingame. 2016. Thirty years of progress in harmonizing and compil-
ing food data as a result of the establishment of INFOODS. Food Chem 193:2–5.
Plakké, T., J. Berkel, A. C. Beynen et al. 1983. Relationship between the fatty acid composition of the diet and
that of the subcutaneous adipose tissue in individual human subjects. Hum Nutr Appl Nutr 37A:365–372.
Pot, G. K., R. Hardy, A. M. Stephen. 2016. Irregularity of energy intake at meals: Prospective associations
with the metabolic syndrome in adults of the 1946 British birth cohort. Br J Nutr 115(2):315–323.
Raben, A. 2002. Should obese patients be counselled to follow a low-glycaemic index diet? No. Obes Rev
3(4):245–256.
Raben, A., T. H. Vasilaras, A. C. Møller et al. 2002. Sucrose compared with artificial sweeteners: Different
effects on ad libitum food intake and body weight after 10 wk of supplementation in overweight subjects.
Am J Clin Nutr 76(4):721–729.
Rimm, E. B., M. B. Katan, A. Ascherio et al. 1996. Relation between intake of flavonoids and risk for coronary
heart disease in male health professionals. Ann Intern Med 125:384–389.
xx Prologue

Santoro, A., E. Pini, M. Scurti et al. 2014. Combating inflammaging through a Mediterranean whole diet
approach: The NU-AGE project’s conceptual framework and design. Mech Ageing Dev 136–137:3–13.
Schoeller, D. A. and E. van Santen. 1982. Measurement of energy expenditure in humans by doubly labeled
water method. J Appl Physiol Respir Environ Exerc Physiol 53(4):955–959.
Simmons, S. F. and D. Reuben. 2000. Nutritional intake monitoring for nursing home residents: A comparison
of staff documentation, direct observation, and photography models. J Am Geriatr Soc 48(2):209–213.
Sjödin, A. M., A. B. Andersson, J. M. Högberg et al. 1994. Energy balance in cross-country skiers: A study
using doubly labeled water. Med Sci Sports Exerc 26(6):720–724.
Theuwissen, E. and R. P. Mensink. 2008. Water-soluble dietary fibers and cardiovascular disease. Physiol
Behav 94(2):285–292.
Tremblay, A., G. Plourde, J. P. Despres et al. 1989. Impact of dietary fat content and fat oxidation on energy
intake in humans. Am J Clin Nutr 49(5):799–805.
Van Staveren, W. A., P. Deurenberg, M. B. Katan et al. 1986. Validity of the fatty acid composition of subcuta-
neous fat tissue microbiopsies as an estimate of the longterm average fatty acid composition of the diet
of separate individuals. Am J Epidemiol 12:455–463.
Vepsäläinen, H., V. Mikkilä, M. Erkkola et al. 2015. Association between home and school food environments
and dietary patterns among 9–11-year-old children in 12 countries. Int J Obes 5(Suppl2):S66–S73.
Waijers, P. M., E. J. Feskens, M. C. Ocke. 2007. A critical review of predefined diet quality scores. Br J Nutr
97(2):219–231.
Westerterp, K. R., A. Smeets, M. P. Lejeune et al. 2008. Dietary fat oxidation as a function of body fat. Am J
Clin Nutr 87:132–135.
Westerterp, K. R., B. Kayser, F. Brouns et al. 1992. Energy expenditure climbing Mt. Everest. J Appl Physiol
73:1815–1819.
Westerterp, K. R., B. Kayser, L. Wouters et al. 1994. Energy balance at high altitude: 6542m. J Appl Physiol
77:862–866.
Westerterp, K. R., E. P. Meijer, M. Rubbens et al. 2000. Operation Everest III: Energy and water balance. Eur
J Physiol 439:483–488.
Westerterp, K. R., P. Robach, L. Wouters et al. 1996b. Water balance and acute mountain sickness before and
after arrival at high altitude: 4350m. J Appl Physiol 80:1968–1972.
Westerterp, K. R., W. H. M. Saris, M. Van Es et al. 1986. Use of doubly labeled water technique in man during
heavy sustained exercise. J Appl Physiol 61:2162–2216.
Westerterp, K. R., W. P. H. G. Verboeket-van de Venne, M. S. Westerterp-Plantenga et al. 1996a. Dietary fat
and body fat: An intervention study. Int J Obes 20:1022–1026.
Westerterp-Plantenga, M. S. 2016. Sleep, circadian rhythm and body weight: Parallel developments. Proc
Nutr Soc 27:1–9.
Westerterp-Plantenga, M. S., K. R. Westerterp, M. Rubbens et al. 1999. Appetite at “high altitude” [Operation
Everest III (Comex-’97)]: A simulated ascent of Mount Everest. J Appl Physiol 87:391–399.
Zeevi, D., T. Korem, N. Zmora et al. 2015. Personalized nutrition by prediction of glycemic responses. Cell
163(5):1079–1094.
 1 Benefits and Limitations
of Traditional Self-Report
Instruments
Hamid R. Farshchi, Ian Macdonald,
Ameneh Madjd, and Moira A. Taylor

CONTENTS
1.1 Introduction .............................................................................................................................. 1
1.2 Self-Reported Methods for Assessing Dietary Intake ..............................................................2
1.2.1 Food Records ................................................................................................................2
1.2.1.1 Benefits and Limitations of Food Records ....................................................3
1.2.2 24-hour Dietary Recall .................................................................................................5
1.2.2.1 Benefits and Limitations of 24-hour Dietary Recall ..................................... 5
1.2.3 Diet History .................................................................................................................. 6
1.2.3.1 Benefits and Limitations of Diet History .......................................................6
1.2.4 Food Frequency Questionnaire..................................................................................... 7
1.2.4.1 Benefits and Limitations of Food Frequency Questionnaire ......................... 8
1.3 Key Issues in Evaluating Dietary Intake Assessment Methods ............................................... 8
1.3.1 Misreporting of Foods and the Amounts Consumed ................................................... 9
1.3.2 Attempts to Quantify the Degree of Error in Dietary Intake Assessment ................... 9
1.3.3 Determinants of Underreporting Dietary Intake ........................................................ 10
1.3.3.1 Body Mass Index ......................................................................................... 10
1.3.3.2 Age and Sex ................................................................................................. 10
1.3.3.3 Socioeconomic Levels and Education ......................................................... 10
1.3.3.4 Eating Behaviors .......................................................................................... 11
1.3.3.5 Diet Variation ............................................................................................... 11
1.3.3.6 Appropriate Selection of Administration Techniques ................................. 11
1.4 Conclusions ............................................................................................................................. 12
References ........................................................................................................................................ 12

1.1 INTRODUCTION
Dietary intake is an important and potentially modifiable determinant of health. Associations, in
some cases demonstrated to be causal, have been reported between dietary intake and morbidity and
mortality, for example, relating to cardiovascular diseases (Mente et al. 2009), cancer (Schwingshackl
and Hoffmann 2015), diabetes (Khazrai et al. 2014), and obesity. Accurately assessing dietary intake,
including the pattern and quantity of food, drinks, and supplement consumption is a fundamentally
important element of nutrition and health research, across the spectrum of surveillance, epidemio-
logical, and interventional studies. It is equally important in clinical practice, to be able to accu-
rately establish an individual’s current dietary intake, whether prior to or after giving dietary advice.
Having confidence in the techniques used to assess dietary intake is essential if existing research
outcomes are to be considered valid, and in order to justify funding for further techniques.

