Anthrop_Nutritional-Assessment.pptx

Nutritional Assessment:
Anthropometric
Methods
EDZELL M. ARCINUE, RND

Anthropometric
Assessment
- Includes measuring the size, weight,
compositions and proportions of the human
body to assess their nutritional status
- measurements of the variations of the
physical dimensions and the gross
of the human body at different age levels and
degrees of nutrition.

Anthropometric Assessment
Widely used for nutritional
assessment
Can be used in determining
chronic imbalances in
protein and energy intake
Diagnose failure and thrive
and overnutrition
Used in targeting in
nutrition intervention
through screening

Anthropometry
Body Size
Body Composition
Body Fat
Fat-free Mass

Technical Error in Measurement
The square root of the
measurement error
variant
Age dependent and
related to the
anthropometric
characteristics of the
study group

Technical Error in Measurement

Head Circumference
Should use a narrow, flexible, non-stretch tape made of fiber glass or steel
about 0.6cm wide
The subject should stand with the left side facing the measurer, with arms
relaxed and legs apart.
The subject must look straight ahead so the line of vision is perpendicular to
the body and the Frankfurt Plane is horizontal.
The tape is placed just above the supraorbital ridges covering the most
prominent part of the frontal bulge and over the part of the occiput that
gives the maximum circumference.
Measurements are made to the nearest millimeter.

Movable
footboard
Fixed
headboard

a. Place the measuring board on a hard flat
surface
b. The assistant kneels with both knees
behind the base of the board if it is on
the ground or floor

c. The measurer kneels on the right side
of the child so that you can hold the
foot piece with your right hand

d. With the mother’s help, lay the child
on the board by supporting the back of
the child’s head with one hand & the
trunk of the body with the other hand

e. Ask the mother to kneel close on the
opposite side of the board facing the
measurer as this will help to keep the
child calm

f. The assistant will cup his/her hands over the
child’s ears. With your arms
comfortably straight,
place the child’s head
against the base of the
board so that the child is
looking straight up.

The child’s line of sight should be
perpendicular to the ground. Your head
should be straight over the child’s head.
Look directly into the child’s eyes.

g. Make sure the child is lying flat & in the center of
the board.
Place your left hand on the child’s shins (above the
ankles) or on the knees.
Press them firmly against the board.
With your right hand, place the foot piece firmly
against the child’s heels.

h. Check the child’s position. Repeat any steps as
necessary.
i. When the child’s position is correct, read & call out
the measurement to the nearest 0.1 cm.
Remove the foot piece & release your left hand
from the child’s shins or knees.

j. Immediately release the child’s head, record
the measurement, & show it to the
measurer.

a. Place the measuring board on a
hard flat surface against a wall,
table, tree, staircase, etc.
Make sure the board is not
moving.

b. Ask the mother to remove the child’s shoes &
accessories that would interfere with height
measurement.
Ask her to walk the child to the board & to
kneel in front of the child.

c. The assistant of the measurer will kneel with
both knees on the right side of the child.
d. The measurer will kneel on her/his right knee
on the child’s left side. This will give the
measurer maximum mobility.

e. Place the child’s feet flat & together in
the center of & against the back &
base of the board/wall.

 Place your right hand just above the child’s ankles on
the shins, your left hand on the child’s knees & push
against the board/wall.
Make sure the child’s legs are straight & heels &
calves are against the board/wall.

f. Tell the child to look straight ahead at the mother
who should stand in front of the child.
Make sure the child’s line of sight is level with the
ground.
Place your open left hand under the child’s chin.
Gradually close your hand.
Do not cover the child’s mouth or ears.

 Make sure the shoulders are level, hands are at the
child’s side, & head, shoulder blades & buttocks are
against the board/wall.
With your right hand, lower the headpiece on
top of the child’s head, making sure the
headpiece pushes through the child’s hair.

g. Check the child’s position.
Repeat any steps as necessary.

h. When the child’s position is correct, read
& call out the measurement to the nearest
0.1 cm.
Remove the headpiece from the child’s
head and your left hand from the child’s
chin.

i. Immediately record the measurement
and show it to the measurer.

