Original

Research Communications-methods

Body composition in children: proposal for a method for calculating body fat percentage from total body density or skinfold-thickness ,2
Jan A Weststrate and Paul
ABSTRACT

Deurenberg
A

method routine defined

is presented methods and used suprailiacal prediction

for

assessing skinfold

childhood

obesity

in a more to total is used relation on the With body

objective density between

way ital, total body lished other

than

most

other

for diagnosing
equations.

childhood
Total body equations

obesity.
density

The sum of bicipto estimate

tricipital, body

subscapular, fat percentage

thicknesses

is related

by use

of theoretically

by use of age-

and

sex-dependent

on the

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fat percentage and body density. These equations are constructed data on changes in the density of fat-free mass with age in children. method childhood obesity can be assessed routinely in a more consistent
routine methods used to diagnose obesity

basis of pubthe proposed with most study 1% from

way

than

indicated

that
body

in children
density. body density.

aged

7-10

y predicted
predicted

in children. body density body density l989;50: skinfolds,

A preliminary validation differed on average < was highly correlated

measured
with

In addition,

(r

>

0.7)

measured

Am J Clin Nutr
children,

1104-15. total body density

KEY WORDS

Body composition,

Introduction A well-known
body composition

and
in

widely
humans

applied

model

for studying two

and

model

(1). This

model
one

divides

components,

consisting

two-component the human body into of pure fat (fat mass)

is the

Densitometry has drawbacks, too, and its validity for assessing body composition is doubtful when applied to, for example, children, elderly people, extremely musculan persons, pregnant women, or edematous persons (1214). In addition, it should be noted that densitometry is

a time-consuming

method

requiring

considerable

equip-

one consisting ofall nonfat material (fat-free mass). The basis ofthe two-component model stems from results of cadaver analyses (2). These analyses showed that the human body consists of a fat and a fat-free body (bones, muscles, water, and organs) ofa relatively constant composition. The chemical and physical properties, especially the density, potassium, and water content, of the

ment that is usually tories. This means

technique for assessing

only available in specialized laborathat densitometry is not a suitable

body composition routinely in

large
curacy

groups

of persons.

Densitometric
ofestimates ofpersons because of estimating body

results

may,

however,

influence

the ac-

fat and
reasonable
obogists

fat-free
and

mass

can be measured
(2-6).

or calculated

with

ofbody fat percentage in large groups the densitometric method is the basis fat percentage from anthropometric,

precision
nutritionists

This has enabled human biover the last four decades to as-

ie, generally,
Skinfold-thickness

skinfold-thickness
measurements

measurements
provide an

(15).
estimate

sess body composition by a variety of procedures based on measurement of either total body density, total body potassium (#{176}K),or total body water content (7-9). A major drawback of these procedures is that it is not known whether in an individual case or a specific group of persons the derived constants for the density, potassium, or water content ofthe fat-free mass are valid. Ac-

ofthe
with

This
centage
nesses

fat, which total body fat mass as assessed from provides the rationale for calculating
from
on

amount

ofsubcutaneous

correlates well densitometry. body fat perthickregression

a regression
total body

equation
density.

of skinfold
Several

equations

have

been

published

(1 5-20).

The

relation

be-

cording to Garrow (2), assessing the fat and fat-free from potassium or total body water measurements be less accurate than from measurements of total
density, ie, from densitometny. Total
body

mass may
body is

I From the Department of Human Nutrition, Agricultural University, Wageningen, The Netherlands. 2 Address reprint requests to JA Weststrate, Unilever Research Lab-

density

used to calculate Brozeks, or other 1104

total body fat percentage equations (10-12).

Am JC/in

using

Siris,

oratory, P0 Box 1 14, NL 3 130 AC Vlaardingen, The Netherlands. Received December 28, 1987. Accepted for publication December 21, 1988. 104-15. Printed in USA. 1989 American Society forClinical Nutrition

Nutr

l989;50:l

BODY

COMPOSITION

IN CHILDREN

1105 with
body

tween total body density and skinfold thickness varies withageandsex(15, 18, 19). For children few reference tables or regression equations exist to relate skinfold thickness to total body fat percentage (2 1-27). The reasons are twofold; in the first place, it is practically difficult to obtain total body density measurements in children aged < 8 y and, secondly, an important assumption of the two-component model regarding the density ofthe fat-free mass is probably only valid for adults and not for children (13, 28, 29). This means that in children the diagnosis of obesity is based on age- and sex-specific reference standards for
weight-for-height, skinfold thicknesses, or weight-height

posed method was in good agreement measured by hydrostatic weighing. Total and body
body

density

body

density

fat percentage from total

body

To calculate sity the following Body volume

=

fat percentage are used.

den-

equations
V)

Fat volume

( Vf) + Fat-free
of a body equation

volume

( Vff)

(1) of its

Because
mass

and

the volume its density, (M) (D) Fat mass Fat density

equals the quotient 1 can be written as

indices (30-34). Arbitrary cutoffpoints are chosen to define obesity, ie, a child is obese when his or her criterion variable exceeds a specific centile value (usually the 95thpercentile value) of a certain reference standard. Such standards, however, normally represent the distribution ofan anthropometnc characteristic in a specific population at a certain time. This means that absolute cutoff points for assessing obesity not only may vary between reference standards (30, 3 1, 33) but also that within a given population, reference standards may vary in time (33, 34) due, for example, to secular trends in body fatness or body height. Theoretically, this is unsatisfactory because prevalence estimates ofobesity will vary according to the reference standard used to assess obesity. Obesity is a situation ofexcess fat accumulation in the body and a diagnosis of obesity should ideally be based on an accurate direct or indirect measure of the total body fat mass. Weight-for-height or weight-height indices are not direct or indirect measures ofthe total body fat mass. Skinfoldthickness measurements and total body density are mdirect measures ofthe total body fat mass. However, even if total body fat mass or total body fat percentage is known, the definition of obesity is to some extent arbitrary, ie, a body fat percentage exceeding 25%, 30%, or 35%, but estimates of body fat percentage may be used as a basis for a more consistent diagnosis of obesity. As in adults, skinfold-thickness measurements in children give an estimate of the size of the subcutaneous fat layer. The problem is to relate this estimate to an accurate estimate oftotal body fat mass or total body fat percentage. Skinfold-thickness measurements can be easily and reliably obtained in children and there is an abundance of data on skinfold thicknesses in children of a wide age range (30, 33, 35, 36). This paper attempts to provide a proposal for a rational method for relating total body density and skinfold thicknesses in children to an estimate of total body fat percentage. The arguments are on the one hand based on published data on the changes of the density of the fat-free mass as a function of age in children and on the other hand on the assumption that the relationships between skinfold thicknesses, total body fat percentage, and total body density vary between birth and age 18 y in a characteristic way. In a preliminary validation study it was shown in a sample of68 Caucasian Dutch children aged 7-10 y that body density as predicted with the pro-

Body Body

mass density
=

(Me) (Df) as + MSDff +

Fat-free Fat-free

mass density

(Mff)

(Dif)

(2)

which

can be written MID 1 ID

= =

(Mf/Df) [(Mf/M)/Df]

[(1

(3)
-

Mf/M)/Dff]

(4)

where Me/Mis the fraction offat mass in total body mass (F1), (1 M1/M) is the fraction of fat-free mass in total body mass (F), which is equal to (1 Ff). Thus equation 4 can be written as
-

lID

(Ff/Df)

+ [(1

Ff)/Dff]

(5)

If D is measured, ie, by densitometry, and Df and Dff are known (from carcass analyses), equation 5 can be solved for Ff and Fif; multiplying Ff by 100 gives total body fat percentage (F%). The density ofthe fat mass can be accurately measured by analysis offat biopsies from different fat depots in the body (37, 38). At body temperature human fat has a density of0.9000 0.00068 kg/L, which varies little between different types of fat (37, 38). The density of the fat-free mass can not be measured accurately. It is impossible to take a representative sample of the fat-free mass in humans. The density of the fat-free mass is a function ofthe relative amounts ofwater, proteins, and minerals (glycogen is ignored) in the total fat-free mass. In normal adults this density is 1 100 kg/L, as determined by cadaver analyses (2). Ifthe values for the densities ofthe fat mass and the fat-free mass are substituted in equation 5, this equation takes the following form for adults:
.

lID

(Ff/0.900)

+ (1

Ff)/l.lOO

(6)

Solving

for

Ff

yields Ff (4.95/D) body (495/D)

-

4.50

(7)

Multiplying

by 100 gives F%
=

fat percentage:
-

450

(8)

Equation 8 is known as Sins equation (10). native to Siris equation, Brozeks equation some investigators:

As an alteris used by

1106
F% = (457.0/10)
-

WESTSTRATE

AND

DEURENBERG density fat-free mass (kg/I)

414.2

(8A)

Brozeks equation is based on the analysis ofthe composition of a reference body. In a body density range of 1 .03-1 10 kg/L, Siris and Brozeks equations differ < 2% in estimates ofbody fat percentages.
.