1
2 Advances in the Assessment of Dietary Intake

However, dietary intake assessment is not without challenges (Thompson et al. 2015b). Some
caution that traditional techniques may provide incorrect data that may result in misguided health
care policies, future research, and clinical judgment (Dhurandhar et al. 2015). Comparisons
between self-reported intake and estimated energy expenditure measured using doubly-labeled
water (DLW) have shown individual differences ranging from +25% to −76% (Schoeller et al.
1990), which assuming stable body weight, raises questions about their accuracy. It is thus essen-
tial that traditional methods are critically reviewed in order to inform whether there is justification
for their continued use, or to identify priority areas for investing in the development of alternative
techniques.
Dietary intake is a chronic and multidimensional phenomenon that may vary over time in rela-
tion to age, life stage, environment, and many other factors (Thompson et al. 2015b). Assessment
methods are potentially required to establish nutrient intake, food choices, or broader patterns of
eating, hence are attempting to measure what, when, how much, and how often foods and drinks are
consumed. Further steps may then need to be taken to establish, for example, an estimate of nutri-
ents using a food composition database. Food composition tables have many inherent limitations,
for example, some foods may not be included, or the composition of the foods analyzed may differ
from the foods consumed (Chapter 19) (Cantwell et al. 2006).
Many different methods have been developed for assessing dietary intake that vary with respect
to cost and the burden placed on the researcher and respondent. Nutritional biomarkers of intake
have been proposed but are not without limitations, such as weak associations with intake, and
only providing information about one dietary component. (Thompson et al. 2010; Freedman 2011)
(Chapters 15, 16, and 18). Nutrition researchers and practitioners thus may choose to rely on more
traditional, self-reported measures. This chapter describes traditional methods for self-reported
dietary intake assessment, considers benefits and limitations, and focuses on key issues in evaluat-
ing traditional dietary intake assessment methods.

1.2 SELF-REPORTED METHODS FOR ASSESSING DIETARY INTAKE

These methods include food records, 24-hour dietary recall (24HR), dietary history, and food fre-
quency questionnaires (FFQs). Data are collected with the assistance of a trained interviewer or by
self-report (after some or no training).

1.2.1 Food RecoRds

A food record consists of a diary, in which participants record the type and amount of food and
beverages consumed during a particular number of days, usually four to seven days. Participants in
order to minimize reliance on memory are advised to record at the time of consumption, and this is
thus viewed as a prospective method. The amounts consumed may be measured using a scale (i.e.,
weighed food record), or recorded using household measures (i.e., estimated food record). The for-
mer involves either a simple scale, or more sophisticated recording device that automatically records
the weight and the respondent’s verbal description of the food, early examples including the PETRA
balance (Boutelle and Kirschenbaum 1998). In the latter, measures such as cups, tablespoons, or
photographs of specific food portions may be used in an attempt to improve the estimate for the
weight of food or drink consumed (Nelson et al. 1997). Food and drink may be photographed prior
to and after eating to support interpretation, subsequently of the food intake record. In both methods,
left-over items should be recorded too so that the weight of food or drink actually consumed can be
calculated.
Generally multiple days are recorded. These are usually consecutive but not necessarily.
Recording periods of more than four sequential days are usually nonproductive, as reported intakes
decrease (Thompson et al. 2015b) because of participant’s exhaustion. Respondents may adapt
their intake or accuracy of recording differently, while keeping records, introducing interindividual
Benefits and Limitations of Traditional Self-Report Instruments 3

confounding. Successive days may not be independent of each other, for example, if left-over foods
are used, or if a day of high consumption is followed by a day of lower consumption. Nonsuccessive
days may provide a more representative view of typical consumption patterns.
To complete a dietary record, each respondent must be trained in the level of detail required
in order to adequately describe the foods and amounts consumed, including the name of the food
(brand name, if possible), preparation and cooking methods, recipes for home prepared foods,
and portion sizes. This places a considerable burden on the respondent. Dietary records may be
recorded by someone else, such as parents reporting for their children, or staff in a residential care
home providing that they are able to witness when food or drink is consumed.
Dietary records are usually collected using an unstructured diary. For example, there should not be
sections for different meals, as this potentially communicates to the respondent that they should have
such a meal pattern, which may introduce bias. However, some diaries are more structured (Schoeller
et al. 1990; Black et al. 1997; Cantwell et al. 2006; Thompson et al. 2010). These forms contain
checklists consisting of food groups, which the respondent reports on whether he or she consumed
foods from a particular food group. The design of these checklists is similar to FFQs, but the time
of the food intake report consumed is different between these two methods. In FFQ (described in a
later section), subjects are asked about intake over a definite time period like the past year or month,
while checklists should be completed at the time of intake or at the end of a day. A checklist may be
designed to evaluate specific main foods that contribute markedly to consumptions of some nutrients
(Kolar et al. 2005), and also to track food contaminants (Rebro et al. 1998). A high level of motivation
is needed in the respondents, or those who complete the record on their behalf (Willett 1998).
Some protocols insist that the food record should be reviewed by a dietitian or other trained inter-
viewer after one day of recording, and again once the record has been completed. The purpose is to
prompt the recall of foods that may have been omitted (e.g., confectionery), clarify the interpretation of
portion sizes, and add details such as the type of fat used, and amount of salt and sugar added at the point
of consumption (Cantwell et al. 2006). Other protocols may not require this step (Kolar et al. 2005). The
foods and drinks in the food record may then be matched to foods in a food composition database that are
usually accessed with the assistance of computer software, and the program is used to derive variables
such as the mean daily intakes by weight of a micronutrient, or percentage of total energy for a particular
macronutrient. Data entry is time consuming, and it may be necessary to add foods to the database, hav-
ing obtained information about composition from packets or direct from the manufacturer.

1.2.1.1 Benefits and Limitations of Food Records

In practical terms, food records have a range of benefits. First, because the format tends to be
unstructured, plentiful information can be obtained from groups with diverse eating habits and
then it can be analyzed using a multitude of techniques to address different research questions.
Concurrent information may be collected, for example, location and mood at the time of eating.
Providing records are completed at the time, as requested, there is a minimal reliance on the memory
of the respondent. Where the participant is unable or unwilling to complete the record, it can be
done by a proxy (e.g., to establish the intake of a child or patient with dementia). Completing a food
record requires a minimum of equipment, facilitating completion of the record away from home and
with minimal expense (with the exception of more sophisticated recording devices).
However, there are also limitations. The awareness that the type and amount of food must be
recorded at the point of consumption may influence both the food selected and the amounts con-
sumed (Rebro et al. 1998; Willett 1998; Vuckovic et al. 2000). This is a disadvantage when the goal
is to assess typical (usual) dietary behaviors. However, during interventional studies in which the
goal is to improve the awareness of dietary behaviors and change them, this effect can be consid-
ered an advantage (Glanz et al. 2006). Recording food intake, per se, supports effective weight loss
(Boutelle and Kirschenbaum 1998; Hollis et al. 2008).
Selecting an appropriate number of recording days can result in a dilemma when the purpose is to
capture habitual intake. Day-to-day variability in food consumed means that several days of records
4 Advances in the Assessment of Dietary Intake