Knemometry
The measurement of knee height in children
Uses either knemometer or portable knee
height measuring device which can be used to
measure knee height in children >3y who are
able to sit quietly and cooperate; otherwise,
use a mini-knemometer.

Knemometer
 first developed in 1971 by Valk, and modified in
1983 to improve its accuracy
enables the distance between the heel and knee
of the right leg-termed the lower leg length--of a
sitting child to be estimated with a technical error
of the measurement (TEM of 0.09-0.16 mm
(Hermanussen, 1988).

Knemometer
To take the measurement, the child is asked to sit on the chair. The
sitting height (A) and the chair back (B) and chair position can be
adjusted. The foot of the child is placed on the foot rest (C) and the
angle and the length of the foot are recorded. The sitting position
of the child is standardized by recording the following:
• sitting height of the child
• distance between the chair and the measuring board
• individual sitting position of the child (i.e.. distance between the
lateral condyle (X] and the back of the chair [B]).

Knemometer
Next, the measuring board
(D) is lowered the maximum
distance that can be reached
during the movements of the
child's knee.
Children should be lightly
dressed when these
measurements are taken.

Knee Height in Adults
highly correlated with stature and may be
used to estimate height in persons with severe
spinal curvature or who are unable to stand
measured with a caliper consisting of an
adjustable measuring stick with a blade
attached to each end at a 90° angle

Recumbent knee height is measured on the left leg, which is bent at
the knee at a 90° angle, while the subject is in a supine position.
One of the blades is positioned under the heel of the left foot and the
other is placed over the anterior surface of the left thigh above the
condyles of the femur and just proximal to the patella.
The shaft of the caliper is held parallel to the shaft of the tibia, and
gentle pressure is applied to the blades of the caliper.
Some of the knee-height calipers are equipped with a locking
mechanism to retain the measurement after removing the caliper from
the leg.

At least two successive measurements should be
made, and they should agree within 5 mm; the
mean is then calculated. Details for measuring knee
height in elderly persons seated in wheel chairs are
given in WHO (1995a).
Formulae are used to estimate stature from knee
height.

Knee
Height in
Adults
Knee height should only be used only for individuals for whom a direct
measurement of stature is not possible, or is likely to be inaccurate because of
flexions or other skeletal deformities.

Arm Span
highly correlated with stature and, hence, can
be used as an alternative measurement when
actual height cannot be used
useful for assessing retrospective stature at
young adulthood - that is stature prior to any
age-associated loss in the elderly -rather than
the current (reduced) height.

Arm Span
The measurement of arm span is easier if
carried out against a flat wall to which is
attached a fixed marker board at the zero
end of a horizontal scale.
Sliding on the scale is a vertical movable
arm. The horizontal scale should be
positioned so that it is just above the
shoulders of the subject.
Two examiners are needed to measure
arm span: one is at the fixed end of the
scale; the other positions the movable arm
and takes the readings.

Arm Span
The individual should stand with feet together, back against the wall, with the arms extended
laterally in contact with the wall, and with the palms facing forward. The arms should be kept at
shoulder height and outstretched maximally.
The measurement is taken when the tip of the middle finger (excluding the fingernail) of the
right hand is kept in contact with the fixed marker board, while the movable arm is set at the tip
of the middle finger (excluding the fingernail) of the left hand. Two readings are taken for each
measurement, which is recorded to the nearest 0.1 cm (Lohman et al., 1988).
Arm span is difficult to measure in non-ambulatory elderly persons and in individuals with
significant chest and spinal deformities.

Weight in Infants and
Young Children
A suspended scale and a weighing sling may be used for
weighing infants and children < 2 y.
They should be weighed naked or with the minimum of
clothing.
After slipping the subject into the sling, the weight is
recorded as soon as the indicator on the scale has stabilized.