Density

of fat-free

mass

in children

(10) (12)

In children the fat-free mass contains relatively more water, less protein, and less minerals than in adults (13, 28, 29, 39). This implies that the density of the fat-free mass is on average lower in children than in adults and that the difference in density is larger between prepubescent children and adults than between pubescent children and adults (1 3, 28, 29, 39). It is generally accepted that children are not chemically matured 2 or 3 y after birth. Bone mineralization and muscle formation, ie, protein deposition, increase from birth to adulthood. Fomon et al (39) published ageand sex-specific values for the density ofthe fat-free mass ofprepubescent reference children, from birth to age 10 y. As pointed out by Fomon et al, these values should be considered preliminary and crude because of the cxtreme sparsity ofdata on chemical analyses of individuals at various ages from infancy to puberty (in fact this comment is to some extent also applicable to adults). The lack of direct data on the chemical composition of the fat-free body in children at various ages necessitated the use of several assumptions about the chemical composition of the fat-free body in children and its changes with age. Ifit is shown that the values ofFomon et al are not valid for children, this will have major consequences for the method proposed in this article for calculating body fat percentage in children from total body density or skinfold-thickness measurements. In addition, it will be clear that children ofa given age and sex may differ in maturation and that the age- and sex-specific constants for the density of the fat-free mass given by Fomon et al may not apply to each child individually. However, we believe that on average and also in individual cases these constants provide a better estimate of the true density of the fat-free mass than the constant generally used for adults, ie, 1 100 kg/L, which, in fact, is based on very few chemical analyses ofadult cadavers (2). The data ofFomon et al (39) show that in the first 2 y oflife the density ofthe fat-free mass changes in a curvilinear way from 1 .0635 to 1 .07 15 kg/L (39). Figure 1 shows the density ofthe fat-free mass in children aged 010 y according to Fomon et al. For children between the ages 2 and 10 y, Fomon et a! describe different patterns of change of the density of the fat-free mass for both sexes. In boys the density would increase in a linear way from 1 .072 to 1 .085 kg/L and in girls, from --S 1.07 1 to ,1 .075 kg/L. From age 2 y onwards there would be a difference in the composition of the fat-free mass between boys and girls, ie, girls would have a higher water content and less protein and minerals in their fat-free mass than boys. It is not known whether this difference also exists in puberty. No data are available on pubescent
.

DO: 0

FOMON etaL.

(11

6
age

( years)

FIG 1. Density of fat-free mass as a function of age in children. Numbers in parentheses refer to equations in text. Squares and circles refer to values for the density of the fat-free mass for boys and girls, respectively, as published by Fomon et aJ (39).

and postpubescent children. It could be that during puberty girls mature more rapidly than boys because it is assumed that there are no differences in the composition ofthe fat-free mass between adult men and women (15). For this paper we have assumed, as usual, no difference in the density ofthe fat-free mass between men and women aged 18 y. With the values from Fomon et al (39) for the density ofthe fat-free mass for children aged 0-10 y and the value of 1 100 kg/L for the density of the fat-free mass in men and women aged 1 8 y, the change ofthe density of the fat-free mass from age 0 to age 18 y can be described with the following four equations.
.

For boys

and girls aged 0- 1 .99 y

Dif

1.0635 2-1 8 y
1.0715

+ 0.00l63[age

(mo)]#{176}5

(9)

For boys

aged
Dff=

+ 0.00l78[age(y)-

2]

(10)

For girls aged

2-10

y + 000044[age(y)2] (11)

Dff=
For girls aged

1.0715 1 1 18 y
-

Dff=

l.0750+0.00313[age(y)-

10]

(12)

The change of the density of the fat-free mass ing to these equations is also illustrated in Figure In boys aged 2-1 8 y one equation is sufficient scribe the age-related change in the density ofthe

accord1. to defat-free

BODY
TABLE Density children 1 of fat-free mass aged 0-10 y

COMPOSITION

IN CHILDREN

1 107 0- 1 .99 y

For boys
according to literature values and equations in

and girls aged

-

F% = ({585
Density offa t-free mass* Equationf I .064 [9] 1.067 [9] 1 .068 [9] 1.069 [9] 1.070 [9] 1.072 [9] 1.075 [10] l.072[ll] l.079[lO] l.073[ll] l.082[lO] l.074[llJ 1.086 [10] l.075[ll]

4.7[age (mo)]#{176}5)/D)
-

{550

5.l[age(mo)]#{176}5)

(13)

Age
Birth

Sex

Literaturet 1.064 1.066 1.068 1.06911 I .070 1.07211 1.076 1.072 1.080 1.073 1.082 1.074 1.085 1.075 decimal places.

For boys

aged
-

2-18 4.2[age

y (y)
-

F% = ({562
M + F

2]}/D)
-

4 mo 9 mo l2mo 18 mo 24mo 4y 6y 8y lOy

M + F M + F M+F M + F M+F M F M F M F M F rounded to three

{525

4.7[age

(y)

2])

(14)

For girls aged F%

=

2- 10 y
-

({562

1.1[age(y)
-

2]}/D)
-

{525

l.4[age (y)

2]}

(15)

Forgirlsaged F%
=

10-18
-

y
-

({553

7.3[age (y)
-

10]}/D)
-

{5 14

8.0[age

(y)

l0]}

(16)

Density

t Data from Fomon et al (39). f Equation number in brackets. Male value, 1.063 kg/L; female
II Male

value, value, value,

1.064 kg/L

(39).

#{182} Male

value, value,

I .068 kg/L; female 1.072 kg/L; female

1.069 kg/L (39). 1.07 1 kg/L(39).

mass. In girls, however, two linear equations are needed, ie, one for the age group of2-lO y and one for older girls. The intercept ofequation 9 is the mean ofthe density of the fat-free mass of newborn reference boys and girls, according to Fomon et al (39). The density ofthe fat-free mass of newborns changes in a curvilinear way to the mean of the density of the fat-free mass in 2-year-old children. The intercepts ofequations 10 and 1 1 are equal to the mean density of the fat-free mass of 2-y-old children, 1 .07 1 5 kg/L. In boys the density of the fat-free mass changes between ages 2 and 10 y in a linear way to 1 .085 kg/L; in girls it changes linearly to 1 .075 kg/L between these ages. Between ages 1 1-1 8 y we assume that in both sexes the density of the fat-free mass increases linearly to 1 100 kg/L. Table 1 shows for different age and sex groups the density values published by Fomon et al (39) and the values for the density of the fatfree mass as calculated with equations 9-12. The differences between the values of Fomon et al and the calcubated age- and sex-specific constants are very small, ie, generally < 0.00 1 kg/L.
.