are needed to establish habitual intake (Bingham 1987). The number of days required depends
on frequency of food consumed, and will be more important in some cases than others. Liver, for
example, while infrequently consumed in the United Kingdom, is a rich source of iron, a mineral
that can be stored. Insufficient days of recording that do not capture the consumption of this particu-
lar food, might erroneously lead to the conclusion that an individual’s iron intake was inadequate.
However, incomplete records increase significantly as more days of records are kept, and the validity
of the collected information declines in the later days of a seven-day recording period, in contrast to
collected information in the earlier days (Gersovitz et al. 1978).
Food records are unsuitable for individuals who are unable to read and write in the language
selected for the assessment. Although translation may be an option, where basic literacy levels are
low, issues remain. Respondents must be cooperative and motivated for this method to have validity
as there is a large respondent burden (see summary in Table 1.1).

TABLE 1.1
Summary of Benefits and Limitations of Traditional Self-Report Instruments for Dietary
Intake
Benefits Limitations
Food records • Can provide typical meal and food • Can alter eating behaviors
pattern information • May influence on both the food
• Recorded at the time of eating with no type and eaten amount
reliance on memory providing reliable • Requires multiple records to
data intake capture habitual intake
• Intake is quantified • High subject burden
• Recordings made away from home suit • High staff cost and burden
for people with irregular lifestyle habits • Requires literate and motivated
• Allows self-monitoring that can population
influence behavior change
24-hour dietary recall • Intake is quantified • Less accurate measurements of
• Less subject burden portion size
• Does not alter eating behaviors • Relies on subject recall
• Does not require literate population for • High staff cost and burden
interviewer provided version • Requires multiple recalls over
several months to capture
habitual intake
Diet history • Evaluate meal patterns and details of • Rely on subject memory
food intake • May overreport good foods and
• Catch details of the methods of food underreport intake of bad foods
preparation • Quantify the relative amount
• Does not require literacy and not the absolute intake
• Less subject burden • Not suitable for people with
irregular meal pattern
• High staff cost and burden
Food frequency • Less subject burden • Relies on subject recall
questionnaires • Less staff cost and time burden • Not as quantifiably precise
• Does not alter eating behaviors • Requires literate population
• Captures habitual intake • Does not provide meal pattern
• Can be shorter and emphasis on foods information
rich in a specific nutrient or a specific • Bias with overestimation
group of foods, for example, fruits and consumption of good foods or
vegetables underestimation of bad foods
Benefits and Limitations of Traditional Self-Report Instruments 5

1.2.2 24-houR dietaRy Recall

The 24HR is a retrospective assessment method in which an interviewer prompts a respondent to
recall and describe all foods and beverages consumed during the previous 24 hours or in the past
day. The interview may be conducted face-to-face or by telephone (Buzzard et al. 1996; Casey
et al. 1999), and may be with paper and pencil, or computer assisted (Vereecken et al. 2008;
Arab et al. 2011). There is evidence of no significant differences in the dietary data obtained by
face-to-face 24-hour recalls compared to telephone 24-hour recalls (Brustad et al. 2003).
Well-trained interviewers are essential because much of the dietary information are collected by
asking investigative questions. Ideally, interviewers would be nutritionists; however, nonnutrition-
ists who have been trained in the use of a standardized instrument can be effective. All interviewers
should be well informed about foods available in the marketplace and about preparation practices,
including prevalent regional or traditional foods.
As a retrospective method, it relies on an accurate memory of intake, reliability of the respondent
not to under/misreport, and an ability to evaluate portion size, which is a limitation (Chapter 10). The
interview is often structured, usually with specific probes, to help the respondent remember all foods
consumed throughout the day. During the interview, the respondent may be encouraged to remember
eating and drinking events by time periods, for example, starting with on awakening or relating to day
time activities such as arriving at work. Probing is particularly valuable in collecting essential details
(e.g., how foods were prepared). It also enables exploration of items not initially reported, such as
common additions to foods (e.g., butter on toast) and eating episodes not firstly reported (e.g., snacks
and beverage breaks). In addition, the interviewer may use prompts to assist the respondent to esti-
mate portion sizes. A previous study showed that with interviewer probing, respondents reported 25%
higher dietary intakes than respondents did without interviewer probing (Campbell and Dodds 1967).
However, interviewers should use standardized neutral-probing questions in order to avoid leading the
respondent to specific answers when they really do not know or remember. 24-hour recalls are particu-
larly challenging in young children (Fisher et al. 2008) and the elderly (Tooze et al. 2007). A child’s
ability to provide a dietary recall noticeably rises after the age of eight years (Livingstone et al. 2003).
Once the 24-hour recall has been completed, foods and drinks are coded and analysis undertaken
similar to that described in a food intake record. Recording consumption for a single day is rarely
representative of an individual’s usual intake due to day-to-day variation. Repeat 24-hour recall, also
known as multiple recalls, can be used to assess a typical diet especially at an individual level. A sin-
gle 24-hour recall, however, is more suitable for measuring intake in a large group and estimating
group mean intakes. The number of recalls needed varies depending on the focus of the research,
variability of the population, and the nutrients of interest. For example, studies evaluating diet and
disease outcomes recommend 7–14 days depending on the nutrients (Hartman et al. 1990), whereas
four repeat 24-hour recalls were recommended as the most appropriate method of dietary assess-
ment in the UK Low Income Diet and Nutrition Survey (LIDNS) (Holmes et al. 2008a, b). In an
Australian study in adults, eight repeat 24-hour recalls were recommended to investigate the varia-
tion in macronutrient intake (Jackson et al. 2008). In the United States, an interviewer-administered
automated multiple-pass recall (AMPR), is the dietary assessment method used in National Health
and Nutrition Examination Survey (NHANES) (Raper et al. 2004; Subar et al. 2007) to assess the
diets of children and adults. The diet is evaluated with this tool over a period of three to five days.
The multiple-pass recall (MPR) is a staged approach to the dietary recall. The precise number of
stages or passes may differ between protocols, but they all monitor the pattern of a free and continu-
ous recall of intake, followed by detailed and probing questions about intake (including quantities
consumed) and concluding with a review of everything that was previously recalled.

1.2.2.1 Benefits and Limitations of 24-hour Dietary Recall

A benefit of this method is that when an interviewer applies the tool and records the responses,
literacy of the respondent is not required. However, for versions completed by the participant, poor
6 Advances in the Assessment of Dietary Intake

literacy can be a limitation. The immediacy of the recall period facilitates recall of foods and drinks;
however, the method does rely on memory that may challenge young children and the elderly. The
burden on the respondent is minimal, so the 24-hour recall method is useful across a wide range
of populations. The 24HR is frequently used in national surveys (Kweon et al. 2014), randomized
clinical trials, and cohort studies (Dauchet et al. 2007; Luke et al. 2011).
Furthermore, in contrast to the food record method, dietary recalls occur after the food has been
consumed, so there is likely to be less impact on dietary habits. Finally, 24HR can be conducted by
telephone or a web-based automated self-administered method (Thompson et al. 2015a) with mini-
mal differences in comparison with interviewer-administered recalls.
However, on the other hand, potential limitations of the 24-hour recall method include inaccura-
cies in the assessment of portion size and individual food intake for a wide range of reasons relating
to knowledge, memory, and the interview conditions. In addition, as a single observation provides
a poor measure of individual intake, so multiple days of recalls may be needed. Although a single
24-hour recall can be used to describe the average dietary intake of a population, multiple recalls
can improve precision (Blanton et al. 2006). Multiple days of recall inevitably increase cost and the
burden placed on the respondent (see summary in Table 1.1).