 Weight gain in
children is an
indicator of growth.
 The most common
method of measuring
growth especially
among children is
through weighing.

Weighing scale
with weighing
pants
Beam Balance Infant Beam Balance

Hooks complete and
in good condition

Needle or
pointer moving
freely

Weighing pants
clean & without
a tear

Rope, strong, long
enough, & tied well

 Act of checking & adjusting the
weighing scale within the possible &
allowable error.
 It is important to:
• make sure that scale is within
tolerable limits of accuracy
• detect deterioration beyond the
tolerable levels of accuracy

 Calibration using standard test
weights
 Calibration using improvised
weight tests

Calibration using
“improvised test
weights”

Return
Demonstration
on Calibration

Hang the scale from a tree
branch, ceiling beam or pole.
Attach the empty weighing pants
to the hook of the scale, adjust
the scale to zero, and then
remove from the scale.

Check if the face or dial of
the scale is at eye level,
not lower or higher.

Check if the child is barefoot,
in minimum clothing and with
empty pockets.
Ask mother or someone to
hold the child.

Put the measurer’s hands
through leg holes.
Gently pull legs through the
leg holes making sure that
the strap is in front of the
child.

Put arms around the child
and attach the strap of the
basket/sling to the hook of
the scale and allow the
child to hang freely.
Check the child’s position.
Make sure the child is not
touching anything.

Hold the scale and read the
weight at eye level to the
nearest 0.1kg.
Read the measurement
when the scale needle is not
moving & record data.

Put arms around the child and
gently lift the child by the
body.
Remove the strap from the
scale.

Give child to mother or
caregiver.
Remove the weighing pants.

Place the platform scale
firmly on a level surface.
Let the child stand at the
center of the scale platform
without touching anything,
barefoot in light/minimum
clothing, with empty pockets.

When the child is
reasonably still,
measure the weight &
record the reading to
the nearest 0.1kg.

Using the beam balance
scale and following the
correct weighing procedure,
obtain the child’s weight by
weighing the mother and the
child together

Then, weigh the mother
alone.
Subtract the weight of the
mother from the weight of
mother and child to get the
child’s weight.
Record the weight to the
nearest 0.1kg.

Weight in Infant and Children
Alternatively, a pediatric scale with a pan may be used. Care
must be taken to ensure that the infant is placed on the pan
scale so the weight is distributed equally on each side of the
center of the pan.
 Once the infant is lying quietly, weight is recorded to the
nearest 10 g.
If there is no alternative, the mother and subject can be
weighed together, and then the mother alone, using a beam
balance or battery-operated precision electronic scales.
The subject's weight can then be calculated by subtraction.

Weight in Older Children
and Adults
The measurement of weight in older children and
adults should be done preferably after the bladder has
been emptied and before a meal.
A beam balance with nondetachable weights should
be used, where possible. Unfortunately, beam balances
tend to be heavy and bulky and therefore unsuitable
for field use. In such cases, a spring balance or,
preferably, electronic scales can be used.

and Adults
The balance should be placed on a hard, flat surface (not
carpet) and checked and adjusted for zero-balance before each
measurement.
The subject should stand in the center of the platform and look
straight ahead, standing unassisted, relaxed but still, and
preferably nude.
If nudity is not possible, the subject can wear light
underclothing or a paper examination gown, and the weight of
these garments should be recorded for later subtraction;
standard corrections for clothing should not be used.

and Adults
The presence of visible edema should also be
recorded. Body weight should be recorded to the
nearest 0.1 kg.
Again, the time at which the measurement is
made should be recorded because diurnal
variations in weight occur.

and Adults
The balance should be calibrated with a set of
weights, both regularly throughout the year and
whenever it is moved to another location.
Special equipment, such as a movable
wheelchair balance beam scale or bed scales, is
needed for weighing nonambulatory persons.

and Adults
Estimates of weight for the U.S. elderly
population can be derived from calf circumference
(calf circ), knee height (knee ht), mid-upper-arm
circumference (MUAC), and subscapular skinfold
(subscap), using equations developed by Chumlea
et al. (1989).

