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Measurement of body composition in children

Authors: Sarah M Phillips, MS, RD, LD, Robert J Shulman, MD

Section Editor: Kathleen J Motil, MD, PhD
Deputy Editor: Alison G Hoppin, MD

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2018. | This topic last updated: Apr 18, 2017.

INTRODUCTION — The measurement of body composition may include direct or indirect measurements of
body fat, lean body mass, and bone mass, and sometimes of the distribution of fat between the visceral or
subcutaneous compartments. The choice of method depends on which of these compartments is of interest,
whether the measurement is for clinical purposes or research, and what degree of precision is required.

The main methods used to estimate body composition are discussed here. Measurements of growth in
children and disorders of under- or over-nutrition are discussed separately. (See "Measurement of growth in
children" and "Definition; epidemiology; and etiology of obesity in children and adolescents" and "Failure to
thrive (undernutrition) in children younger than two years: Etiology and evaluation".)

THEORETICAL MODELS OF BODY COMPOSITION — Theoretical models of body composition divide the
body into two, three, or multiple compartments:

● In the two-compartment model, the body is divided into the fat and fat-free mass. Bioimpedance is a
method used to assess body composition based on the two-compartment model. The two-compartment
model is useful in clinical practice because of the ease with which body fat and fat-free mass can be
measured and the simplicity with which their changes during health and disease can be assessed.
However, the two-compartment model is subject to error because the methods used to measure body fat
and fat-free mass are based upon the assumption that the chemical composition of these tissue stores
remains constant across a broad range of ages and disease states.

In the three-compartment model, the body is divided into fat, fat-free mass, and bone. Dual energy x-ray
absorptiometry (DXA) is a method to assess body composition based on the three compartment model.
The body composition of children from birth to 16 years of age has been measured using this method
(table 1) [1-3]. Fat-free mass and body fat increase with age throughout childhood, but vary at any given
age depending on gender and race or ethnicity [1-4]. These estimates provide reference values for
healthy children and useful comparative indices to assess nutritional deficits in children who are ill [5].

● Multicompartment models reduce the errors inherent in the two-compartment model by dividing the body
into components based on its atomic, molecular, cellular, or tissue composition (figure 1) [6]. Although
these models describe body composition more precisely, the techniques required to measure these
components are limited to research settings.

ESTIMATES OF ADIPOSITY — Numerous measures are used for clinical assessment of obesity in children
and adolescents and include body mass index (BMI), weight-for-height, skinfold thickness, and waist
circumference or waist-to-hip ratio. BMI is the standard measure of obesity for children older than two years;
waist circumference and waist-hip ratio are used primarily for research purposes. (See "Definition;
epidemiology; and etiology of obesity in children and adolescents".)

Body mass index — The body mass index (BMI) is the most practical way to evaluate the degree of excess
weight and risk for metabolic syndrome [7]. It correlates with body fat and is relatively unaffected by height. It
is calculated from the weight and square of the height and can be determined using a calculator for boys
(calculator 1) and for girls (calculator 2). In children, BMI varies with age and gender (figure 2A-B). It also
varies to a lesser extent with pubertal maturation stage and ethnicity, and these factors should be taken into
account when BMI measures are used for research [8-10]. (See "Measurement of growth in children", section
on 'Body mass index (BMI)'.) and (see "Definition; epidemiology; and etiology of obesity in children and
adolescents").

BMI is a good predictor of adiposity in the healthy pediatric population [8,11-13]. As an example, BMI was
compared with percentage of fat obtained by using dual energy x-ray absorptiometry (DXA) in a study of 979
children [11]. The standard error for an individual BMI measurement compared to percentage fat was 4.7 to
7.3 percent of body weight. However, BMI is not a direct measure of adiposity, and may slightly overestimate
fatness in children who are short or who have relatively high muscle mass. BMI also may underestimate
adiposity in a substantial proportion of children, such as those with reduced muscle mass due to low levels of
physical activity [14]. Finally, children of different stature but the same BMI do not necessarily have the same
body composition [15].

Weight-for-height — Weight-for-height measurements are another means to assess adiposity, and are the
preferred method for clinical assessment of obesity or failure to thrive in children younger than two years old.
In older children, overweight, simple obesity, and severe obesity are sometimes defined as weight-for-height
measurements greater than 110, 120, and 140 percent of expected, respectively [16]. Expected body weight
is determined from the weight percentile that is proportionate to the height percentile for chronologic age
using standard growth curves (figure 3A-B and figure 4A-B).