1.2.3 diet histoRy

The diet history is another common method used in epidemiological studies (Heitmann et al. 1995;
Van Staveren et al. 2002; Eiben et al. 2004; Rothenberg 2009) and clinical practice. To evaluate
individual long-term dietary intake, Burke established a dietary history method in 1947, which is
a detailed retrospective dietary assessment used to estimate a person’s typical food and/or nutrient
intake over a period of typically six months to one year. This method is furthermore used to deter-
mine the frequency and amount of food intake. However, it may not capture the entire intake of a
particular nutrient of interest as not all foods consumed are probed.
A dietary history is a structured interview method. The traditional Burke diet history included
three features: a comprehensive interview about usual pattern of consumption, a food list probing for
quantity and usual frequency of consumption, and a three-day dietary record (Burke 1947), which
either may not be used or may be replaced by a 24-hour recall. The detailed interview (that occasion-
ally contains a 24-hour recall) is the essential feature of the Burke dietary history, with the food fre-
quency checklist and the three-day diet record used as cross-checks of the history. Many variations
of the Burke method have attempted to determine the usual eating patterns for an extended period
of time, including type, frequency, and amount of foods consumed; many include a cross-check fea-
ture (Bloemberg et al. 1989). Highly expert professionals are required to collect information on the
participant’s usual diet using a detailed interview (approximately 90 minutes to complete). So, this
method is used more in clinical practice instead of research and epidemiological studies.

1.2.3.1 Benefits and Limitations of Diet History

The major benefit of the diet history method is its evaluation of meal patterns and details of food
intake rather than intakes for a short period of time (as in food records or 24HR), or for identifying
the frequency of food consumption. Details of the methods of preparation of foods can be useful in
better describing nutrient intake, such as frying versus baking, as well as exposure to other factors
in foods (e.g., salt and flavors).
When the information is collected as discrete meals, analyses of the combined effects of foods
eaten together are possible, such as effects on iron absorption of concurrent intake of tea. Although
a meal-based method often needs more time from the respondent than does a food-based method,
it may provide more cognitive support for the recall process. For example, the respondent may pre-
cisely report the total bread consumed by reporting bread typically eaten at each meal. Literacy is
not required for individuals providing a diet history. This method may cover usual diet in detail, so
only one interview is required for the specific time period.
Benefits and Limitations of Traditional Self-Report Instruments 7

However, respondents are asked to make many judgments about both the usual foods and the
amounts of those foods consumed. So, respondents may overreport good foods and underreport
intake of bad foods according to their perceptions. In addition, these subjective tasks may be dif-
ficult for many respondents. Burke cautioned that nutrient intakes estimated from these data should
be interpreted as relative rather than absolute. The meal-based approach is not useful for individu-
als who have no particular eating pattern and may be of limited use for individuals who graze (i.e.,
eat throughout the day rather than at defined mealtimes) or shift workers who have varied meal
patterns.
A further limitation of this method is reliance on the memory of the respondent that may result
in recall bias. This may be a particular issue for older individuals who may become fatigued and
unable to complete the interview in one session; a typical session lasts 60–90 minutes. All of these
limitations are also shared with the food frequency method.
Given the need for a trained interviewer, the approach tends to be expensive and vulnerable to
inconsistency in the exact method used. Poor standardization has resulted in difficulties in repro-
ducing studies, and in comparing between studies (see summary in Table 1.1).

1.2.4 Food FRequency questionnaiRe

The food frequency method interrogates respondents about their usual frequency of consumption
of each food from a list of foods for a definite period, and therefore aims to obtain habitual intake
(Zulkifli and Yu 1992; Willett 1998).
FFQs, generally, are designed to collect dietary information from larger populations (100 people
or more) and are normally self-conducted, though interviewer-conducted and telephone interview
are alternative approaches (Haraldsdóttir et al. 2001) (Chapter 4). The size of the food list may vary
according to the nutrients or foods under consideration. If a variety of different nutrients and energy
values are needed, the list of foods may be up to 150, while for specific, limited nutrients, the FFQ
may contain just a few food items.
Using an appropriate food list is an essential issue in this method (Block et al. 1986). The whole
range of an individual’s diet, which includes many different foods, brands, and preparation prac-
tices, cannot be fully captured with a finite, predetermined food list. Obtaining precise reports for
foods consumed both as single items and in mixtures is challenging.
FFQs usually deliver data on frequency, with minimal additional information about other com-
ponents, such as the methods of cooking, or how foods are combined in meals. To improve the
validity of the FFQ, researchers have developed a range of refinements, such as markers of season-
ality. FFQs designed to evaluate total diet usually list for more than 100 specific line items, which
take 30–60 minutes to complete. The degree of details sought may be inversely reflected in the
response rate, although this has not been noted by all (Johansson et al. 1997; Morris et al. 1998;
Subar et al. 2001).
A further refinement relates to gathering more detailed information about portion size in addition
to frequency of consumption via semiquantitative FFQs. In most circumstances, the purpose of an
FFQ is to obtain a rough estimate of total intakes during a designated time period. However, there is
a debate whether portion size inquiries should be included in FFQs. Frequency has been established
to be a greater contributor than serving size to the alteration in intake of most foods (Heady 1961);
hence, some researchers favor FFQs without the extra respondent burden of recording serving sizes
(Willett 1998). On the other hand, others report that including usual serving size for each food may
improve the performance of FFQs (Block et al. 1992).
The time period over which the inquiry relates is an important factor to consider. Some tools ask
about usual intakes during the past year (Rimm et al. 1992), but it may be asked about the past week
(Dunn et al. 2011) or months (Segovia-Siapco et al. 2007), subject to designed research conditions.
When investigating the previous year, the season in which the FFQ is administered may impact on
the overall results (Fowke et al. 2004).
8 Advances in the Assessment of Dietary Intake

Finally, it is important to consider how missing data will be treated, especially in self-administered
questionnaires. Zero values may be entered; having made the assumption that failure to answer
questions relates to foods that respondents rarely or never consume (Rimm et al. 1992). Imputation
of frequency values for unanswered questions is the other solution for this issue (Parr et al. 2008).
However, it is now unclear whether imputation improves FFQ analyses (Fraser et al. 2009).
As a tool designed to obtain the habitual dietary intake, FFQs have been used commonly in epi-
demiological studies evaluating relations between diet and disease. In this case the aim may be to
rank the intake of respondents relative to others, or as quantiles, as opposed to determining absolute
intake. Two well-known FFQs (Willett et al. 1985; Block et al. 1986) with some adaptations have
been used in many national studies (Lamb et al. 2007; Barclay et al. 2008).