Elbow Breadth
 A good measure of skeletal dimensions and,
hence, frame size.
The measure is less affected by adiposity than
many other anthropometric dimensions and is
highly associated with lean body mass and muscle
size
Elbow breadth is measured as the distance
between the epicondyles of the humerus.

Elbow Breadth
The right arm is raised to the horizontal and the
elbow is flexed to 90°, with the back of the hand
facing the measurer.
The measurer then stands in front of the subject
and locates the lateral and medial epicondyles of the
humerus.
The two blades of a flat-bladed sliding caliper are
applied to the epicondyles, with the blades pointing
upward to bisect the right angle formed at the
elbow.

Elbow Breadth
Care must be taken to ensure that the
caliper is held at a slight angle to the
epicondyles and that firm pressure is
exerted to minimize the influence of soft
tissue on the measurement.
The latter is taken to the nearest
millimeter

Growth Indices
The correct interpretation of anthropometric measurements
requires the use of anthropometric indices.
They are usually calculated from two or more raw
anthropometric measurements. In the simplest case the
indices are numerical ratios such as weight/(height)? (kg/m2).
Combinations such as weight-for-age, height-for-age, and
weight-for height are more complex
These latter indices are not ratios and, to avoid confusion
with numerical ratios, should not be written as
"wt/age,"ht/age” and "wt/height."

Growth Indices
Combinations such as weight-for-age are expressed, instead, as Z-scores, percentiles,
or percentage of the median, relative to appropriate reference data.
They can then be used to compare an individual or a group with a reference
population. Deficits in one or more anthropometric indices of body size are frequently
regarded as evidence of malnutrition.
The influence of nutrition and health on indices of body size depends on the index and
the circumstances, and thus it may vary across or within populations.

Growth Indices: Head Circumference-
for-Age
can be used as an index of chronic protein-energy deficiency for children < 2 y.
Chronic malnutrition during the first few months of life, or intrauterine growth
retardation, may hinder brain development and result in an abnormally low head
circumference.
 Beyond 2 y, growth in head circumference is slow and its measurement is no longer
useful. Head circumference-for-age is not sensitive to less extreme malnutrition.
Certain non-nutritional factors, including some diseases and pathological conditions,
genetic variation, and cultural practices such as binding of the head during infancy, as well
as a difficult or forceps-assisted delivery at birth, may also influence head circumference.

Growth Indices:
Head
Circumference-
for-Age

Growth Indices: Weight-for-Age
Weight-for-age reflects body mass relative to chronological age. Low weight-for-
age is described as "lightness" and reflects a pathological process referred to as
"underweight," arising from gaining insufficient weight relative to age, or losing
weight.
Because of its simplicity and the availability of scales in most health centers in
low-income countries.
Need to use DOB of children in age-in-months

Growth Indices: Weight-for-height
measures body weight relative to height. Low weight-for-height in children is
described as "thinness" and reflects a pathological process referred to as
"wasting”.
It arises from a failure to gain sufficient weight relative to height or from losing
weight. High weight-for-height in children is termed "overweight“ and arises from
gaining excess weight relative to height or from gaining insufficient height relative
to weight.

Growth Indices: Height-for-Age
Height-for-age is a measure of achieved linear growth that can be
used as an index of past nutritional or health status. Low height-for-
age is defined as "shortness" and reflects cither a normal variation or a
pathological process involving failure to reach linear growth potential.
The outcome of the latter process is termed "stunting," or the
gaining of insufficient height relative to age.

Growth Indices: Weight Change
Changes in body weight do not provide any information on the relative changes among these
components.
In normal adults, there is a tendency to increased fat deposition with age, concomitant with a
reduction in muscle protein. Such changes are not evident in body weight measurements but can be
seen by determining either body fat or the fat-free mass. In healthy persons, the daily variations in body
weight are generally small (i.e., less than ~0.5 kg). In conditions of acute or chronic illness, however,
negative energy-nitrogen balance may occur as the body can use endogenous sources of energy
(including protein) as fuel for metabolic reactions.
Consequently, body weight declines in conditions of total starvation, the maximal weight loss is
approximately 30% of initial body weight, at which point death occurs.
In chronic semistarvation, body weight may decrease to approximately 50%-60% of ideal weight.