Table 2 shows the differences in calculated body fat percentage between the standard Siri formula (Eq 8) and the sex- and age-specific formulas (Eqs 13-16). The differences between both estimates of body fat percentage vary with the age of the child, ie, they are smaller in older children compared with younger children. Equations 13-16 specify the relation between body fat percentage and total body density as a function of age and sex ofthe child. The validity ofthese equations cannot be directly assessed because it is not yet possible to measure the density of the fat-free mass in children directly with a noninvasive and accurate method. However, it is very likely that in comparison with the Siri equation, these equations may be more appropriate to use in children and may permit a more accurate estimation of body composition in children from total body density measurements.

TABLE 2 Body fat percentage densities calculated

in children aged 0-18 with various equations

y at different

total

body

Body fat pe rcentage Total body density (D)

kg/L

(F%)

Age
y

Sex

Equations*

Sin equation [8]

1.000 1.010 1.020 1.030 1.050

0 1 2 6 10 14 18

Total

body

density

and body

fat percentage

in children
1.060 1.070

It is now possible to substitute age- and, if necessary, sex-specific values for the density ofthe fat-free mass into equation 5 to define the relation between body fat percentage and total body density. Ifthese values are substituted in equations 6 and 7, the following equations result (see appendix for derivation ofequations 13-16).

M+F M+F M+F M F M F M F M F

35.0[13] 30.8[l3] 25.9[13] 23.1 [14] 22.0 [ 15] 15.8[14] 13.1 [15] l4.0[14] 12.2[l6J l2.6[l4] l2.2[l6]

45.0 40.1 35.3 30.6 30.6 21.4 21.4 17.0 17.0 12.6 12.6

Equation

number

in brackets.

1108 Relating
density

WESTSTRATE

AND

DEURENBERG TABLE Durnin relating 3 and Rahamans and Durnin and Womersleys skinfold thicknesses to total body density
Sex Total

skmfold
in children

thicknesses

to total

body

equations

for

In principle, it should be possible now to assess fat percentage from total body density measures in dren by use of equations 13-16. In several studies body density has been measured in groups ofchildren different ages (2 1 , 22, 24-29). However, total body
sity measurements are generally laborious and may

body chiltotal of denbe

Age 13-1 5 y 16-19 20-29 y y

body 0.0643 0.0598 0.0630 0.0678 0.0632 0.07 17

density

(kg/L) thickness*)t thickness)t thickness4 thickness)f thickness)t thickness)f skinfold

difficult to perform, especially in very young children. In addition, estimates ofbody fat percentage in children from total body density using the Siri or Brozek equation may be biased. The Brozek and Siri equations may not be applicable to children (13, 28, 29). Because of practical difficulties in obtaining total body density measurements in children, efforts have been made to find more convenient ways of assessing body composition in children, based on some easily obtained anthropometric variables (2 1, 22, 25-27, 40, 41). In contrast to the situation for adults (42), relatively few prediction equations have been published for children that relate a function of anthropometric variables to total body density. The anthropometric indicators used in these equations may vary considerably. Generally, skinfold thicknesses are incorporated in the formulas; in addition, weight, height, or bone widths or circumferences are added to the equations (2 1, 22, 25-27, 40, 41). These empirically defined prediction equations may suffer from one or more serious flaws in design (42), ie, lack ofcross-validation of the equations and incorporation ofsometimes awkward and difficult combinations of anthropometric variables (42). Most published equations contain a function of skinfold thickness, usually the sum ofone or more skinfold thickness(es) measured on the extremities and the trunk (15-19, 21-23, 25-27). Such a combination of skinfold thickness measurements is most likely to be a valid indicator of the total amount of subcutaneous fat. Durnin and Womensley (1 published one of the most extensive data sets relating skinfold thickness measurements to body density for a variety ofage and sex groups, including adolescents aged 16-19 y (15). From the same group, regression equations were published relating similar skinfold-thickness measurements to body density in children aged 13-15 y (2 1). Durnin and Rahamans (21) prediction equations relate a linear function of the logtransformed sum ofthe bicipital, tricipital, subscapular, and suprailiacal skinfold thicknesses, ie, ofextremity and trunk skinfold thicknesses, to total body density. Prediction equations are generally constructed on the basis ofan empirically derived relation between anthropometric variables and total body density. In contrast to this procedure is the derivation of prediction equations for children that uses an extrapolation on theoretical grounds of the prediction equations of Durnin and Womersley for adolescents (1 5). These equations have not been extensively cross-validated and may as such be slightly population-specific. For example, it was shown that the equations of Durnin and Womersley tend to overestimate body fat percentage in relatively lean adult athletes (43, 44). On the other hand, it has been reported
5)

M F M F M F of bicipital,

D D D D D D

=
=

1 . 1533

=
=

=
=

I. 1. 1. 1. 1.

1369 1620 1549 163 1 1599

log (skinfold log(skinfold log(skinfold log(skinfold log(skinfold log(skinfold and suprailiacal

Sum

tricipital,

subscapular, equations (21).

thicknesses.

t Dumin t Durnin

and Rahamans and Womersleys

equations(15).

that Durnin and Womersleys equations give relatively good predictions of total body density in an adult male population that has more variation in fatness levels than in a population of athletes (45). In spite of the fact that
the prediction equations ofDurnin and Womersley may

be less applicable to relatively lean persons, we will use these equations as the basis for equations relating skinfold thickness to total body density in children. The skinfold-thickness measurements used in the equations of Durnin and Womersley are considered to be a valid mdicator of the total amount of subcutaneous fat; in addition, they can be easily and reliably obtained in children (35,36). Table 3 presents the equations of Durnin and Womersley (1 5) and ofDurnin and Rahaman (2 1). Theoretically, if extrapolation were justified, the intercepts ofthese equations represent total body density when no subcutaneous fat can be measured, ie, is present. However, it can be seen from the equations in Table 3 that extrapolation is probably not justified, because this would mean that for a body without (subcutaneous) fat, total body density would be far in excess of the density of the fat-free mass, ie, 1 100 kg/L. However, it should be realized that skinfold thicknesses always measure a double layer of skin, even when no subcutaneous fat is present. On average, a reasonable estimate of the total thickness of a double layer of skin is mm (4648); four skinfolds would correspond to P-- 10 mm. If this value is substituted in Durnins equations (1 5, 2 1), the resulting total body density will be a less biased estimator of the density of the fat-free mass than the intercepts of the uncorrected equations. Table 3 shows that the difference between the sexes and between the age groups in intercepts corroborates our ideas on the influence of age and sex in children on the density ofthe fat-free mass. At ages 13-15 y the intercept is lower than at ages 16-19 y in both sexes, and the intercept is higher in boys than in girls. The differences between the sexes in the regression coefficients of the equations ofDurnin and Womersley and ofDurnin and Rahaman are generally small. Ifthe density ofthe fat-free mass in reality changes binearly from ages 2-10 or 18 y, it can be expected that the
. ---2-2.5

BODY
intercepts

COMPOSITION

IN CHILDREN

1109

ofregression equations relating skinfold thicknesses to total body density will also increase linearly with age. Similarly, ifin reality the density ofthe fat-free mass changes in a curvilinear way between ages 0 and 2 y, it can be expected that the intercepts of an equation relating skinfold thicknesses to total body density will also change in a curvilinear way between these ages. In developing a theoretical equation that relates skinfold thickness to total body density, three assumptions form the basis ofsuch an equation, which has the general form

intercept

slope

log (sum

ofskinfold

thicknesses) (1 7)

1) The intercept of the equation should be age- and sex-specific; at ages 0-1.99 y no difference between the sexes in the intercept will exist. The intercept will increase in a curvilinear way from an average value in

newborn children to an average value in children aged 1 .99 y. The intercept will increase linearly from this value at age 1.99 y, close to values in the sex-specific equations of Durnin and Womersley for young adults (aged l6-l9y). 2) The relation between increments in skinfold thickness and body density, ie, the slope of the equation,

on the estimate of total body density. We hypothesize that this bias is more or less constant for children aged 0-18 y. This is an important assumption because it allows the intercept ofthe theoretical equation to be specifled as a function ofage. This assumption can be substantiated with data on the thickness ofthe skin layer without subcutaneous fat in infants, older children, and adults (46-48). These data show relatively little change with age in the thickness ofthe dermis layer. This means that in a newborn child the intercept will be 1.0635 (Table 1) plus 0.06, or 1 1235 kg/L; in a child aged 2 y, the intercept will be 1.07 1 5 (Table 1) plus 0.06, or 1 1 3 15 kg/L. Between the ages 0 and 2 y the density of the fat-free mass changes in a curvilinear way. Thus the intercept ofan equation relating skinfold thicknesses to total body density will also change in a curvilinear way. Between the ages 2 and 18 y the intercept changes in a linear way from 1 1 3 15 kg/L in children aged 2 y to --1.160 kg/L in men aged 18 y and to --1.135 kg/L in girlsaged 10 yandto ---1.160 kg/Lin women aged 18 y. It is now possible to specify the intercept of the equation between skinfold thicknesses and body density as a function of age. Equations 18-2 1 relate skinfold thicknesses to total body density with their respective inter. . .

cepts.

should change in the age group of 0-18 y because at a given total of the skinfold thicknesses the volume of the
subcutaneous fat mass constitutes a larger proportion of

For children D
=

aged

0-b .99 y (mo)]#{176}5}

.

{1.1235
aged
{1.l3l5

+ 0.00l6[age
-

body weight at the lower range of body volumes, ie, of body weights, than at the higher range ofbody volumes, ie, of body weights. This means that during growth at a constant thickness of the subcutaneous fat layer, the increase in total subcutaneous body-fat volume will be relatively less than the increase in total body volume. 3) No difference in slope will exist between the sexes in the 0-l.99-y age group. Table 4 illustrates the second assumption. In cases IIII (newborn), the decrease in total body density is larger than the decrease in density in cases IV-VI (children aged 2 y), which is again larger than in cases VII-IX (children aged 10 y) and than in cases X-XII (children aged 18 y). This indicates that, ceteris paribus, at greater total
body volumes (older children) a given increase in skin-

log (skinfold

thicknesses)

(18)

For boys D=

2- 18 y
+0.0018[age(y)-2]}
-

52

.log (skinfold

thicknesses)

(19)

For girls aged D=

2-10

{1.l315 +0.0004[age(y)-2]}
-

S3 .bog (skinfold

thicknesses)

(20)

For girls aged D=

11 18 y
-

{l.l350+0.003l[age(y)-

lO]}
54

fold thicknesses will correspond to a smaller increase in total body fat percentage and, as a corrollary, to a smaller decrease in total body density than at smaller total body volumes (younger children). The increase in total body volume with growth is best indicated by changes in average body weight. Between ages 0 (6 mo) and 18 y body weight changes in a more or less linear way by about a factor 10(42). Theoretical equations to total body density The equations that the intercept relating skinfold thickness

log (skinfold

thicknesses)

(21)

where

Table

S is the slope. 4 shows that

fat volume

at a given
represents

skinfold
a smaller

thickness,
fraction

the
of

subcutaneous

total body volume at larger body volumes. On average

and Womersley (15) show estimator of the density of the fat-free mass. The bias is --0.06 kg/L in young adults. This bias can be largely accounted for by the influence of the thickness ofthe skin layer (without subcutaneous fat)

of Durnin is a biased

body volumes than at smaller this is a difference ofa factor of3 comparing newborn children with l8-y-old children, of a factor of 2 comparing 2-y-old children with 1 8-yold children, and ofa factor of 1.25 comparing lO-y-old children with 18-y-old children. Table 4 also shows that this difference is more or less independent of the thickness of the fat layer at a given total body volume. Thus, between body volumes of ---3 L and -70 L, a given
thickness of the subcutaneous fat layer may represent a

threefold should

decrease in body fat percentage. However, it be clear that changes in body volume during

1110
TABLE 4 Influence ofdifferences

WESTSTRATE

AND

DEURENBERG

in total

body

volume

on relative

amount

ofsubcutaneous Total subcutaneous fat volume (V5)t L 0.433 0.703 1.311 1.021 1.671 3.186 2.189 3.606 7.000 3.729 6.158 12.034

fat and total

body

density

at given

skinfold

thicknesses Fatfree mass (V8)11 kg 2.806 2.509 1.940 9.600 8.885 7.218 33.339 31.780 28.047 73.104 70.432 63.968

Case

Height (V1)

Mean body circumference (V2) m 0.25 0.25 0.25 0.35 0.35 0.35 0.55 0.55 0.55 0.70 0.70 0.70 average .(body (V22
2T

Mean thickness ofsubcutaneous fat layer (V3) m

Total body volume (V4)* L 2.984 2.984 2.984 9.748 9.748 9.748 32.497 32.497 32.497 70.187 70.187 70.187

Percent subcutaneous fat (V6)t % 14.5 23.5 43.9 10.5 17.1 32.7 6.7 1 1.1 21.5 5.3 8.8 17.1
=
-

Subcutaneous fat mass (V7)II kg 0.390 0.633 1.180 0.919 1.504 2.867 1.970 3.245 6.300 3.356 5.542 10.831

Total body density (V9)** kg/L 1.0710 1.0529 1.0121 1.0791 1.0657 1.0347 1.0865 1.0778 1.0569 1.0894 1.0825 1.0657

m
I II III IV V VI VII VIII IX 0.60 0.60 0.60 1.00 1.00 1.00 1.35 1.35 1.35 1.80 1.80 1.80 V4 = V V4
=
.

0.003 0.005
0.010

0.003 0.005
0.010

0.003 0.005
0.010

x
XI XII
*

0.003 0.005
0.010 body surface

cross-sectional radius)2

j V6

V,

. 100 V4 It is assumed that all fat consists

ofsubcutaneous

fat

V4=

V1.T.

II V7 = V5.0.900 (ie, density of fat) #{182} V8=(V4V5).l.lOO(ie,densityoffat-freemass)

**V9 V7 V4 + V8

V2

2,r.body V4
-

radius body
=

t V5

fat-free volume volume volume volume

volume V, . average V1 . ir.(fat-free V1 V,

.

Fat-free Fat-free Fat-free Fat-free

body body body body

cross-sectional body radius V3]

-

fat-free

body

surface

radius)2 V3)2

ir

(body
.

[(ft)

v5=

v4-

vvlr.

[/V2\

Il-I-V3

growth cannot simply be represented by changes in the volume of a symmetrical body, ie, of a cylinder. It is known that during growth the relative increases in head and truncal volume are smaller than the increases in the volumes of the extremities. Furthermore, it is possible that during growth the proportion of internal fat increases and that the distribution of subcutaneous fat changes. Between ages 0 and 2 y body volume triples on average (49). According to Table 4, body fat percentage at a given total skinfold thickness would decrease between ages 0 and 2 y by a factor of --0.7. However, we assume that during the first 2 y oflife, the proportion ofinternal body fat stores increases. This assumption can be substantiated with data on changes in body fat content of infants during the first 2 y oflife. On average a newborn child of 40 wk gestation has a body fat content of -400-500 g,

corresponding to 10-15% ofbody weight (39, 50). It is estimated that at birth 70-80% ofthe body fat content is located subcutaneously (47). In the first 2 y of life body fat percentage increases 1 50-200% to values between 20% and 25% (39). This rapid increase in body fat percentage is accompanied by an increase in skinfold thicknesses during this period (5 1-53). On average, between birth and the age of2 y skinfold thicknesses increase also , 1 50-200% (5 1-55). Table 4 shows that, for a body without internal fat, skinfold thicknesses increase twofold in the first 2 y oflife and body fat percentage shows a relatively smaller increase (compare case II with case VI). This indicates that if in reality there is a twofold in---

crease

in body

fat

percentage

and

skinfold

thicknesses

in

the first 2 y oflife, the relative increase in internal bodyfat stores between ages 0 and 2 y would compensate for the relative decrease in subcutaneous fat stores. Thus be-

BODY tween ages 0 and skinfold thicknesses

COMPOSITION

IN CHILDREN For boys D

=

1111

2 y the slope of an equation relating to total body density will remain relativeby constant whereas the intercepts will vary (Eq 18). The slope value for children of this age group depends on the relative changes in body fat percentage at a given total skinfold thickness between ages 2 and 1 8 y. These changes have to be estimated. For this purpose we will use a model that describes the average (males and females together) pattern ofchange in body fat percentage at a given total skinfold thickness between ages 2 and 18 y. The model assumes that at a given total thickness of the subcutaneous fat layer, total body fat percentage decreases between ages 2 and 1 8 y by a factor of --0.67 and between ages 2 and 10 y by a factor of --0.80. This is in contrast with findings from Table 4, which show that between ages 2 and 18 y and ages 2 and 10 y, at a given total thickness of the subcutaneous fat layer, total body fat percentage would decrease by a factor of 0.50 and 0.67, respectively. For the calculations in Table 4 it was assumed that the proportion of internal body fat stores remains constant during growth. However, in reality the proportion of internal fat may increase during growth and the distribution of subcutaneous fat may change from a more peripheral to a more truncal type of distribution (56, 57). Increases in truncal volume during growth may be less than increases in total body volume, which would also cause a smaller decrease in body fat percentage at a given total thickness ofthe subcutaneous fat layer between ages 2 and 1 8 y. We have elaborated on the model with the example of an l8-y-old child with a total sum ofskinfold thicknesses of --40 mm, which corresponds on average to 18.5% body fat, ie, the average of the male and female values according to the tables of Durnin and Womersley (15). We have to use average values here because we assumed that no difference will exist in slope between the sexes in the age group of 0 to 2 y. A sum of skinfold thicknesses of --40 mm would be equivalent, according to our model, to a body fat percentage of ----28% (a factor of 1/ 0.67) in a 2-y-old child, which would be equal to a total body density (Eq 14 or 1 5) of 28=(562/D)-525 where D, then, is 1.0163 kg/L. Substitution ofthis
(22)

and girls aged

+
-

0-1 .99 y

{l.1235

(0.0016[age(mo)]#{176}5)} 0.07 19 -log (skinfold thicknesses)

(25)

For

boys
= {l.l315

ages

2-1 8 y
+

D
-

(0.00l8[age(y) (y)
.

2])}

{0.07l9
(26)

(0.0006[age

2] log (skinfold y
-

thicknesses)))

For girls aged D

-

2-10

{1.l3l5 + (0.0004[age(y) (y)

.

2]))

{0.0719
(27)

(0.0003[age

2] log (skinfold

thicknesses)))

For girls aged D=

-

1 1 18 y 10]))
-

{l.1350+(0.003l[age(y)(0.0003[age (y)
-

{0.0719
(28)

2] log (skinfold
-

thicknesses)))

Applicability Equations
because they

of prediction 25-28
are part

equations be regarded
proposed but not

should
ofa

as preliminary
yet validated

method of estimating body fat percentage in children form easily obtained skinfold-thickness measurements. Any formula that predicts total body density or total body fat from skinfold thicknesses involves the assumption that the amount of subcutaneous fat relates closely

to total body fat. It has been firmly established, both for adults and children (1 5, 19, 21, 22), that total body density or total body fat is closely associated with skinfold thicknesses, ie, with an indicator ofthe amount of subcutaneous body fat fat.

25-28 predict total be directly answered. To answer this question, data are needed on skinfold thicknesses, body density, and total body fat mass, assessed with a direct, accurate, and, preferably, noninvasive method. Such a method is not yet available. With our equations it is possible, however, to compare predicted total body density with measured total body
accurately in children cannot density in samples ofchildren equations from different age and sex

The question

ofwhether

equations

value

groups.
the

in equation 1.0 163 Solving

=

(19) or (20) yields 1 1 3 15

. -

52

log (skinfold

thicknesses)

(23)

for

52

gives

S2

0.07 19

(24)

For boys and girls this value is assumed to be relatively constant between ages 0 and 1.99 y. For both sexes the slopes decrease linearly between ages 2 and 18 y to the values found in the equation ofDurnin and Womersley, ie, to -0.0630 for boys and to ----0.0678 for girls (15). We can now define the slopes ofthe equations as a function ofage. The complete equations are as follows.

would allow a conclusion on with respect to the prediction ofbody density in different samples ofchildren and, thus, on the generalizability ofthe prediction equations. In a preliminary study skinfold thicknesses and body density were measured in a sample of 68 Caucasian Dutch children varying in age between 7 and 10 y. Skinfold thicknesses and body density were measured as described before (57, 58). The children and their parents or supervisors were informed of the nature and purpose of the experiments. When a child wanted to participate and the parents or supervisors gave their informed consent, the child was eligible for the study. The study protocol was approved by the Medical Ethical Committee of the Wageningen Agricultural University. In 10 subjects the reproducibility ofbody density meavalidity of the

This

information

1112
TABLES Age, weight,

WESTSTRATE

AND

DEURENBERG

skinfold

thicknesses,

and measured

and predicted

total

body

density Girls
(n=33)

in girls and boys Boys

(n=35)

Age(y) Weight(kg)
Skinfoldthicknesses(mm)

8.5 28.7
28.2

0.2 0.7

8.7 31.6
26.7

0.2 0.9
1.5

1.3

Measured density (D)(kg/L) Predicted density(D)(kg/L) Difference (D - D)(kg/L) Correlation (D, D) Regression ofD on D [(D D)2/n - 2105t (kg/L)
*

I .039 1.034

0.002 0.001

0.005
D
=

0.001*

0.73t -0.094 + 1.096 X D 0.0076 D

=

1.0420.002 1.048 0.002 -0.006 0.00 1* 0.77t -0. 189 + 1 . 174 X D 0.0089

This difference

is significantly

different

from

zero; p <0.001. ofD on D.

t This correlation is significant; p < 0.001. t Square root ofresidual mean square ofregression

surements was assessed. The average coefficient of intraobserver measurement error was 0.6%. Body density was measured five times on 3 different days and measurements were always performed by the same investigator. Table 5 gives age, weight, skinfold thicknesses, and measured and predicted body density in these children. Predicted body density was quite similar to measured total body density. The difference between measured and predicted total body density was, however, significant. Predicted and measured total body densities were significantly correlated. The difference between measured fat percentage, ie, fat percentage based on measured total body density, and predicted body fat percentage was on average small: -2.6 0.7% (1 SEM) in girls and 3.1 0.8% in boys. We also calculated the difference between measured total body density and body density predicted with Durnin and Womersleys equation for children aged 16-19 y. The difference was -0.019 0.001 kg/L for girls and -0.032 0.002 kg/L for boys, which is a factor 3 to more than with our prediction equations. We conclude from this study that our prediction equations provide accurate predictions oftotal body density, ie, the absolute mean difference between predicted and observed total body density is < 0.006 kg/L. In addition, we compared total body density predicted with equations 25-28 with total body density predicted with equations published by Durnin and Rahaman (21) for different skinfold thicknesses. Table 6 shows total body density calculated by equations 26 and 28 and by the equations ofDurnin and Rahaman for different total skinfold thicknesses. The differences in body densities calculated with the various equations are small. The mean difference between the set of equations of Durnin and Rahaman and equations 26 and 28 in calculated body densities is, respectively, 0.001 5 kg/L for men and 0.0005 kg/L for women, corresponding to differences in estimated body fat percentage of< 1%. We also calculated body fat percentage with equations 13- 16 and 25-28 by use of published data on skinfold thicknesses and body composition in children (39-55). Vaucher et al (55) found that the median values for vari5