1.2.4.1 Benefits and Limitations of Food Frequency Questionnaire

FFQ is a common tool to estimate usual dietary intake in large epidemiological studies due to the
lower cost and time burden of data collection and processing on respondents and investigators than
other dietary assessment methods. This tool may be self-administered via e-mail or the Internet that
makes it relatively easy to administer compared with other methods.
FFQ may be used to assess habitual consumption over an extended period of time without
impacting on eating behaviors. Semiquantitative portion-size estimates can be used to obtain abso-
lute nutrient intakes. This tool may also be used to collect data on a variety of foods, or designed
to be shorter with an emphasis on foods rich in a specific nutrient or a specific group of foods (e.g.,
fruits and vegetables).
On the other hand, FFQs have limitations, principally in terms of the measurement error (Prentice
et al. 2011). Many components of food intake are not measured, and the quantification of intake is
considered less accurate than recalls (Schatzkin et al. 2003), or records (Yang et al. 2010).
As this method relies on the memory of respondents attempting to estimate usual portion size,
the accuracy of the data may suffer due to highly variable portion sizes across eating events (Hunter
et al. 1988). On account of the inevitable error in the food-frequency approach, it is generally con-
sidered inappropriate to use FFQ data to estimate quantitative parameters, such as the mean and
variance, of a population’s usual dietary intake (Rimm et al. 1992; Carroll et al. 1996). Accordingly,
evidence has suggested that FFQ data might be combined with recall or record data to improve
estimated intakes (Haubrock et al. 2011; Carroll et al. 2012).
Bias may also be presented with respondents reporting eating good foods more often (overesti-
mation), or the consumption of bad foods less frequently (underestimation). In addition, a fairly high
grade of literacy and numeracy skills are necessary if self-administered, but interviewers can help
overcome this problem.
As mentioned, self-administered FFQs may not be completed fully, which may cause problems
with interpreting questions.
Due to variability in dietary habits and food composition in different areas, FFQs developed in
one region, country, or for a specific subpopulation are unlikely to be suitable for use in another
population. Critical to the process of developing a FFQ is that it is compared against other meth-
ods such as serial 24-hour recalls, food records, or biomarkers. Clearly the method is thus only as
accurate as alternative methods used in development, and against what it is compared (Shahar et al.
2003) (see summary in Table 1.1).

1.3 KEY ISSUES IN EVALUATING DIETARY INTAKE ASSESSMENT METHODS

A range of traditional methods of dietary assessment have thus been described and their respective
strengths and limitations considered. It is clear that there is no perfect method of assessing dietary
intake that can be viewed as a gold standard against which others can be compared. When com-
parisons are made, different outcomes are found (Bingham 1987; Freedman et al. 2014). However,
it is not known which result is closer to the true intake. In some individuals with a very varied diet
Another random document with
no related content on Scribd:
 The analysis of the first German shell indicated that the mustard
gas contained therein had been prepared by the method published by
Victor Meyer (1886) and later used by Clark (1912) in England. It was
natural, therefore, that attention should be turned to the large scale
operation of this method.
The following operations are involved: Ethylene is prepared by the
dehydration of ethyl alcohol. The interaction of hypochlorous acid
(HClO) and ethylene yields ethylene chlorhydrin, ClCH₂CH₂OH.
When this is treated with sodium sulfide, dihydroxyethyl sulfide forms,
which, heated with hydrochloric acid, yields dichloroethyl sulfide.
Chemically, the reactions may be written as follows:

CH₃CH₂OH = CH₂ : CH₂ + H₂O

CH₂ : CH₂ + HClO = HOCH₂CH₂Cl
2HOCH₂CH₂Cl + Na₂S = (HOCH₂CH₂)₂S + 2NaCl
(HOCH₂CH₂)₂S + 2HCl = (ClCH₂CH₂)₂S + 2H₂O
Without going into the chemistry of this reaction, which is
thoroughly discussed by Gomberg[18] (see also German Manufacture),
it may be said that this “procedure proved to be unsuitable for large
scale production” (Dorsey). As Pope remarks, “That he (the German)
should have been able to produce three hundred tons of mustard gas
per month by the large scale installation of the purely academic
method (of Meyer) constitutes indeed ‘a significant tribute to the
potentialities represented by the large German fine chemical
factories.’” It is true that a great deal of experimental work was carried
out by the Allies on this method, but further study was dropped as
soon as the Pope method was discovered.
The first step in advance in the manufacture of mustard gas was
the discovery that ethylene would react with sulfur dichloride. While
American chemists were not very successful in their application of this
reaction, either in the laboratory or the plant, it was apparently,
according to Zanetti, the only method used by the French (the only
one of the Allies that manufactured and fired mustard gas). The plant
was that of the Société Chimique des Usines du Rhone and was
started early in March, 1918, with a production of two to three tons a
day. In July it was producing close to twenty tons a day. The plant was
being duplicated at the time of the Armistice, so that probably in
December, 1918, the production of mustard gas by the dichloride
process would have reached about 40 tons. Zanetti points out,
however, that the process involved complicated and costly apparatus
and required considerable quantities of carbon tetrachloride as a
solvent. It is for this reason that the Levinstein process would have
been a tremendous gain, had the war continued.
About the end of January, 1918, Pope and Gibson, in a study of the
reaction originally used by Guthrie, found that the action of ethylene
upon sulfur chloride (S₂Cl₂) at 60° yielded mustard gas and sulfur:

2CH₂ : CH₂ + S₂Cl₂ = (CH₂ClCH₂)₂S + S

The reaction at this temperature caused the separation of sulfur;
this occurred after the product stood for some time or immediately if it
was treated with moist ammonia gas. While this process was put into
commercial operation, both in England and America, it offered
considerable difficulty from an operating standpoint. The sulfur would
often separate out and block the inlet tubes (ethylene). While it is
comparatively easy to remove the mustard gas from the separated
sulfur by decantation, a certain amount always remains with the sulfur.
It is almost impossible to economically remove this, and its presence
adds to the difficulty of removing the sulfur from the reactors; the men
engaged in this operation almost always become casualties.
 Fig. 29.—The Levinstein Reactor
as Installed at Edgewood Arsenal.

It was especially important, therefore, when Green discovered that,

if the reaction was carried out at 30°, the sulfur did not settle out but
remained in “pseudo solution” in the mustard gas (Pope) or as a loose
chemical combination of the monosulfide (mustard gas) with an atom
of sulfur (Green). This material has all the physiological activity of the
pure monosulfide, while the enormous technical difficulties of handling
separated sulfur are entirely obviated by this method of manufacture.
To carry out the reaction Levinstein, Ltd., devised the Levinstein
“reactor.” The apparatus is shown in Fig. 29. The process consists
essentially in bringing together sulfur chloride and very pure ethylene
gas in the presence of crude mustard gas as a solvent at a
temperature ranging between 30-35° C. A supply of unchanged
monochloride is constantly maintained in the reacting liquid until a
sufficiently large batch is built up. Then the sulfur monochloride feed is
discontinued and the ethylene feed continued until further absorption
ceases. By controlling the ratio of mustard gas to uncombined
monochloride, the reaction velocity is so increased that the lower
temperature may be used.
The product thus obtained is a pale yellow liquid which deposits no
sulfur and requires no further treatment. It is ready for the shell filling
plant at once. The obvious advantage of this method led to its
adoption in all American plants started for the manufacture of mustard
gas (Edgewood, Cleveland and Buffalo).