Growth Indices: Weight Change
Body weight can only be used to assess the severity of undernutrition in subjects with relatively
uncomplicated, non-edematous forms of semistarvation.
In disease conditions in which edema, ascites (fluid in the abdominal cavity), dehydration,
diuresis, massive tumor growth, and organomegaly occur, or in obese patients undergoing rapid
weight loss, body weight is a poor measure of body energy-nitrogen re-serves. In such conditions, a
relative increase in total body water, for example, may mask actual weight loss that results from
losses of fat or skeletal muscle.
Massive tumor growth may also mask losses of fat and muscle tissue, which may occur during
severe under-nutrition. Hence, additional anthropometric measurements (e.g., mid-upper-arm
circumference and triceps skinfold thickness) should be taken to obtain more information on the
origin of any change in body weight (Heyms-field et al., 1984).

BMI (Quetelet’s Index) in Adults
Weight to height ratios indicate body weight in relation to
height and are particularly useful for providing a measure of
overweight and obesity in adult populations.
It is now used extensively internationally to classify
overweight and obesity in adults.
Body mass index is relatively unbiased by height and
appears to correlate reasonably well with laboratory-based
measures of adiposity in most younger and older adults

BMI (Quetelet’s Index) in Adults
BMI is employed in large-scale nutrition surveys and epidemiological studies as a measure of
overweight and obesity; measurements of weight and height are easy, quick. relatively
noninvasive, and more precise than skinfold thickness measurements.
Nevertheless, BMI does not distinguish between weight associated with muscle and weight
associated with body fat. Hence, in some circumstances, an elevated BMI may result from
excessive adiposity, muscularity, or edema.
BMI gives no indication about the distribution of body fat. Anomalies in the distribution of
abdominal fat are now recognized to be as great a risk factor for disease as is excess body fat per
se.

BMI (Quetelet’s
Index) in Adults
Differences in body proportions
and in the relationship between
BMI and body fat content may
result in certain population groups
being misclassified as overweight
or obese, based on BMI.

Other computations
for Anthropometry

Percentage of
Ideal/Desirable
Body Weight and
Usual Body Weight

Percentage of
Ideal/Desirable
Body Weight
and Usual
Body Weight

Percentage of Ideal/Desirable Body Weight and Usual Body
Weight

Body Composition
Two chemically distinct compartments: fat and fat-free mass. The
latter - also referred to as the body cell mass -consists of the skeletal
muscle, non-skeletal muscle, soft lean tissues, and the skeleton.
Anthropometric techniques can indirectly assess fat and the fat-
free mass, and variations in their amount and proportion can be
used as indices of nutritional status.

Body Composition
The anthropometric measurement of body composition is both fast and noninvasive, and it
requires the minimum of equipment compared to laboratory techniques.
Indices of body composition are used in clinical settings to identify hospital patients with
chronic under- or overnutrition and to monitor long-term changes in body composition during
nutritional support. In public health they can identify individuals who are vulnerable to under- or
overnutrition and help evaluate the effectiveness of nutrition intervention programs.

Assessment of Body Fat
The body fat content is the most variable
component of the body, differing among
individuals of the same sex, height, and weight.
On average, the fat content of women is higher
than that of men, representing 26.9% of their total
body weight compared with 14.7% for men.

Body fat is deposited in two major types of sites: one for essential lipids, and the
other for storage of fat.
Essential lipids are found in the bone marrow, central nervous system,
mammary glands, and other organs and are required for normal physiological
functioning, fat from these sites makes up about 9% (4.9 kg) of body weight in
reference woman and 3% (2.1 kg) in reference man.
Storage fat consists of inter- and intramuscular fat, fat surrounding the organs
and gastrointestinal tract, and subcutaneous fat.