For children older than two years, BMI has replaced weight-for-height estimates as the standard measure for
adiposity because weight-for-height measurements do not correlate well with body fat and are affected by
height to a greater degree. (See 'Body mass index' above.)

FAT DISTRIBUTION — Adults with abdominal adiposity (also called central, visceral, android, or male-type
obesity) are at increased risk for heart disease, diabetes, hypertension, and some forms of cancer. The
evidence for this association in children and adolescents is weaker. However, data from the Bogalusa Heart
Study generated age-specific thresholds for body mass index (BMI) and waist circumference in children and
adolescents that were predictive of having three or more risk factors for cardiovascular disease (high blood
pressure; low high-density lipoprotein cholesterol concentration; or high low-density lipoprotein cholesterol,
triglyceride, glucose, or insulin concentration, adjusted for age) (figure 5A-B) [17].

Abdominal obesity is evaluated clinically by measuring the waist circumference or the ratio of waist
circumference to the hip circumference (waist-to-hip ratio, or WHR). Waist circumference is measured just
above the uppermost lateral border of the right ilium, at the end of a normal expiration. The hip circumference
is measured in a horizontal plane at the level of maximum circumference of the hips and buttocks.

Waist-to-hip ratio — Men with a WHR of 0.95 or more and women with a WHR of 0.85 or more are
considered to be at increased cardiovascular risk. Similar definitions have not been developed for children,
although they, too, are at increased risk of cardiovascular disease if they have abdominal adiposity [18-25].
One study of 127 children and adolescents aged 9 to 17 years, as an example, found correlations between
abdominal fat distribution and triglycerides, high density lipoprotein cholesterol, systolic blood pressure, and
left ventricular mass [18].

Waist circumference — Waist circumference percentile curves have been developed for Canadian [26],
British [27], Italian [28], Spanish [29], and Australian children [30]. Data from the Third National Health and
Nutrition Examination Survey (NHANES III) were used to estimate age-, sex- and ethnicity-specific waist
circumference percentiles for children and adolescents in the United States (table 2) [31].

The waist circumference values at different percentiles describe the existing population of children and
adolescents and do not establish a standard of what "should be." Some, but not all, definitions of the
metabolic syndrome in children include waist circumference (table 3), and these features do not track
consistently to metabolic syndrome in adulthood. Nonetheless, this measurement, in conjunction with the
BMI, may serve as a useful clinical tool to estimate obesity-related comorbidities [25,32]. (See "Comorbidities
and complications of obesity in children and adolescents" and "The metabolic syndrome (insulin resistance
syndrome or syndrome X)", section on 'Children and adolescents'.)

Waist-to-height ratio — The waist-to-height ratio is another measure of abdominal adiposity that has been
associated with cardiovascular risk. Analysis of data from NHANES III indicates that the waist-to-height ratio
may be a better predictor of increased low-density lipoprotein cholesterol, total cholesterol, and fasting
triglycerides than BMI in children aged 4 to 17 years [33].

Imaging — Magnetic resonance imaging (MRI) or computed tomography (CT) can be used to measure
visceral adipose tissue. The technique usually quantifies adipose tissue in a single-slice cross-section at the
level of the L4/L5 lumbar disc. The subcutaneous fat (outside the abdominal musculature) may be measured
in the same image. These measures of visceral adiposity correlate with insulin resistance, triglycerides,
hepatic steatosis, and other components of the metabolic syndrome [34,35]. The technique is used for
research in obesity and metabolic disease, and does not contribute to clinical care.

MEASURES OF BODY COMPOSITION — Measurement of body composition, particularly body fat, can be
an important part of nutritional assessment because fat is the major source of stored energy in the body and
a good indicator of nutritional state. In addition, lean body mass indicates the water and protein content, and
bone density indicates the calcium and mineral stores [36]. The methods used to measure body composition
differ in their ease of determination, cost, accuracy, use of radiation, and utility for estimating body fat (table
4) or other body compartments relevant to nutritional status (eg, bone density). The most commonly used
techniques are described below.

Anthropometrics — The most widely used anthropometric measurements to assess body composition are
the triceps skinfold and the mid-upper arm circumference. The triceps skinfold reflects body fat and the mid-
upper arm cross-sectional area reflects lean body mass. Because the precision and reproducibility of these
measures is low, they add little to the clinical evaluation for most patients [37]. For the same reason, most
research studies seeking a measure of body composition will use one of the more precise measures
discussed below when possible.

Skinfold thickness — Measurements of multiple skinfold thicknesses are used widely because the
technique is noninvasive, inexpensive, and easy to perform. However, measurements of skinfold thickness
often are less accurate than are measurements of height or weight, particularly in obese subjects [38]. One
study compared the agreement between eight widely used skinfold thickness equations and the value
obtained on the basis of measurements of body density, body water, and bone mineral content [39]. The use
of skinfold measurement calculations over- or underestimated individual fat mass by approximately 10
percent. A review of the literature substantiates these concerns [40].

Although skinfold thickness measurements may have limited clinical value, they may be useful in the long-
term monitoring of nutritional therapy in children who are malnourished, have diseases that are associated
with changes in body composition, or are obese [41,42].

The triceps skinfold is measured as follows:

● The child's arm should hang freely

 ● The upper arm skinfold (skin and fat minus the underlying muscle) should be pulled out 1 cm above
midpoint

● The calipers should be applied 1 cm in depth at the measured midpoint

● The calipers should be released, and the reading should be obtained to the nearest 1 mm as soon as the
needle is steady

● The average of duplicate measurements should be recorded [43]

Mid-arm muscle circumference — The mid-upper arm circumference is measured as follows:

● The child's right arm should be flexed at a 90-degree angle and hang freely

● The midpoint between the tip of the olecranon and acromion should be marked

● The circumference of the arm should be measured to the nearest 0.1 cm at the midpoint with a flexible
metal tape [43]

The mid-arm muscle circumference (MAMC) can be calculated from the triceps skinfold (TSF) and the mid-
arm circumference (MAC) as follows:

MAMC = MAC – (3.1416 x TSF)

The measured values for TSF and MAC and the calculated MAMC are compared with reference values (table
5A-C) [44]. Values less than the 5th percentile for age are consistent with acute malnutrition, and values
greater than the 90th percentile are consistent with obesity.

Hydrodensitometry — Underwater weighing is the oldest method for determining body density; it has been
largely replaced by dual energy absorptiometry (see below). Body density is estimated from the weight of the
subject in air and water, using appropriate correction factors for temperature, air in the respiratory tract, and
constants for the densities of fat and fat-free tissue [45]. Hydrodensitometry can be performed only in children
who can hold their breath for a period of time and have no contraindication to complete underwater
submersion. In addition, the technique is not reliable in younger children because of the change in density of
lean body mass during maturation [46]. (See "Normal puberty".)

Isotope dilution — In isotope dilution techniques, the volume of a body compartment is determined by the
ratio of the dose of a tracer, administered orally or intravenously, to its concentration in the body compartment
after a sufficient equilibration period has elapsed. Total body water, as an example, is estimated by isotope
dilution using the stable isotopes of deuterium (2H2O) or oxygen (H218O) [47]. Once total body water has
been determined, the fat-free mass of the body can be calculated, based upon the assumption that the
hydration of lean tissue is constant across a broad range of ages and for both genders. Potential errors can
occur when hydrogen isotopes are used because they exchange with non-aqueous hydrogen resulting in
overestimation of total body water by 5 to 10 percent. Isotope dilution is impractical in the clinical setting
because of the expense of the stable isotopes and the analytical equipment.

Bioelectrical impedance analysis — Bioelectrical impedance analysis (BIA) relies upon an electrical current
to measure the fat and fat-free mass (FFM) of the body [48,49]. The lean tissues of the body, because of their
dissolved electrolytes, are the major conductors of electrical current, whereas body fat and bone are relatively
poor conductors. Thus, BIA primarily measures total body water from which an estimate of FFM is obtained.
BIA frequently is used because it is noninvasive, portable, and inexpensive. However, small changes in body
water result in large differences in the estimate of FFM. Placement of the electrodes is site-specific and can
compound errors of measurement. The placement of the electrodes (hand-to–foot, hand-to-foot, or foot-to-
foot), will affect the capacity to predict body fat percentage. The foot-to-foot models (eg, Tanita SC-240)
measure resistance in the lower part of the body, and has only fair precision [50,51]. The hand-to-foot models
(eg, Biodynamics) measure resistance in both the lower and upper body [52]. In addition, BIA is influenced by
sex, age [53], disease state, and level of fatness (because total body water and relative extracellular water
are greater in obese individuals) [54]. The data suggest BIA remains problematic in its ability to assess
percent body fat, fat mass, or fat-free mass [55].

Air-displacement plethysmography — Air-displacement plethysmography is a method for determining

body volume and hence, fat mass. Using the same whole-body measurement principle as underwater
weighing, air-displacement plethysmography measures a subject's mass and volume, from which the whole-
body density can be determined. The subject is placed inside the device; computerized pressure sensors
then determine the amount of air displaced by the subject's body. Body fat and lean muscle mass can then be
calculated [56].

The accuracy of air-displacement plethysmography (as compared with a gold standard of hydrostatic
weighing or isotope dilution) is very good in adults [57]. Compared with the four compartment model (fat, fat-
free mass, total body water and bone), the accuracy and precision of air-displacement plethysmography are
good in school-aged children (± 2 percent for fat mass), providing that child-specific equations for lung
volume are used [58-60]. The technique also has good accuracy in infants using a device specifically
designed for this age group (eg, PeaPod) [59,61,62].

Dual-energy x-ray absorptiometry — The above methods inform the two-compartment model of body
composition. In contrast, dual-energy x-ray absorptiometry (DXA) estimates FFM, body fat, and bone mineral
density by using the differential absorption of x-ray or photon beams of two levels of intensity. DXA relies on
the principle that the intensity of an x-ray or photon beam is altered by the thickness, density, and chemical
composition of an object in its path [63]. In children, the scan takes approximately 10 minutes. The average
radiation dose, depending on the instrument and body size, is 0.04 to 0.86 mRem, less than the average
exposure of a chest radiograph [54]. The precision of DXA (coefficient of variation) is less than 2 percent [64].
DXA has been used to measure body composition in children from birth to 16 years of age (table 1) and is
becoming more readily available in the clinical setting [1-3]. The technique is limited because estimates of fat
mass become less accurate as the individual's trunk thickness increases and it appears more accurate at a
group level, compared with the individual level [40,65]. (See "Overview of dual-energy x-ray absorptiometry",
section on 'Children'.)

Neutron activation analysis — Body composition techniques, such as electrical impedance, tracer dilution,
and DXA, provide information related to tissue density or volume but not chemical content. In contrast,
neutron activation analysis allows the direct elemental analysis of the body. Virtually all the major elements of
the body can be assayed in vivo: hydrogen, oxygen, carbon, nitrogen, calcium, phosphorus, sodium, chlorine,
and potassium.

The method uses the principle that exposure to a given dose of neutrons generates a known amount of
radioactivity within a given mass [66]. When an atom captures a neutron, the atom is transformed to another
nuclear state of the same chemical element. The new atom can be stable or radioactive, but it will have
excess energy that must be released. If the new atom is radioactive, it will decay over time with a known half-
life. Thus, when the body is exposed to neutrons, gamma rays are emitted immediately (prompt) and for
some time thereafter (delayed); these gamma rays can be measured in a counting chamber. The particular
element being examined can be identified by the characteristic energy of the electromagnetic radiation it
emits and its rate of decay. The use of this technique is limited by its expense and radiation exposure.

Total body potassium — Total body potassium counting, another method that determines elemental
composition, measures the content of radioactive potassium (40K) in the body while the child lies between
detectors in a well-shielded metal counting chamber [67]. Radioactive potassium emits a characteristic high-
energy gamma ray (1.46 MeV) that in turn serves as a marker for total body potassium, body cell mass, and
fat-free mass. These relationships are based upon several assumptions:

● 40K exists in the body at a fixed proportion (0.0118 percent) to naturally occurring body potassium.

● The total potassium content of the FFM remains constant with respect to tissue nitrogen, a major
component of FFM.

Although this method is noninvasive and safe, the limited availability of the instrument, particularly one with
sufficient sensitivity to measure small infants, renders this method impractical in the clinical setting.

SUMMARY AND RECOMMENDATIONS

● The choice of method for measuring body composition depends on whether the measurement is for
clinical purposes or research, and what degree of precision is required.

● Body mass index (BMI) is the best determinant of adiposity for clinical purposes. It is sufficiently
correlated with adiposity to provide a clinical estimate of weight-related medical risk, and it is noninvasive
and inexpensive. (See 'Body mass index' above.)

● Estimates of fat distribution, including waist-to-hip ratio and waist circumference, also are associated
with weight-related medical risks in adults. The association is less clear for children and adolescents,
and these measures are for the purposes of research rather than for their clinical utility. (See 'Fat
distribution' above.)

● Direct measures of body composition include anthropometrics, air-displacement plethysmography, and

dual-energy x-ray absorptiometry (DXA). These measures vary considerably in their precision and
expense; they generally are not valuable for the clinical evaluation of a patient. For the purposes of
research studies requiring a precise measure of body composition, DXA or air-displacement
plethysmography typically are used. (See 'Measures of body composition' above.)

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61. Yao M, Nommsen-Rivers L, Dewey K, Urlando A. Preliminary evaluation of a new pediatric air
displacement plethysmograph for body composition assessment in infants. Acta Diabetol 2003; 40
Suppl 1:S55.
62. Ellis KJ, Yao M, Shypailo RJ, et al. Body-composition assessment in infancy: air-displacement
plethysmography compared with a reference 4-compartment model. Am J Clin Nutr 2007; 85:90.
63. Lukaski HC. Soft tissue composition and bone mineral status: evaluation by dual-energy X-ray
absorptiometry. J Nutr 1993; 123:438.
64. Ellis KJ, Shypailo RJ, Pratt JA, et al. Accuracy of DXA-based body composition measurement for pediat
ric studies. In: Human Body Composition. In Vivo Methods, Models, and Assessment, Ellis KJ, Eastman
JD (Eds), Plenum Press, New York 1993. p.153.
65. Horan M, Gibney E, Molloy E, McAuliffe F. Methodologies to assess paediatric adiposity. Ir J Med Sci
2015; 184:53.
66. Heymsfield SB, Wang Z, Baumgartner RN, et al. Body composition and aging: a study by in vivo
neutron activation analysis. J Nutr 1993; 123:432.
67. Ellis KJ, Nichols BL Jr. Body composition. Adv Pediatr 1993; 40:159.

Topic 5363 Version 11.0

GRAPHICS
Body composition of healthy children

Age Height Weight Fat-free Fat mass

Gender Race/ethnicity
(years) (cm) (kg) mass (kg) (kg)

Female Multiracial Birth 50 3.3 2.8 0.5

0.5 66 7 5.1 1.9

1 74 9 6.8 2.2

2 85 12 9.6 2.4

Caucasian 4 107 18 14 4

8 127 28 20 7

12 151 44 30 12

16 164 56 38 15

African-American 4 106 18 14 4

8 133 33 23 9

12 157 54 36 16

16 162 63 40 21

Hispanic 4 106 19 14 4

8 124 30 19 8

12 153 57 32 17

16 161 67 39 25

Male Multiracial Birth 52 3.5 3.0 0.5

0.5 68 8 6.0 2.0

1 76 10 7.8 2.2

2 87 13 10.5 2.5

Caucasian 4 103 17 13 3

8 126 26 20 5

12 157 52 38 12

16 174 67 54 10

African-American 4 105 18 15 2

8 127 29 23 4

12 161 60 46 13

16 176 83 66 8

Hispanic 4 99 16 12 1

8 127 30 21 4

12 158 56 39 9

16 172 69 54 6

Data from:
1. Fomon SJ, Haschke F, Ziegler EE, Nelson SE. Am J Clin Nutr 1982; 35:1169.
2. Ellis KJ, Abrams SA, Wong WW. Am J Clin Nutr 1997; 65:724.
3. Ellis KJ. Am J Clin Nutr 1997; 66:1323.

Graphic 70879 Version 3.0

Five perspectives on body composition

In this figure, the human body is classified into increasingly general categories,
proceeding from the atomic level through molecular, cellular, tissue-system, and whole
body. Each perspective is characterized by a set of unique components, which define its
measurement parameters.

ECS: extracellular solids; ECF: extracellular fluid.

Adapted from: Wang Z, Pierson RN, Heymsfield SB. The five-level model: a new approach to
organizing body-composition research. Am J Clin Nutr 1992; 56:19.

Graphic 79699 Version 5.0

Body mass index-for-age percentiles, boys, 2 to 20 years, CDC growth
charts: United States

BMI: body mass index; CDC: Centers for Disease Control and Prevention.

Developed by the National Center for Health Statistics in collaboration with the National Center for
Chronic Disease Prevention and Health Promotion (2000).

Graphic 60784 Version 5.0

Body mass index-for-age percentiles, girls, 2 to 20 years, CDC growth
charts: United States

BMI: body mass index; CDC: Centers for Disease Control.

Developed by the National Center for Health Statistics in collaboration with the National Center for
Chronic Disease Prevention and Health Promotion (2000).

Graphic 68478 Version 5.0

Weight-for-length percentiles, girls 0 to 24 months, WHO growth
standards

WHO: World Health Organization.

Reproduced from: Centers for Disease Control and Prevention based on data from the WHO Child
Growth Standards.

Graphic 73036 Version 6.0

Weight-for-length percentiles, boys 0 to 24 months, WHO growth
standards

WHO: World Health Organization.

Reproduced from: Centers for Disease Control and Prevention based on data from the WHO Child
Growth Standards.

Graphic 53474 Version 5.0

Weight-for-stature percentiles for boys 2 to 5 years, CDC growth charts:
United States

Developed by the National Center for Health Statistics in collaboration with the National Center for
Chronic Disease Prevention and Health Promotion (2000).

Graphic 55850 Version 4.0

Weight-for-stature percentiles for girls 2 to 5 years, CDC growth
charts: United States

Developed by the National Center for Health Statistics in collaboration with the National Center for
Chronic Disease Prevention and Health Promotion (2000).

Graphic 65129 Version 5.0

Thresholds for defining cardiovascular risk in boys, Bogalusa Heart
Study

Smoothed body mass index (BMI) and waist circumference thresholds for predicting risk
factor clustering among male children and adolescents in the Bogalusa Heart Study (1992-
1994). Each curve defines the optimal BMI or waist circumference which predicts having
three or more cardiovascular risk factors (high blood pressure; low high-density lipoprotein
cholesterol concentration; or high low-density lipoprotein cholesterol, triglyceride, glucose,
or insulin concentration, adjusted for age) at a given age.

Data from: Katzmarzyk PT, Srinivasan SR, Chen W, et al. Body mass index, waist circumference,
and clustering of cardiovascular disease risk factors in a biracial sample of children and adolescents.
Pediatrics 2004; 114:e198.

Graphic 51934 Version 4.0

Thresholds for defining cardiovascular risk in girls, Bogalusa Heart
Study

Smoothed body mass index (BMI) and waist circumference thresholds for predicting risk
factor clustering among female children and adolescents in the Bogalusa Heart Study (1992-
1994). Each curve defines the optimal BMI or waist circumference which predicts having
three or more cardiovascular risk factors (high blood pressure; low high-density lipoprotein
cholesterol concentration; or high low-density lipoprotein cholesterol, triglyceride, glucose,
or insulin concentration, adjusted for age) at a given age.

Data from: Katzmarzyk PT, Srinivasan SR, Chen W, et al. Body mass index, waist circumference, and
clustering of cardiovascular disease risk factors in a biracial sample of children and adolescents.
Pediatrics 2004; 114:e198.

Graphic 59701 Version 3.0

90th percentile for waist circumference for European-American, African-
American, and Mexican-American children and adolescents, according to sex

Boys Girls
Age
(y) European African Mexican European African Mexican
American American American American American American

6 64.2 62.8 67.1 64.0 64.8 66.2

7 67.6 66.1 70.6 66.8 68.5 69.4

8 71.0 69.3 74.1 69.7 72.2 72.6

9 74.3 72.5 77.6 72.6 75.8 75.8

10 77.7 75.7 81.0 75.5 79.5 78.9

11 81.1 78.9 84.5 78.3 83.2 82.1

12 84.5 82.1 88.0 81.2 86.9 85.3

13 87.9 85.3 91.5 84.1 90.5 88.5

14 91.3 88.5 95.0 86.9 94.2 91.7

15 94.7 91.7 98.4 89.8 97.9 94.8

16 98.1 94.9 101.9 92.7 101.6 98.0

Adapted from: Fernandez JR, Redden DT, Pietrobelli A, Allison DB. J Pediatr 2004; 145:439.

Graphic 80082 Version 3.0

Definitions of metabolic syndrome in children and adolescents

IDF (10 to 16
Parameters Modified ATP III NHANES III
years)

Required

Waist circumference ≥90th percentile* ≥90th percentile

Number of ≥3 ≥2 All
abnormalities

Triglyceride >95th percentile ≥150 mg/dL (1.7 ≥110 mg/dL (1.24 mmol/L)
mmol/L)

HDL <5th percentile <40 mg/dL (1.03 ≤40 mg/dL (1.03 mmol/L)
mmol/L)

BP Either Either ≥90th percentile

Systolic >95th percentile >130 mmHg

Diastolic >95th percentile ≥85 mmHg

Glucose Impaired glucose ≥100 mg/dL (5.6 Fasting ≥110 mg/dL (6.1
tolerance mmol/L) mmol/L)

ATP III: Adult Treatment Panel; IDF: International Diabetes Federation; NHANES: National Health and Nutrition
Examination Survey; HDL: high-density lipoprotein; BP: blood pressure.
* Ethnic-specific waist circumference (see Fernandez JR, Redden DT, Pietrobelli A, et al. Waist circumference
percentiles in nationally representative samples of African-American, European-American, and Mexican-American
children and adolescents. J Pediatr 2004; 145:439).

Graphic 66120 Version 4.0

Methods of estimating body fat and its distribution

Ease of Measures
Method Cost Accuracy
Use Regional Fat

Height and weight $ Easy High No

Skin folds $ Easy Low Yes

Circumferences $ Easy Moderate Yes

Ultrasound $$ Moderate Moderate Yes

Density

Immersion $ Moderate High No

Plethysmograph $$$ Difficult High No

Heavy water

Tritiated* $$ Moderate High No

Deuterium oxide or heavy oxygen $$$ Moderate High No

Potassium isotope (40K) $$$$ Difficult High No

Total body electrical conductivity $$$ Moderate High No

Bioelectric impedance (BIA) $$ Easy High No

Absorptiometry (dual energy X-ray = DEXA; dual $$$ Easy High No

photon = DPA)

Computed tomography* $$$$ Difficult High Yes

Magnetic resonance imaging $$$$ Difficult High Yes

* Radiation involved.

Graphic 51556 Version 1.0

Triceps skin fold - normal values

Triceps skinfold percentiles, mm

Age
5 10 25 50 75 90 95

Males

1 - 1.9 6 7 8 10 12 14 16

2 - 2.9 6 7 8 10 12 14 15

3 - 3.9 6 7 8 10 11 14 15

4 - 4.9 6 6 8 9 11 12 14

5 - 5.9 6 6 8 9 11 14 15

6 - 6.9 5 6 7 8 10 13 16

7 - 7.9 5 6 7 9 12 15 17

8 - 8.9 5 6 7 8 10 13 16

9 - 9.9 6 6 7 10 13 17 18

10 - 10.9 6 6 8 10 14 18 21

11 - 11.9 6 6 8 11 16 20 24

12 - 12.9 6 6 8 11 14 22 28

13 - 13.9 5 5 7 10 14 22 26

14 - 14.9 4 5 7 9 14 21 24

15 - 15.9 4 5 6 8 11 18 24

16 - 16.9 4 5 6 8 12 16 22

17 - 17.9 5 5 6 8 12 16 19

18 - 18.9 4 5 6 9 13 20 24

19 - 24.9 4 5 7 10 15 20 22

25 - 34.9 5 6 8 12 16 20 24

Females

1 - 1.9 6 7 8 10 12 14 16

2 - 2.9 6 8 9 10 12 15 16

3 - 3.9 7 8 9 11 12 14 15

4 - 4.9 7 8 8 10 12 14 16

5 - 5.9 6 7 8 10 12 15 14

6 - 6.9 6 6 8 10 12 14 16

7 - 7.9 6 7 9 11 13 16 18

8 - 8.9 6 8 9 12 15 18 24

9 - 9.9 8 8 10 13 16 20 22

10 - 10.9 7 8 10 12 17 23 27

11 - 11.9 7 8 10 13 18 24 28

12 - 12.9 8 9 11 14 18 23 27

13 - 13.9 8 8 12 15 21 26 30

14 - 14.9 9 10 13 16 21 26 28

15 - 15.9 8 10 12 17 21 25 32

16 - 16.9 10 12 15 18 22 26 31
 17 - 17.9 10 12 13 19 24 30 37

18 - 18.9 10 12 15 18 22 26 30

19 - 24.9 10 11 14 18 24 30 34

25 - 34.9 10 12 16 21 27 34 37

Percentiles for triceps skinfold for whites of the United States Health and Nutrition Examination Survey 1
of 1971 to 1974.

Adapted from Frisancho, Am J Clin Med 1981; 34:2540.

Graphic 67683 Version 1.0

Percentiles of upper arm circumference and estimated upper arm muscle
circumference for Caucasian boys in the US Health and Nutrition Examination
Survey I of 1971-1974

Mid arm circumference (MAC) Mid arm muscle circumference

Age, years percentiles (MAMC) percentiles
males
5th 50th 90th 95th 5th 50th 90th 95th

1-1.9 142 159 176 183 138 156 172 177

2-2.9 141 162 178 185 142 160 176 184

3-3.9 150 167 184 190 143 167 183 189

4-4.9 149 171 186 192 149 169 184 191

5-5.9 153 175 195 204 153 175 203 211

6-6.9 155 179 209 228 156 176 204 201

7-7.9 162 187 223 230 164 183 216 231

8-8.9 162 190 220 245 168 195 247 261

9-9.9 175 200 249 257 178 211 251 260

10-10.9 181 210 262 274 174 210 251 265

11-11.9 186 223 261 280 185 224 276 303

12-12.9 193 232 282 303 194 237 282 294

13-13.9 194 247 286 301 202 243 301 338

14-14.9 220 253 303 322 214 252 304 322

15-15.9 222 264 311 320 208 254 30 322

16-16.9 244 278 324 343 218 258 312 325

17-17.9 246 285 336 347 220 264 324 350

18-18.9 245 297 353 379 222 258 312 325

19-24.9 262 308 355 372 221 265 319 345

25-34.9 271 319 363 374 241 290 356 378

35-44.9 278 326 363 374 241 290 356 378

45-54.9 267 322 362 376 242 299 362 384

55-64.9 258 317 355 369 243 303 367 385

65-74.9 248 307 344 355 240 299 356 373

Adapted from: Frisancho AR. Am J Clin Nut 1981; 34:2540.

Graphic 78703 Version 3.0

Percentiles of upper arm circumference and estimated upper arm muscle
circumference for Caucasian girls in the US Health and Nutrition Examination
Survey I of 1971-1974

Mid arm circumference Mid arm muscle circumference

Age, years (MAC) percentiles (MAMC) percentiles
females
5th 50th 90th 95th 5th 50th 90th 95th

1-1.9 138 156 172 177 105 124 139 143

2-2.9 142 160 176 184 111 126 142 14

3-3.9 143 167 183 189 113 132 146 14

4-4.9 149 169 184 191 115 136 152 15

5-5.9 153 175 203 211 125 142 159 16

6-6.9 156 176 204 211 130 145 166 17

7-7.9 164 183 216 231 129 151 171 17

8-8.9 168 195 247 261 138 160 183 19

9-9.9 178 211 251 260 147 167 194 19

10-10.9 174 210 251 265 148 170 190 19

11-11.9 185 224 276 303 150 181 217 22

12-12.9 194 236 282 294 162 191 214 22

13-13.9 202 243 301 338 169 198 226 24

14-14.9 214 252 304 322 174 201 232 24

15-15.9 208 254 300 322 175 202 228 24

16-16.9 218 258 318 334 170 202 234 24

17-17.9 220 264 324 350 175 205 239 25

18-18.9 222 258 312 325 174 202 237 24

19-24.9 221 265 319 345 179 207 236 24

25-34.9 233 277 342 368 183 212 246 26

35-44.9 241 290 356 378 186 218 257 27

45-54.9 242 299 362 384 187 220 260 27

55-64.9 243 303 367 385 187 225 266 28

65-74.9 240 299 356 373 185 225 264 27

Adapted from: Frisancho AR. Am J Clin Nut 1981; 34:2540.

Graphic 72246 Version 3.0

Contributor Disclosures
Sarah M Phillips, MS, RD, LD Nothing to disclose Robert J Shulman, MD Consultant/Advisory Boards:
BioGaia [Probiotics]; Mead-Johnson [Infant formula]; Nutrinia [Enteral insulin]. Kathleen J Motil, MD,
PhD Consultant/Advisory Boards: Mallinckrodt Pharmaceuticals/InfaCare Pharmaceutical Corporation
[Jaundice (Stannsoporfin)]. Alison G Hoppin, MD Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
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