Ethylene
It was known from the work of certain French chemists that in the
presence of such a catalyst as kaolin, ethyl alcohol is dehydrated at an
elevated temperature to ethylene. The process as finally developed by
American chemists consisted essentially in introducing mixtures of
alcohol vapor and steam, in the ratio of one to one by weight, into an
8-inch iron tube with a 3-inch core, in contact with clay at 500-600° C.
The use of steam rendered the temperature control more uniform and
thus each unit had a greater capacity of a higher grade product. The
gaseous products were removed through a water-cooled surface
condenser. One unit of this type had a demonstrated capacity of 400
cubic feet per hour of ethylene, between 92 and 95 per cent pure,
while the conversion efficiency (alcohol to ethylene) was about 85 per
cent. The Edgewood plant consisted of 40 such units. This would have
yielded sufficient ethylene to make 40 tons of mustard gas per 24-hour
day.
The English procedure consisted in the use of phosphoric acid,
absorbed onto coke. An American furnace was designed and built
which gave 2,000 cubic feet per hour of ethylene, with a purity of 98 to
99 per cent. This furnace was not used on a large scale, because of
the satisfactory nature of the kaolin furnaces.
 Fig. 30.—Experimental Installation for the Production
of Ethylene by Kaolin Procedure.
Capacity 400-600 cu. ft. Ethylene per hr.

Sulfur Chloride
Since chlorine was prepared at Edgewood, it was logical that some
of this chlorine should be utilized in the preparation of sulfur chloride.
The plant constructed consisted of 30 tanks (78 inches in diameter
and 35 feet long), each capable of producing 20,000 pounds of
monochloride per day. The tanks are partially filled with sulfur and
chlorine passed in. The reaction proceeds rapidly with sufficient heat
to keep the sulfur in a molten condition. If the chlorine is passed in too
rapidly, the heat generated may be sufficient to boil off the sulfur
chloride formed. Hence water pipes are provided so that a supply of
cold water may be sprayed upon the tanks, keeping the temperature
within the proper limits.
 Fig. 31.—Row of Furnaces for the Preparation of
Ethylene.

In the manufacture of one ton of mustard gas, about one ton of

sulfur chloride and a little less than half a ton of ethylene (12,640 cubic
feet) are required.

German Method of Manufacture[19]

 Fig. 32.—Preparation of Ethylene at
Badische Anilin und Soda Fabrik. 60 units.

“Preparation of Ethylene—The gas was

prepared by passing alcohol vapor over aluminum
oxide at a temperature of 380° to 400°. The details of
the construction of one of the furnaces are given in
Figs. 32 and 33. The furnaces were very small and
sixty units were needed to furnish the amount of gas
required. The tubes containing the catalyzer were
made of copper and were heated in a bath of molten
potassium nitrate. It was stated that the catalyzer was
made according to the directions of Ipatieff, and that
its life was from 10 to 20 days. The gas produced
was washed in the usual form of scrubber. The yield
of ethylene was stated to be about 90 per cent of the
theoretical.
 Fig. 33.—Ethylene Production at
Badische Anilin und Soda Fabrik. 1 unit.

Fig. 34.—Chlorhydrin reaction kettle at

Badische Anilin und Soda Fabrik. 16 units.
 “Preparation of Ethylene Chlorhydrin—The
reaction was carried out in a cylindrical tank resting
on its side. The tank was furnished with a stirrer and
was insulated by means of cork in order to prevent
the transfer of heat from the atmosphere to the
inside. Enough chloride of lime was introduced into
the tank to furnish 500 kg. of available chlorine,
together with 5 cu. m. of water. At first, about 20 cu.
m. of carbon dioxide were led into the mixture, next
ethylene, and later carbon dioxide and ethylene
simultaneously. The rate of absorption of ethylene
was noted and when it slackened, more carbon
dioxide was added. Fuller details as to the addition of
the two gases were not given as it was stated that it
was a matter of judgment on the part of the workman
who was carrying out the operation. The reaction
should be carried out at as low a temperature as
possible, but it was found impossible to work below
5° with the apparatus employed in this factory. The
temperature during the reaction varied between 5°
and 10°. In order to maintain this temperature, the
solution was constantly pumped from the apparatus
through a coil which was cooled by brine. When
ethylene was no longer absorbed and there was an
excess of carbon dioxide present, the solution was
tested for hypochlorous acid. The time required for
the introduction of ethylene was between 2 and 3 hrs.
“The contents of the apparatus were passed
through a filter press by means of which the calcium
carbonate was removed. The solution thus obtained
contained from 10 to 12 per cent of ethylene
chlorhydrin. It was next distilled with steam and a
distillate collected which contained between 18 and
20 per cent of chlorhydrin. The yield of chlorhydrin
was from 60 to 80 per cent of that calculated from the
ethylene used.
Fig. 35.—Mustard Gas Manufacture at Leverkusen.
Layout for Chlorination of Thiodiglycol.

“Preparation of Dihydroxyethylsulfide—To
prepare the hydroxysulfide, the theoretical quantity of
sodium sulfide, either in the form of the anhydrous
salt or as crystals, was added to the 18 to 20 per cent
solution of chlorhydrin. After the addition of the
sulfide, the mixture was heated to about 90° to 100°.
It was then pumped to an evaporator, and heated
until all the water was driven off. The glycol was next
filtered from the salt which separated, and distilled in
a vacuum. The yield of glycol was about 90 per cent
of the theoretical, calculated from the chlorhydrin.
“Preparation of Dichlorethylsulfide—The
thiodiglycol was taken from the rail to two large
storage tanks and thence drawn by vacuum direct to
the reaction vessel. Each reaction vessel was placed
in a separate cubicle ventilated both from above and
below and fitted with glass windows for inspection.
The vessels themselves were made of 1¼ in. cast
iron and lined with 10 mm. lead. They were 2.5 m.
high and 2.8 m. in diameter. These tanks were
jacketed so that they could be heated by water and
steam, and the reaction was carried out at 50°. The
hydrochloric acid coming from the main pipe was
passed through sulfuric acid so that the rate could be
observed, and passed in by means of 12 glass tubes
of about 2 cm. diameter. The rate of flow was
maintained at as high a rate as possible to procure
absorption. The vapors from the reaction were led
from the vessel through a pipe into a collecting room,
and then through a scrubber containing charcoal and
water, through a separator, and then, finally, into the
chimney. These exhaust gases were drawn off by
means of a fan which was also connected with the
lower part of the chamber in which the reaction
vessels were set, so that all the gases had to pass
through the scrubber before going to the chimney.
When the reaction was completed, the oil was
removed by means of a vacuum, induced by a water
pump, into a cast iron washing vessel.
“The hydrochloric acid layer was removed to a
stoneware receiver, also by vacuum. A glass enabled
the operator to avoid drawing oil over with the acid.
The pan was fitted with a thermometer to the interior
as well as to the jacket. For testing the material
during reaction, provision was made for drawing
some up by vacuum to a hydrometer contained in a
glass funnel. The final test at this point read 126° Tw.
Another portion could be drawn up to a test glass and
hydrochloric acid passed through it in full view. A float
contained in a glass outer tube served to show the
level of the liquid in the vessel. The pans in which the
operation is carried on, as well as those employed for
washing and distilling the product, were of a standard
pattern employed in many other operations in the
works.
“The washer consisted of a cast iron vessel, lead
lined, and was 2.5 m. in diameter, 2 m. deep, and
fitted with a dome cover and stirring gear. Lead pipes
served for the introduction of sodium carbonate
solution and water. Similar pipes were fitted for
drawing these off by means of a vacuum. A manhole
on the cover, with a flat top, was fitted with light and
sight glasses to which were fitted a small steam coil
for keeping them clear. The washed oil is drawn off to
a distillation still, which is a cast iron vessel
homogeneously lead coated, 1.5 m. in diameter and
2 m. deep, fitted with a lead heating coil and
connected through a spiral lead condenser and
receiver to a vacuum pump. The water is distilled
from the oil at a pressure of from 62 to 70 mm.
absolute pressure. When dried, the oil is sent by
vacuum to a mixing vessel, similar in most respects
to the washing vessel, in which it is mixed with an
appointed quantity of solvent, which, in this factory,
was usually chlorobenzene but occasionally carbon
tetrachloride. The relative quantities varied with the
time of year, and instructions were sent from Berlin
on this point. Thence the mixture was passed to a
storage tank and into tank-wagons.”