Body fat can be expressed either in absolute terms (the weight of total body fat in
kilograms) or as a percentage of the total body weight. It is highly correlated with
many health-related indices such as risk of mortality or morbidity, specifically
coronary heart disease, high blood pressure, and type 2 diabetes
In population studies, body fat is often assessed by anthropometry. Skinfold
thickness determinations, either alone or in association with limb circumference
measurements, are frequently used to estimate the percentage body fat.

Skinfold Thickness Measurements
Skinfold thickness measurements provide an estimate of the size
of the subcutaneous fat depot, which, in turn, provides an estimate
of total body fat.
Such estimates are based on two assumptions: (a) the thickness of
the subcutaneous adipose tissue reflects a constant proportion of
the total body fat, and (b) the skinfold sites selected for
measurement, either singly or in combination, represent the
average thickness of the entire subcutaneous adipose tissue.
Neither of these assumption is true.

Skinfold Thickness Measurements
In fact, the relationship between subcutaneous and internal fat is
nonlinear and varies with body weight and age: very lean subjects
have a smaller proportion of body fat deposited subcutaneously
than obese subjects have.
Moreover, variations in the distribution of subcutaneous fat occur
with sex, race or ethnicity, and age (Wagner and Hey-ward, 2000).
The following sites, described in detail in Lohman et al. (1988), are
commonly used
Triceps skinfold is measured at the midpoint of the back of the
upper arm

Skinfold Thickness
Measurements
Biceps skinfold is measured as the thickness of a vertical
fold on the front of the upper arm, directly above the
center of the cubital fossa, at the same level as the
triceps skinfold.
Subscapular skinfold is measured below and laterally to
the angle of the shoulder blade, with the shoulder and
arm relaxed.
Placing the subject's arm behind the back may assist in
identification of the site. The skinfold should angle 45°
from horizontal, in the same direction as the inner
border of the scapula (i.e., medially upward and laterally
downward

Skinfold Thickness
Measurements
Suprailiac skinfold is measured in the mid-
axillary line immediately superior to the iliac
crest.
The skinfold is picked up obliquely just
posterior to the midaxillary line and parallel to
the cleavage lines of the skin (Figure 11.2B).
Midaxillary skinfold is picked up horizontally on
the midaxillary line, at the level of the xiphoid
process.

Skinfold Thickness
Measurements
Skinfold thickness measurements are
best made using precision thickness
calipers; they measure the compressed
double fold of fat plus skin. As a result of
the compression, they always
underestimate actual subcutaneous fat
thickness

Skinfold Thickness
Measurements
Precision calipers are designed to exert a defined and
constant pressure throughout the range of measured
skinfolds and to have a standard contact surface area or
"pinch" area of 20-40 mm2.
The skinfold calipers must be recalibrated at regular
intervals using a calibration block.
Both the Harpenden and Holtain skinfold calipers, which
have a standard jaw pressure of 10 g/mm2, give smaller
skinfold values than Lange calipers, which are fitted with a
lighter spring (Gruber et al., 1990).

Skinfold Thickness
Measurements
For all the skinfold measurements, the subject should stand
erect with the weight evenly distributed and feet together,
shoulders re-laxed, and arms hanging freely at the sides.
The measurement technique is described in detail for the
triceps skinfold, as the latter is the site most frequently used to
obtain a single indirect measure of body fat; the technique
used for the other skinfold sites' is similar.
There is no consensus as to whether the left or right side of
the body should be used. The current practice of the National
Health and Nutrition Examination Survey (NHANES) is that
skintold sites are measured on the right side of the body.

Skinfold Thickness
Measurements
There is no consensus as to whether the left
or right side of the body should be used. The
current practice of the National Health and
Nutrition Examination Survey (NHANES) is that
skinfold sites are measured on the right side of
the body.