and extremity skinfold thicknesses in newof normal gestational age varied between mm. This corresponds to a sum of skinfold as used in our equations, of 14 mm. Subvalue in equation 25 gives a predicted total of - 1 .041 kg/L and an estimated body fat percentage of 12%, which is in good agreement with the data from Fomon et al (39). In the first year of life the sum of the bicipital, tricipital, subscapular, and supraiiacal skinfold thicknesses increases to 30 mm (59), corresponding to a predicted density of 1.023 kg/ L and a body fat percentage of -24%, which is also in good agreement with Fomon et als values (39).
---

ous truncal born children 2.9 and 4.0 thicknesses, stituting this body density

TABLE 6 Total body density calculated from skinfold thicknesses equations in boys aged 14.7 y and in girls aged 14.9 y
Total

with different

body

densityt

Durnin and Rahamant Skinfold thicknesses* mm 20 30 40 60 80 100

*

Equation Male. kg/L

26

Equation Femalell

28

Male

Female

1.070 1.058 1.050 1.039 1.031

1.025

1 .059 1.049 1.041 1.031 1.023

1.017

1.069 1.057 1.049 1.037 1.029

1.023

1.062

1.050 1.041 1.029 1.021

1.014

Sum

of bicipital,

tricipital,

subscapular,

and

suprailiacal

skinfold

thicknesses.

t Density rounded to three decimal places. :1: From reference 21. Difference in total body density ofmales,
Durnin and Rahaman (1 SD). II Difference of Durnin and kg/L. (21) and equation

between the equation of 26, was 0.0015 0.005 kg/L

in total body density offemales, between the equation Rahaman (21) and equation 28, was 0.0005 0.0023

BODY
TABLE 7 Skinfold thicknesses* at different total body density and total body

COMPOSITION

IN

CHILDREN

1113

body fat percentages in children density to body fat percentage Percent body 25% fat, male 30%

aged 0-18

y according

to theoretical

equations

relating

skinfold

thicknesses

to

Perce nt body 35% mm 15%

20% 25%

fat, female
30% 35%

Age y

15%

20%

ot
lt
2

17 18
18

22 24
25

30 32
34 37 41

40 43
45 51 57

52 58
60 68 78

17 18
18 18 19

22

30

40

52

24
25 25 25

32
34 34 35

43
45 46 47

58
60 62 63

4 6 8 10
12

20
22

27
30

23 25
27

33 36
40

46 51
57

64 72
81

88 101
115

19 19
21 23

26 27
30 33

35 37
42 47

48 51
58 66

65 69
80 92

14 16 18
*

27 32 34 Sum ofbicipital, tricipital,

44 48 52 suprailiacal,

63 71 79 and subscapular

92
104

117 skinfold

132 152 175 thicknesses.

25 27 Skinfold thicknesses

37 40

53 58 were calculated

75 85 with equations 25-28.

106 122

t Mean

age was used (6 mo). j: Meanagewasused(18 mo).

We also measured skinfold thicknesses, but not total body density, in a sample of 2285 Dutch children aged 0-18 y (57) and found the mean body fat percentage calculated with our prediction equations were, for each age and sex group, in good agreement with data reported by other investigators (22, 23, 47, 60). These calculations are not proof of the validity of the presented prediction equations; they simply show that our prediction equations provide biologically meaningful estimates of body fat percentage in children. However, it should be clear that more information is needed on the validity of equations 25-28 before a definite conclusion can be drawn on the applicability ofthe presented equations. The derivation of equations 13-16 is based on published data on the changes of the density of the fat-free mass in children between birth and the age of 10 y (39). Equations 25-28 are derived from prediction equations (1 5) that have been proposed as general equations (19), ie, applicable to a given age and sex group with a large variation in fatness level. The derivation of equations 25-28 is based on theoretical arguments that use three basic assumptions on the relationships between subcutaneous fat, total body fat, and total body density. Until a sufficient amount of empirical data and/or a better theory on the aforementioned relationships invalidate(s) the extrapolation of our prediction equations 25-28 from the equations of Durnin and Womersley (1 5), we propose to use the presented equations for estimating body fat percentage in children from skinfold-thickness measurements as a consistent and objective method. Age- and sex-specific thicknesses at given
With

and with equations 13-16, calculated total body density can be used to estimate total body fat percentage and to define age- and sex-specific cutoff values for skinfold thicknesses at given body fat percentages. Table 7 gives cutoff values for skinfold thicknesses (sum of bicipital, tricipital, subscapular, and suprailiacal skinfold thicknesses) at given body fat percentages, calculated with equations 25-28. Conclusions In children the definition of obesity is to some extent arbitrary. It is not known at which body fat percentage the health risks increase in children or whether there is an
increased health risk at all for moderately obese children

body

reference values for skinfold fat percentages it is possible to relate skinfoldin children to total body density

compared with nonobese children. In the absence of clear cutoff points for an undesirably high body fat percentage in children, obesity may be defined as a body fat percentage > 25% (for pubertal boys), > 30% (for prepubertal children), or > 35% (for pubertal girls). With the use of Table 7, it is now possible to relate skinfold thicknesses in a more objective, consistent, and perhaps more accurate way to body fat percentages. This is a major advantage in diagnosing childhood obesity compared with the more traditional criteria, ie, reference standards for anthropometric characteristics (30-34). In extremely fat children, as in extremely fat adults, skinfold thicknesses cannot be accurately measured. In these cases, generally corresponding to a sum ofskinfold thicknesses exceeding 120-140 mm, skinfold thicknesses cannot be used to estimate body fat percentages and Table 7 may not beused. #{163}3
We are indebted to Annemieke Paling and to Patricia Withagen carrying out skinfold-thickness and body-density measurements children. We would also like to thank the children and their parents their enthusiastic participation in this study. for in for

thickness

equations 25-28 measurements

1114 References

WESTSTRATE

AND

DEURENBERG
26. Harsha DW, Frerichs RR, Berenson GS. Densitometry and anthropometry ofblack and white children. Hum Biol 1978;50:26l80. Lohman TG, Boileau RA, Massey BH. Prediction of lean body mass in young boys from skinfold thickness and body weight. Hum Biol l975;47:245-62. Boileau RA, Lohman TG, Slaughter MH, Ba1ITE, Going SB, Hendrix MK. Hydration ofthe fat-free body in children during maturation. Hum Biol l984;56:651-66. Slaughter MH, Lohman TG, Boileau RA, et al. Influence of maturation on relationships of skinfolds to body density: a cross-sectional study. Hum Biol 1984; 56:681-9. Cronk CE, Roche AF. Race- and sex-specific reference data for triceps and subscapular skinfolds and weight/stature2. Am J Cm Nutr 1982; 35:347-54. Rolland-Cachera MF, Semp#{233} M, Guilloud-Bataille M, Patois E, P#{233}quignot-Guggenbuhi F, Fautrad V. Adiposity indices in children. Am J Cm Nutr l982;36: 178-84. Huenemann RL. Environmental factors associated with preschool obesity. J Am Diet Ass 1974;64:480-91. Tanner JM, Whitehouse RH. Revised standards for triceps and subscapular skinfold in British children. Arch Dis Child l975;50: 142-5. Tanner JM, Whitehouse RH. Standards for subcutaneous fat in British children. Br Med J l962;244:446-50. Owen GM. Measurement, recording, and assessment of skinfold thickness in childhood and adolescence: report ofa small meeting. Am J Cm Nutr 1982; 35:629-38. Branson RS, Vaucher YE, Harrison GG. Inter- and intra-observer reliability ofskinfold thickness measurements in newborn infants. Hum Biol 1982;54:l37-43. Fidanza F, Keys A, Anderson JT. Density ofbody fat in man and other mammals. J Appl Physiol l953;6:252-6. Mendez J, Keys A, Anderson JT, Grande F. Density of fat and bone mineral of the mammalian body. Metabolism 1960;9:
472-7.

1. Lukaski HC. Methods for the assessment ofhuman body composition: traditional and new. Am J Cm Nutr 1987;46:537-56. 2. GarrowJS. Indices ofadiposity. Nutr Abstr Rev 1983;53:697-708. 3. Mitchell HH, Hamilton TS, Steggerda FR, Bean HW. The chemical composition of the adult human body and its bearing on the biochemistry ofgrowth. J Biol Chem 1945; 158:625-37. 4. Widdowson EM, McCance RA, Spray CM. The chemical composition ofthe human body. Gin 5th 1951; 10:113-25. S. Forbes RM, Cooper AR, Mitchell HH. The composition of the adult human body as determined by chemical analysis. J Biol Chem 1953;203:359-66. 6. Forbes RM, Mitchell HH, Cooper AR. Further studies on the gross composition and mineral elements of the human body. J Biol Chem 1956;223:969-75. 7. Behnke AR, Feen BG, Welham WC. The specific gravity of healthy men: body weight and volume as an index of obesity. JAMA 1942; 1 18:495-8. 8. Forbes GB, Gallup J, Hirsch JB. Estimation oftotal body fat from potassium-40 content. Science 1961; 133:101-2. 9. Schoeller DA, van Santen E, Peterson DW, Dicta W, Jaspan J, Klein PD. Total body water measurement in humans with 180 and 2H labelled water. Am J Clin Nutr 1980; 33:2686-93. 10. Siri WE. Body volume measurements by gas dilution. In: Brozek J, Henschel A, eds. Techniques for measuring body composition. Washington, DC: National Academy ofSciences, 196 1:108-17. 1 1. Brozek J, Grande J, Anderson T, Keys A. Densitometric analysis of body composition: revision of some quantitative assumptions. AnnNYAcadSci l963;llO:l13-40. 12. Van Raaij JMA, Peek MEM, Vermaat-Miedema SH, Schonk CM, Hautvast JGAJ. New equations for estimating body fat mass in pregnancy from body density or total body water. Am J Cm Nutr l988;48:24-9. 13. Lohman TG, Slaughter MH, Boileau RA, Bunt J, Lussier L. Bone mineral measurements and their relation to body density in children, youth and adults. Hum Biol 1984;56:667-79. 14. Womersley J, Durnin JVGA, Boddy K, Mahaffy M. Influence of muscular development, obesity and age on the fat-free mass of adults. J Appl Physiol l976;4l:223-9. 15. Durnin JVGA, Womersley J. Body fat assessed from body density and its estimation from skinfold thickness: measurement on 481 men and women from 12-72 years. Br J Nutr 1974; 32:77-97. 16. Haisman MF. The assessment of body fat content in young men from measurements ofbody density and skinfold thickness. Hum Biol l970;42:679-88. 17. Sloan AW. Estimation of body fat in young men. J Appl Physiol 1967;23:3l 1-5. 18. Jackson AS, Pollock ML. Generalized equations for predicting body density in men. Br J Nutr l978;40:497-SQ4. 19. Lohman TG. Skinfolds and body density and their relation to body fatness: a review. Hum Biol l98l;53:18l-225. 20. Norgan NG, Ferro-Luzzi A. The estimation of body density in men: aregeneral equationsgeneral?Ann Hum Biol 1985; 12:1-15. 21. Durnin JVGA, Rahaman NM. Assessment ofthe amount offat in the human body from measurements of skinfold thicknesses. Br J Nutr l967;21:681-9. 22. Parizkova J. Total body fat and skinfold thickness in children. Metabolism l961;lO:41-8. 23. Forbes GB, Amirhakimi GH. Skinfold thickness and body fat in children. Hum Biol l970;42:401-l8. 24. Cramwinckel AB, Doesburg WH, Lemmens WAJG, Reintjes AGM, Kennes WAAM. Estimating body fat mass in children Voeding l975;36:638-45 (in Dutch). 25. Young CM, Sipin 55, Roe DA. Body composition studies of preadolescent and adolescent girls. J Am Diet Assoc l968;53:469-75.

27.

28.

29.

30.

31.

32. 33.

34. 35.

36.

37. 38.

Fomon SJ, Haschke F, Ziegler EE, Nelson SE. Body composition of reference children from birth to age 10 years. Am J Cm Nutr 1982;35:l 169-75. 40. Parizkova J, Roth Z. The assessment ofdepot fat in children from skinfold thickness measurements by Holtain (Tanner-Whitehouse) caliper. Hum Biol 1972;44:6l3-20. 41. Dugdale AE, Griffiths M. Estimating fat body mass from anthropometric data. Am J Clin Nutr 1979; 32:2400-3. 42. Johnston FE. Relationships between body composition and anthropometry. Hum Biol 1982;54:22l-45. 43. Sinning WE, Wilson JR. Validity of generalized equations for body composition in women athletes. Res Q Exerc Sport l984;55: 153-60. 44. Sinning WE, Dolny DG, Little KD, et al. Validity of generalized equations for body composition analysis in male athletes. Med Sci Sports Exerc 1985; 17:124-30. 45. Norgan NE, Ferro-Luzzi A. The estimation of body density in man: aregeneral equationsgeneral?Ann Hum Biol 1985; 12:1-15. 46. Lee MMC, Ng CK. Postmortem studies of skinfold caliper measurements and actual thickness of skin and subcutaneous tissue. Hum Biol l965;37:91-l03. 47. Dauncey MJ, Gandy G, Gairdner D. Assessment oftotal body fat in infancy from skinfold thickness measurements. Arch Dis Child 1977; 52:223-7. 48. Barker DE. Skin thickness in the human. Plast Reconstr Surg l951;7:l 15-6. 49. Roede MJ, van Wieringen JC. Growth diagrams 1980. Netherlands third nation-wide survey. Tijdschr Soc Gezondheidszorg l985;63(suppl): 1-34. So. Friis-Hansen B. Body composition during growth. In vivo mea39.

BODY
surements

COMPOSITION

IN

CHILDREN

1115

5 1. 52.

53. 54.

55.

56.

and biochemical data correlated to differential anatomiPediatrics 197 l;47:264-74. Garn SM, Greaney GR, Young RW. Fat thickness and growth progress during infancy. Hum Biol l956;28:232-50. Karlberg P, Taranger J. The somatic development ofchildren in a Swedish urban community. A prospectivelongitudinal study. Acta PaediatrScand [Suppl] 1976;258:l-78. Hutchinson-Smith B. Skinfold thickness in infancy in relation to birthweight. Dev Med Child Neurol 1973; 1S:628-34. Oakley JR, Parsons RJ, Whitelaw AGL. Standards for skinfold thickness in British newborn infants. Arch DisChild 1977; 52:28790. Vaucher YE, Harrison GG, Udall JN, Morrow G III. Skinfold thickness in north american infants 24-41 weeks gestation. Hum Biol l984;56:7 13-31. Weststrate JA, Van Klaveren H, Deurenberg P. Changes in skinfold thicknesses and body mass index in 171 children, initially 1 to 5 years ofage: a 5#{189} year follow-up study. mt J Obes 1986; 10:313calgrowth. 21.

For males aged 2-18

Dff

y 178 [age (y)

-

1 .07 1 5 + 0.00

2]

(5)

For females

aged 2- 10 y
Dff=

l.07l5+0.00044[age(y)-2]

(6)

For females

aged 10-1 8 y
Dff=
1.0750 + 0.00313 [age(y)
-

10]

(7)

Substitution
Age

ofDff in equation
Sex

1 results in the following

F.l00 585 --550 D 562 --525 D 495 --450 D 553 --514 D 495 A D A0 A1 D A2 _A3 A4
--

Dff

0(mo) 24(mo) 18(y) 10(y) 18(y)

M,F M,F M F F

1.0635 1.0715 1.1000 1.0750 1.1000

57.

Weststrate JA, Deurenberg P. van Tinteren H. Indices ofbody fat distribution and adiposity in Dutch children from birth to 18 years ofage. Int J Obes(in press). 58. Den Besten C, Vansant G, Weststrate JA, Deurenberg P. Resting metabolic rate and diet-induced thermogenesis in abdominal and gluteal-femoral obese women before and after weight reduction. Am J Clin Nutr l988;47:840-7. 59. Semp#{233} M, P#{233}dron G, Roy-Pernot MP. The science ofgrowth methods and charts. Paris, Theraplix, 1979 (in French). 60. Parizkova J. Age trends in fat by normal and obese children. J Appl Physiol l96l;l6:l73-4.

B1

-j--

v [age

A0
B0

-+

A1 according
B, according

to a square to a square
to a linear, to a linear, to a linear, to a linear, to a linear, to a linear,

root, ie,

K.

(mo)]#{176}5,

function
-+

root, ie, K1 [age (mo)]#{176}5,

.

function

APPENDIX Derivation ofequations 13-16

A
B1

A2 according
B2 according

ie, ie, ie, ie, ie, ie,

K2 [age (y)
.

2], function 2], function 2], function 2], function

K3 [age (y)
.

A2
B2
Df) D

A3 according
B3 according

[age (y)

K5 [age (y)
. K

Ff.l00=F%={l00.[

D (Dff X Df)/(Dff

A3
B3
-

A4 according
B4 according

[age (y)

10], function
10], function

K7 [age (y)
.

-[loo.(DD)j

(1) (2)

Derivation A1 -A0=
age 1
-

of
-23 age0

K0

Df=
Dff
For males and females

0.900. f(sex,
aged

lO3kg.m3 age)

= -24
=

-23 4.7

Ko.(24)#{176}5

(3)
Ko

23/(24)#{176}

0-1 .99 y 1 63 [age (mo)]#{176}5

(4)

Dff

1 .0635

+ 0.00

For other equations, a similar way.

derivation

ofK, (where

= 2-7)

is done

in

428
density increased. If the predictive nature of calcium limited studies, mass.

SENTIPAL
intake on

ET
14.

AL
Bouchard C, Tremblay A, Leblanc C, et al. A method to assess energy expenditure in children and adults. Am I Clin Nutr l983;37: 46 1-7. Kelly TL, Slovik DM, Schoenfeld DA, et al. Quantitative digital radiography versus dual photon absarptiometry ofthe lumbar spine. I Clin Endocrinol Metab l988;67:839-42. National Research Council. Recommended dietary allowances. 10th ed. Washington, DC: National Academy Press, 1989. US Department ofAgriculture. The hassle free guide to a better diet. Washington, DC: US Government Printing Office, 1980. (Leaflet no. 567.) Carroll MD, Abraham 5, Dresser CM. Dietary intake source data, 1976-1980. Washington, DC: US Government Printing Office, 1983. [DHHS Publication no. (PHS) 83-1681.] National Center for Health Statistics. Caloric and selected nutrient values for persons 1-74 years of age. First Health and Examination Survey, 1971-1974. Washington, DC: US Government Printing Office, 1979. [DHEW publication (PHS) 79-157.]

the variance in V-BMD study can be substantiated further development translate tentially teoporasis. evidence of of the peak

observed in this in longitudinal importance vertebral bane

cross-sectional it will provide intake This could on the then poas16.

17.

of calcium

15.

into higher bone density contribute to prophylaxis

at menopause and thus against subsequent spinal

We thank the Clinical Studies Center staff at Childrens Hospital, Columbus, OH, and Ormand Berg far all oftheir time and work on the study. We are also indebted to Fei Fei Wei for her statistical advice and Linda Boyne for her pediatric nutrition advice and editorial comments.

18.

19.

References
1. Riggs 2. BL, Melton 1986;3 14:1676-86.

LI.

Involutional

osteoporosis.

N Engl

I Med

3.

4.
5.

6.

7.

8.

9. 10.

1 1.
12.

C, Rodbro P, Thorgen Nielsen C. Bone mineral content and estimated total body calcium in normal children and adolescents. Scand I Lab Clin Invest 1975;35:507-lO. Matkovic V. Calcium metabolism and calcium requirements during skeletal modeling and consolidation ofbone mass. Am I Clin Nutr 199 1;54:245S-60S. Angus RM, Sambrook PN, Pocock NA, Eisman IA. Dietary intake and bone mineral density. Bone Miner l988;4:265-72. Matkovic V, Kosital K, Simanovic I, et al. Bone status and fracture rates in two regions ofYugaslavia. Am I Clin Nutr l979;32:540-9. Sandler RB, Slemenda CW, LaPorte RE, et al. Post-menopausal bone density and milk consumption in childhood and adolescence. Am I Clin Nutr l985;42:270-4. Matkavic V. Fontana D, Tominac C, God P. Chestnut CH III. Factors that influence peak bone mass formation: a study of calcium balance and the inheritance ofbone mass in adolescent females. Am I Clin Nutr 1990;52:878-88. Picard D, Ste-Marie LG, Coutu D, et al. Premenopausal bone mineral content relates to height, weight and calcium intake during early adulthood. Bone Miner 1988;4:299-309. Tanner IM. Growth at adolescence. 2nd ed. Oxford, England: Blackwell Scientific Publications, 1962. Office of Maternal and Child Health. Nutritional screening of Children: a manual for screening and followup. Washington, DC: US Government Printing Office, 1981. [DHHS publication (PHS) 815114.] Axelson JM, Csernus MM. Reliability and validity of a food frequency checklist. I Am Diet Assoc 1983;83: 152-5. Bingham SA. The dietary assessment of individuals: methods, accuracy, new techniques, and recommendations. Nutr Abstr Rev Christiansen l987;57:705-l 1.

APPENDIX

Subject Sex:
Race: Desirable weight: Medications:

rejection

criteria
Male Non-Caucasian < 10% or centile Intake
sants, thiazide

body

>

90%

of

height-related anticonvul-

per-

of

glucocorticoids,
diuretics,

aluminum-containing

antacids,

or isoniazid problems, bone disof growth than one), renal diathat of cigarettes cx-

Prematurity: Medical condition:

Gestation <36 wk History of or current medical including thyroid problems, ease, physician problem, bone persistent
disease,

indication fractures (more

bone
kidney

pain, liver disease, stones, pregnancy, A supplement the RDA packs

betes Vitamin A supplementation: Nicotine: Alcohol: Long-term immobilization: Physical activity: Diet plus vitamin ceeds five times Smokes a week Intake Forced Present
physical

one

or more

of > 200 g ethanol/wk bed rest for > 1 ma or past activity SMR participation
>

in any

1 y

in a routine weight already group) lifting, met (n program

7 h/wk,

or a competitive TANNER Maturity Sexual Rating Specific

=

gymnastics category in each

13. Cellier KM, Hankin ME. Studies of nutrition in pregnancy: some considerations in collecting dietary information. Am I Clin Nutr 1963; 13:55-60.

9 to 1 1 subjects

(SMR):

ERRATUM
Am should J Clin read Nutr l989;50: 1 104-15. Two brackets were misplaced in equations 26-28. The equations as follows:
{0.0018[age(y)-2]})-({0.0719
-

D=(l.13l5+

0.0006[age

(y)

2]

} } }
-

log (skinfold

thickness)

(26)

D=(1.13l5+{0.0004[age(y)-2]})-({0.0719
-

0.0003[age
-

(y)

2]

log (skinfold

thickness)

(27)

1.1350 + {0.003l[age

(y)

10]})
-

({0.07l9
(y)
-

0.0003[age

2]

log (skinfold

thickness))

(28)