American Method of Manufacture

 The Chemical Warfare Service investigated carefully the three
methods (German, French, and English) and finally adopted the
Levinstein process. The following discussion is taken from a report
originally made during construction, Sept., 1918.
The Levinstein reactor consisted of a jacketed and lead-lined
vessel or steel tank, 8 feet 5 inches in diameter and 14 feet tall. The
reactor contained 1,400 feet of lead pipe (outside diameter 2⅜
inches), made up into five coils, giving a total cooling surface of 1,200
square feet. The finished charge of such a reactor is 12 tons.
Ethylene was introduced through lead injectors, of which there
were 16, each suspended from its own opening in the top and hanging
so that the end of the injector tube was 12 inches from the bottom of
the reactor. The nozzle of the injector was ³/₁₆ inch outside diameter
and ethylene was introduced through it at 40 pounds pressure.
In starting the reaction, enough sulfur chloride was introduced into
the reactor to cover the central nozzles. Ethylene was now introduced,
and as the reaction proceeded sulfur chloride was added in sufficient
quantities to give a high rate of reaction. Brine or cold water was
introduced through the cooling coils and jacket to keep the reacting
temperature at 35° C.
When the charge was completed, the ethylene was turned off so
that only a small amount bubbled through the nozzles and the charge
syphoned off to the settling tank. These were constructed of iron, 8
feet in diameter and 19 feet tall. They were provided with iron coils by
which the liquid may be cooled down, or the sulfur, which precipitates
in the bottom, melted. The tank was large enough to hold six complete
charges of mustard gas and all the sulfur from these charges was
allowed to accumulate before removal of the sulfur. The supernatant
mustard gas was drawn off from above this sulfur to storage tanks.
Among the factors which influence the reaction are the following:
A temperature of over 60° C. in lead will decompose the product
slowly when sulfur chloride is present.
The presence of iron decomposes the product rapidly at a
temperature of 50° C. and probably at a considerably lower
temperature.
The purity of the product is dependent upon the time of reaction.
There is always a slow reaction between the mustard gas and sulfur
chloride, and because of this the charge should be completed in 8
hours.
In general the more sulfur that comes out of the solution, the better
is the product. Temperature has a marked effect on the separation of
sulfur. In order to entirely remove the sulfur from the product it was the
custom to increase the temperature at the close of the reaction from
55° to 70° C. This, however, caused plugging of the lines and the
reactor.

Properties
Dichloroethylsulfide (mustard gas) is a colorless, oily liquid, which
has a faint mustard odor. The pure material is said to have an odor
very suggestive of that of water cress. While the odor is more or less
characteristic, it is possible to have extremely dangerous amounts of
the gas in a neighborhood without being detected through its odors. It
still seems to be an open question whether mustard gas paralyzes the
sense of smell. One can find opinions on both sides.
Mustard gas boils at 215°-217° C. at atmospheric pressure, so that
it is at once seen to be a very persistent gas. It distills without
decomposition at this temperature but is best purified by vacuum
distillation, or by distillation with steam. A still for the vacuum
distillation of mustard gas has been described by Streeter.[20]
Mustard gas melts, when pure, at 13° to 14° C. (The ordinary
summer temperature is 20°-25° C.). The ordinary product, as obtained
from the “reactor,” melts from 9°-10° C. In order that the product in the
shell might be liquid at all temperatures, winter as well as summer, the
Germans added from 10 to 30 per cent of chlorobenzene, later using a
mixture of chlorobenzene and nitrobenzene and still later pure
nitrobenzene. Carbon tetrachloride has also been used as a means of
lowering the melting point. Many other mixtures, such as chloropicrin,
hydrocyanic acid, bromoacetone, etc., were tested, but were not used.
The effect on the melting point of mustard gas is shown in the
following table:

Melting point of Mustard gas Mixtures

Per
Carbon
Cent Chloropicrin Chlorobenzene
Tetrachloride
Added
0 13.4° C. 13.4° C. 13.4° C.
10 9.8 8.4 9.8
20 6.3 6.4 6.6
30 2.6 -1.0 3.1
The mustard gas as finally made by the United States contained
about 17 to 18 per cent sulfur in solution. The gas was then put in
shell and fired without the addition of any solvent. In actual practice
this impure product seemed even more powerful in causing casualties
than equal quantities of the pure mustard gas. Accordingly no
redistilling as originally contemplated was actually carried out.
The specific gravity of mustard gas at 20° is 1.2741. The solid
material has a slightly higher value, being 1.338 at 13°. Its vapor
pressure at room temperature is very low; at 20° this value has been
found to be about 0.06 mm. of mercury.
Mustard gas is practically insoluble in water, less than 0.1 per cent
forming a saturated solution. The reports that a 1 per cent solution
could be obtained did not consider the question of hydrolysis. Mustard
gas is freely soluble in all the ordinary organic solvents, such as
ligroin, alcohol, ether, chloroform, acetic acid, chlorobenzene, etc. In
case the solvent is miscible with water, dilution throws out the product
as an oil.