Measurement of
Triceps Skinfold
The measurement of the triceps skinfold is
performed at the midpoint of the upper right
arm, between the acromion process and the tip
of the olecranon, with the arm hanging relaxed.
To mark the midpoint, the right arm is bent 90°
at the elbow, and the forearm is placed palm
down across the body.

Measurement of Triceps Skinfold
Then the tip of the acromion process of the
shoulder blade at the outermost edge of the
shoulder and the tip of the olecranon process of the
ulna are located and marked.
The distance between these two points is
measured using a nonstretchable tape, and the
midpoint is marked with a soft pen or indelible
pencil, directly in line with the point of the elbow
and acromion process. The right arm is then
extended so that it is hanging loosely by the side.

The examiner grasps a vertical fold of skin plus the
underlying fat, 2 cm above the marked midpoint, in
line with the tip of the olecranon process (Figure
11.1), using both the thumb and forefinger. The
skinfold is gently pulled away from the underlying
muscle tissue, and then the caliper jaws are applied
at right angles, exactly at the marked midpoint
(Figure 11.4). The skinfold remains held between the
fingers while the measurement is taken.

When using the Lange, Harpenden, or Hol-tain calipers,
pressure must be applied to open the jaws before the
instrument is placed on the skinfold; the jaws will then
close under spring pressure. As the jaws compress the
tissue, the caliper reading generally diminishes for 2-3s,
and then the measurements are taken.
Skinfolds should be recorded to 0.1 mm on the
Harpenden and Holtain skin-fold calipers and to 0.5mm on
the Lange.
Duplicate skinfold measurements made with precision
calipers should normally agree to within 1 mm.

Triceps skinfold measurements can also be made
with the subject lying down. The subject lies on the
left side with legs bent, the head supported by a
pillow, and the left hand tucked under the pillow.
The right arm rests along the trunk, with the palm
down. The measurement is taken at the marked
midpoint of the back of the upper right arm, as
described above. The examiner should be careful to
avoid parallax errors by bending down to read the
calipers while taking the measurements (Chumlea et
al., 1984).

Assessing Body Fat with
Single Skinfolds
Skinfold measurements at a single site are sometimes
used to estimate total body fat or the percentage of
body fat. If this single measurement approach is used, it
is critical to select the skinfold site that is most
representative of the whole subcutaneous fat layer,
because subcutaneous fat is not uniformly distributed
about the body.
Unfortunately, the most representative site is not the
same for both sexes, nor is it the same for all age and
ethnic groups.

Single Skinfolds
Hence, it is not surprising that there is no
general agreement as to the best single
skinfold site as an index of total body fat.
The assessment of total body fat from a single
skinfold is particularly difficult in adult females,
for whom the distribution of subcutaneous fat
is more variable than in males.

Multiple Skinfolds
The optimum combination of skinfold
measurement sites for assessing subcutaneous fat
and, by inference, total body fat has not been
extensively investigated.
Moreover, the proportion of total body fat that is
distributed subcutaneously in adults varies with
age, sex, degree of adiposity, and race or ethnicity.

Multiple Skinfolds
In general, when studying both children and
adults, investigators recommend taking one limb
skinfold (right triceps) and one body skinfold
measurement (right subscapular) to account for the
differing distribution of subcutaneous fat.
When estimating body fat, multiple skin-folds, not
just a single skinfold measurement, are particularly
advisable when individuals are undergoing rapid
and pronounced weight gain.

Waist-Hip
Circumference Ratio
 The waist-hip circumference ratio (waist circumference
divided by hip circumference) (WHR) is a simple method
for distinguishing between fatness in the lower trunk
(hip and buttocks) and fatness in the upper trunk (waist
and abdomen areas). Lower trunk fatness (i.e., lower
waist to hip ratio) is often referred to as "gynoid
obesity" because it is more typical of females. Upper
trunk or central fatness (higher waist to hip ratio) is
called "android obesity" and is more characteristic of
males.

Waist-Hip
Circumference Ratio
The WHR correlates strongly with total body fat mass.
Several prospective cohort studies have confirmed that in
both men and women an elevated WHR is strongly
associated with an increased risk of developing coronary
heart disease, stroke, and type 2 diabetes mellitus.
With the application of new laboratory methods including
computerized tomography and magnetic resonance
imaging. semi-quantitative estimates of the total fat stored
within the abdomen have been obtained.

Waist-Hip
Circumference Ratio
Some metabolic consequences of obesity such as
disturbances in lipoprotein metabolism and plasma
insulin-glucose homeostasis are much more likely to be
associated with an android distribution of adipose tissue
(upper trunk fatness) than a gynoid distribution of
adipose tissue (lower trunk fatness)
Several studies in adults have shown that the WHR
varies with race or ethnicity, age, sex, geographic region,
and the degree of overweight.

Waist-Hip
Circumference Ratio
In the WHO Multinational MONItoring of trends and
determinants of CArdiovascular disease (MONICA)
project, the WHR was also reported to increase with age,
the increase being more pronounced in women, as
shown in Figure 11.6. This study used a standard
protocol to measure waist and hip circumferences in
men and women 25-64 y in 19 countries (Molarius et al.,
1999). Mean waist-hip ratio in the 19 countries varied
considerably among the study populations, ranging from
0.87 to 0.99 for men and from 0.76 to 0.84 for women.

Measurement of Waist-
Hip Circumference
Currently, no universally accepted procedure exists for
defining the site for the measurement of waist circumference.
Two sites are frequently used: (a) at the natural waist, i.e.,
mid-way between the tenth rib (the lowest rib margin) and the
iliac crest, as recommended by WHO (2000) and Lohman et al:
(1988), and (b) at the umbilicus level (van der Kooy and
Seidell, 1993). The latter site is preferred for obese subjects
because it is sometimes difficult to identify a waist narrowing.
Hip circumference is measured at the widest point over the
buttocks (Lohman et al., 1988).

Hip Circumference
Subjects should be asked to fast overnight prior to measurement
and wear little clothing to allow the tape to be correctly
positioned.
Subjects should stand erect with the abdomen relaxed, arms at
the sides, feet together, and their weight equally divided over both
legs.
To perform the measurement at the natural waist, the lowest rib
margin is first located and marked with a felt tip pen. The iliac
crest is then palpated in the midaxillary line and also marked. An
elastic tape is then applied horizontally midway between the
lowest rib margin and the lateral iliac crest: it is tied firmly so that
it stays in position around the abdomen about the level of the
umbilicus.

Hip Circumference
The elastic tape thus defines the level of the waist circumference,
which can then be measured by positioning a flexible nonstretch
fiberglass tape over the clastic tape (Jones ct al., 1986). Subjects are
asked to breathe normally and to breathe out gently at the time of the
measurement to prevent them from contracting their muscles or from
holding their breath. The measurement is taken without the tape
compressing the skin. The reading is taken to the nearest millimeter.
For the hip circumference measurement, the subject should stand
erect with arms at the side and feet together.
The measurement should be taken at the point yielding the maximum
circumference over the buttocks (Jones et al., 1986), with the tape
held in a horizontal plane, touching the skin but not indenting the soft
tissue (Lohman et al.1988).

Hip Circumference
The measurement is taken to the nearest millimeter. The
degree to which factors such as postprandial status, standing
position, and depth of inspiration contribute to error in the
measurement of waist hip circumference ratio is uncertain.

Interpretation of Waist-
Hip Circumference
Björntorp (1987) was the first to suggest that waist-hip ratios
> 1.0 for men and > 0.85 for women indicated abdominal fat
accumulation and an increased risk of cardiovascular
complications and related deaths. These cutoffs have now
been widely accepted for international use (Han et al., 1997a;
WHO, 2000).
Nevertheless, the appropriateness of using universal cutoffs
to assess health risk across ethnic groups has been questioned,
in view of the known ethnic variations in body fat distribution
(Wagner and Heyward, 2000).

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