Chemical Properties
Mustard gas is very slowly decomposed by water, owing to its very
slight solubility. The products are dihydroxyethylsulfide and
hydrochloric acid:

(ClCH₂CH₂)₂S + 2H₂O = (HOCH₂CH₂)₂S + 2HCl

Certain sulfonated oils accelerate the rate of hydrolysis, both by
increasing the rate of solution and the solubility of the mustard gas.
Alkalies also increase the rate of hydrolysis. Oxidizing agents destroy
mustard gas. This reaction was made use of practically in that solid
bleaching powder was early introduced as a means of destroying
mustard gas in the field. (Fig. 9.)
Chlorinating agents (chlorine, sulfur dichloride, etc.) rapidly
transform mustard gas into an inactive (non-blistering) substance.
Sulfur dichloride was a valuable reagent in both laboratory and works
in “cleaning up” mustard gas. This reaction also explains why the early
attempts to prepare mustard gas by the interaction of ethylene and
sulfur dichloride were unsuccessful. Mustard gas is probably formed,
but is almost immediately chlorinated by the excess of sulfur
dichloride. Sulfur chloride on the other hand has no effect on mustard
gas. Chloramine-T and Dichloramine-T (the valuable therapeutic
agents introduced by Dakin and Carrel for treatment of wounds) also
react with mustard gas. For this reason they were advocated as
treatment for mustard gas burns. But as we will see later, they were
not altogether successful.

Detection
At first the only method of detecting mustard gas was through the
sense of smell. It was then believed that concentrations which could
not be detected in this way were harmless. Later this proved not to be
the case, and more delicate methods had to be devised. In the
laboratory and in the field these tests were not very satisfactory,
because most of them depended upon the presence of chlorine, and
the majority of the war gases contained chlorine or one of the other
halogens. The Lantern Test depended upon the accumulation of the
halogen upon a copper gauze and the subsequent heating of the
gauze in a Bunsen flame. This test could be made to detect one part
of mustard gas in ten million parts of air. Another field detector devised
by the Chemical Warfare Service consisted in the use of selenious
acid. Here again the lack of specificity is apparent, for while certain
halogen compounds did not give the test, arsine and organic
arsenicals gave a positive reaction and often in a shorter time than
mustard gas.

Fig. 36.—Field Detector for Mustard Gas.

The Germans are said to have had plates covered with a yellow
composition which had the property of turning black in the presence of
mustard gas. These plates were lowered into the bottom of recently
captured trenches and if, after a few minutes, they turned black, the
presence of mustard gas was suspected. It is also stated that the
characteristic yellow paint on the olive of the mustard gas shell had
the same composition, and was useful in detecting leaky shell.
According to a deserter’s statement, however, reliance upon this test
resulted in casualties in several instances.
A white paint has also been reported which turned red in the
presence of mustard gas. This color change was not characteristic, for
tests made by our Army showed that other oils (aniline, turpentine,
linseed) were found to produce the same effect.
 The Chemical Warfare Service was able to develop an enamel and
an oil paint which were very sensitive detectors of mustard gas. Both
of these were yellow and became dark red in contact with mustard
gas. The change was practically instantaneous. The enamel consisted
of chrome yellow as pigment mixed with oil scarlet and another dye,
and a lacquer vehicle, which is essentially a solution of nitrocellulose
in amyl acetate. One gallon of this enamel will cover 946,500 sq. cm.,
or a surface equivalent to a band 3 cm. wide on 12,500 seven cm.
shell.
The paint was composed of a mixture of 50 per cent raw linseed oil
and 50 per cent Japan drier, with the above dye mixture added to the
required consistency. In contact with liquid mustard gas, this changes
to a deep crimson in 4 seconds. Furthermore, in contact with
arsenicals, this paint changes to a color varying from deep purple to
dark green, the color change being almost instantaneous and very
sensitive, even to the vapors of these compounds. Other substances
have no effect upon the paint.
For field work, however, nothing was found equal to the trained
nose, and it is questionable if any of the mechanical means described
will be used in the field.

Physiological Action
One of the most interesting phases of mustard gas is its peculiar
physiological action. This has been studied extensively, both as relates
to the toxicity and to the skin or blistering effect.

Toxicity
When one considers the high boiling point of mustard gas, and its
consequent low vapor pressure, he is likely to conclude that such a
substance would be of comparatively little value as a toxic or poison
gas. While it is true that an important part of the military value of
mustard gas has been because of its vesicant properties, the fact still
remains that it is one of our most toxic war gases. The following
comparison with a few of the other gases indicates this:
 Mg. per Liter
Mice Dogs
Mustard gas 0.2 0.05
Phosgene 0.3 ···
Hydrocyanic acid 0.2 0.1
Chloropicrin 1.5 0.8
··· 3.0
When an animal is exposed to the vapors of mustard gas in high
concentration, it subsequently shows a complexity of symptoms, which
may be divided into two classes:
(1) The local effects on the eyes, skin and respiratory tract. These
are well recognized and consist mainly of conjunctivitis and superficial
necrosis of the cornea; hyperemia, œdema and later, necrosis of the
skin, leading to a skin lesion of great chronicity; and congestion and
necrosis of the epithelial lining of the trachea and bronchi.
(2) The systemic effects due to the absorption of the substance into
the blood stream, and its distribution to the various tissues of the body.
The most striking observation about the symptoms of mustard gas
poisoning is the latent period which elapses after exposure before any
serious objective or subjective effects are noted. The developments of
the effects are then quite slow, unless very high superlethal doses
have been inhaled.
At first it was a very serious question whether or not the temporary
blindness resulting from mustard gas would not be permanent. Later,
as the depth and seriousness of some of the body burns became well
known, it was a seven-day wonder that no permanent blindness
occurred.
The reason seems to be largely a mechanical one. The constant
winking of the eyelids apparently washes the mustard gas off the
eyeball and carries it away so that not enough remains to burn to the
depth necessary to cause permanent blindness.
 Due to the very slight concentrations ordinarily encountered in the
field, resulting from a very slow rate of evaporation, the death rate is
very low, probably under 1 per cent among the Americans gassed with
mustard during the war.
If, on the other hand, the gas be widely and very finely dispersed
by a heavy charge of explosive in the shell, the gas is very deadly. In
such cases the injured breathe in minute particles of the liquid and
thus get hundreds of times the amount of gas that would be inhaled as
vapor. This so-called “high explosive mustard gas shell” was a
German development in the very last months of the war. Its effects
were great enough to make it certain that in the future large numbers
of these shell will be used.
The similarity of the symptoms and pathological effects after the
inhalation of large amounts of the vapor and those following an
injection of an olive oil or water solution of mustard gas led Marshall
and his associates to conclude that in high concentrations mustard
gas is absorbed through the lungs. A further bit of evidence consists in
the isolation of the hydrolysis product, dihydroxyethylsulfide, in the
urine of animals poisoned by inhalation of mustard gas. This product is
not toxic and is not responsible for the effects of mustard gas.
Hydrochloric acid, however, does produce very definite effects upon
the animal and may cause death.
From these facts Marshall[21] has proposed the following
mechanism of the action of mustard gas:
“Dichlorethylsulphide is very slightly soluble in
water and very freely soluble in organic solvents, or
has a high lipoid solubility or partition coefficient. It
would, therefore, be expected to penetrate cells very
readily. Its rapid powers of penetration are practically
proven by its effects upon the skin. Having
penetrated within the living cell, it would undoubtedly
hydrolyze. The liberation of free hydrochloric acid
within the cell would produce serious effects and
might account for the actions of dichlorethylsulphide.
To summarize, then, the mechanism of the action of
dichlorethylsulphide appears to be as follows: