Phase angle and its determinants in healthy subjects: influence of
body composition1
Maria Cristina Gonzalez,2* Thiago G Barbosa-Silva,3 Renata M Bielemann,3 Dympna Gallagher,4 and Steven B Heymsfield5
2
Post-graduation Program on Health and Behavior, Catholic University of Pelotas, Pelotas, Brazil; 3Post-graduation Program in Epidemiology, Federal
University of Pelotas, Pelotas, Brazil; 4The New York Obesity Nutrition Research Center, St. Luke’s–Roosevelt Hospital Center, College of Physicians
and Surgeons, Columbia University, New York, NY; and 5Pennington Biomedical Research Center, Baton Rouge, LA
ABSTRACT
Background: The phase angle (PA) has been used as a prognostic
marker in several clinical situations. Nevertheless, its biological
meaning is not completely understood.
Objective: We verified how body-composition components could
explain the PA.
Design: The trial was a cross-sectional study involving 1442 partici-
pants (women: 58.5%; Caucasian: 40.2%) from body-composition stud-
ies. Labeled tritium dilution and total-body potassium were used to
estimate total-body water (TBW) and intracellular water (ICW), respec-
tively. Extracellular water (ECW) and the ECW:ICW ratio were esti-
mated from the difference and the ratio of these values. Fat-free mass
(FFM) and fat mass (FM) were estimated with the use of dual-energy
X-ray absorptiometry, underwater weighing (UWW), and TBW. The PA
was estimated with the use of a single-frequency bioelectrical impedance
analysis system. Correlations between the PA and all body-composition
variables were evaluated. A multivariate linear regression analysis was
performed to adjust for the effects of body-composition variables on the
PA variability. All analyses were performed separately by sex.
Results: Compared with men, women exhibited significantly larger
ECW:ICW ratios and FM. The highest positive correlation was shown
between the PA and FFM obtained with the use of UWW (both sexes).
The highest negative correlation was shown between the PA and ECW:
ICW ratios for both sexes. Age, race, height, ECW:ICW, and FFM
from UWW were significant PA determinants in a multivariate linear
regression model. Even after adjustment for all significant covariates,
the explained PA variance was low (adjusted R2 = 0.539 and 0.421 in
men and women, respectively). The greatest impact on the total PA
prediction in both men and women were age, FFM, and height.
Conclusions: Age is the most significant PA predictor in men and
women followed by FFM and height. The ECW:ICW contribution
may explain the association of the PA observed in the clinical setting
and in people who are obese. Am J Clin Nutr 2016;103:712–6.
Keywords: adults, bioelectrical impedance analysis, body compo-
sition, phase angle, determinant factors
INTRODUCTION
A bioelectrical impedance analysis (BIA)6 has been widely
used over the past 30 y as a method of measuring body com-
position in clinical practice. The increasing use of a BIA is due
712 Am J Clin Nutr 2016;103:712–6. Printed in USA. Ó 2016 American Society for Nutrition
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to the advantages associated with this method, including the
low cost, instrument portability, and ease of measurement com-
pared with the use of other instruments that are often limited to
research environments. However, despite extensive literature
showing the usefulness of a BIA in body-composition assessment
in groups of healthy subjects, there remain limitations when eval-
uating individual subjects in the clinical setting (1).
In addition to measuring resistance and reactance, a BIA can
also provide an estimate of the phase angle (PA). Although BIA
predictions of body composition often rely on population-specific
equations, the PA is estimated directly without additional con-
version to specific body compartments. The PA concept is based
on changes in resistance and reactance as alternating current passes
through evaluated tissues. A phase shift occurs as part of the current
is stored in the resistive compartments of cellular membranes.
Therefore, the measured PA depends on several biological factors
such as the quantity of cells with their respective cell membranes,
cell membrane integrity, and related permeability and the amounts
of extracellular and intracellular fluids (1). A PA theory and
applications in clinical practice have been discussed in several
previous reviews (1–3). Nevertheless, the electrical theory of PA
as it relates to in vivo biological effects remains incomplete.
At an empirical level, some studies have reported that age, sex,
and BMI are major PA determinants in healthy subjects (2).
Reference values for the PA vary indifferent populations although
all populations share similar features in relation to age and sex
(4). Although Bosy-Westphal et al. (5) reported an association
between BMI and the PA in a healthy German population, to our
knowledge, no other studies have directly assessed the influence
of body-composition components on measured values for the PA.
The PA has also been used as a nutritional status marker because
the measured values reflect the amounts of various tissue com-
partments and hydration status (1).
1
The authors reported no funding received for this study.
*To whom correspondence should be addressed. E-mail: cristinagbs@
hotmail.com.
6
Abbreviations used: BIA, bioelectrical impedance analysis; ECW, extra-
cellular water; FFM, fat-free mass; FM, fat mass; ICW, intracellular water;
PA, phase angle; TBW, total-body water; UWW, underwater weighing.
Received June 6, 2015. Accepted for publication November 16, 2015.
First published online February 3, 2016; doi: 10.3945/ajcn.115.116772.
 PHASE-ANGLE DETERMINANTS 713
TABLE 1 The volunteers were recruited from the hospital staff and the local
Body-composition characteristics of the 1442 healthy subjects1 community. All participants signed a written consent form, and
Men (n = 599) Women (n = 843) P the Institutional Review Board of St. Luke’s–Roosevelt Hospital
approved the protocols.
Weight, kg 76.1 (68.2–86.1) 65.7 (56.8–79.1) ,0.001
Body composition was estimated with the use of several
Height, cm 173.8 (169.0–179.0) 161.5 (157.0–166.2) ,0.001
BMI, kg/m2 25.3 (22.9–28.2) 25.6 (22.0–30.0) 0.4
methods that were described in detail in previous publications (4,
TBW, kg 44.6 (39.6–49.2) 32.2 (28.9–35.6) ,0.001 7) and are summarized in the following text.
ECW:ICW 0.79 (0.70–0.91) 1.03 (0.91–1.16) ,0.001 All subjects were assessed after a $8-h fast. Body weight was
FM-DXA, kg 16.1 (10.8–23.4) 24.5 (16.6–34.8) ,0.001 measured to the nearest 0.1 kg with the use of a Weight-Tronix
FM-UWW, kg 17.6 (11.6–23.7) 23.7 (16.6–33.0) ,0.001 scale (Scale Electronics Development). Height was measured to
FM-TBW, kg 15.5 (10.2–22.0) 22.8 (15.9–32.1) ,0.001 the nearest 0.1 cm with the use of a wall-mounted stadiometer
FFM-DXA, kg 60.4 (53.9–66.0) 42.5 (38.8–46.3) ,0.001 (Holtain Ltd.). BMI (in kg/m2) was calculated as body weight
FFM-UWW, kg 59.6 (53.2–65.5) 43.4 (38.6–48.1) ,0.001
divided by the square of height. Total body water (TBW; in L)
,0.001

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FFM-TBW, kg 61.2 (54.2–67.3) 44.1 (39.6–48.8)
PA, o 7.58 (6.79–8.20) 6.51 (5.89–7.11) ,0.001
was estimated with the use of labeled tritium dilution (3H2O).
1
Intracellular water (ICW) was quantified with the use of total-
All values are medians; IQRs in parentheses. P values were determined body potassium with extracellular water (ECW) estimated as the
with the use of the Mann-Whitney U test. ECW:ICW, extracellular water:
difference between TBW and ICW (8). The fluid distribution
intracellular water ratio; FFM-DXA, fat-free mass from dual-energy X-ray
absorptiometry; FFM-TBW, fat-free mass from total body water; FFM-
was calculated as the ECW:ICW ratio. Fat-mass (FM) and fat-free
UWW, fat-free mass from underwater weighing; FM-DXA, fat mass from mass (FFM) compartments were estimated with the use of un-
dual-energy X-ray absorptiometry; FM-TBW, fat mass from total body wa- derwater weighing (UWW), dual energy X-ray absorptiometry
ter; FM-UWW, fat mass from underwater weighing; PA, phase angle; TBW, (Lunar DPX software 3.6; GE Lunar), and TBW. BIA measure-
total-body water. ments were made after a 5-min rest in a supine position with RJL
model 101 analyzer (RJL Systems), which uses an 800-mA cur-
Malnutrition and the presence of inflammation also appear to rent at a single frequency of 50 KHz. The PA was estimated as
influence the measured PA (6) with low values that are typically
Xc 180
related to more-severe illnesses and worse clinical prognoses. PA ¼ arctangent 3 ð1Þ
Applications in patients with acute and chronic diseases require R p
reference values for the PA. The aims of the current study were to
evaluate the relation between the PA and body composition and
Statistical analyzes were conducted with STATA 12.1 (STATA
how much the PA variability could be explained by body com-
Corp.). All analyzes were performed separately for each sex group.
position in a large sample of healthy adults.
Descriptive tables present the results as the median and IQR of
continuous variables. Sex differences between body-composition
METHODS variables were tested with the use of the Mann-Whitney U test. We
The subject pool included data from our previously published evaluated the correlations between the PA and all other measures
study (4). These data included healthy subjects who were evaluated (i.e., FM, FFM, and ECW:ICW). A multivariate linear regression
between 1986 and 1999 at St. Luke’s–Roosevelt Hospital Center. analysis was performed to adjust the effect of multiple variables
and to identify significant determinants of the PA. The h2 esti-
mation was used to estimate the proportion of the total variance
TABLE 2
Pearson correlation coefficients (r) between the phase angle and all other
associated with each variable after the linear regression analysis.
anthropometric and body-composition variables in the 1442 healthy P , 0.05 was considered statistically significant.
subjects1
Men Women
RESULTS
Weight 0.16 0.31
Height 0.12 0.11 The initial sample included 1967 subjects, and only those
BMI 0.12 0.28 individuals with complete body-composition evaluations (n =
TBW 0.39 0.40 1442) were included in the current report. More than one-half of
ECW:ICW 20.39 20.20 the subjects (58.5%) were women. The sample was composed of
FM-DXA 20.10 0.23 Caucasians (n = 579; 40.2%), African Americans (n = 387;
FM-UWW 20.18 0.17 26.8%), Asians (n = 143; 9.9%), and Hispanics (n = 86; 6.0%).
FM-TBW 20.16 0.20 The remainder of the sample was identified as other or multi-
FFM-DXA 0.39 0.38
racial. The median sample age was 43 y (IQR: 31–61).
FFM-UWW 0.43 0.45
FFM-TBW 0.39 0.40 The sample body-composition characteristics are summarized
in Table 1. All measures except BMI were significantly different
1
All correlations were significant at P , 0.05. ECW:ICW, extracellular (P , 0.001) between men and women. The men had greater
water:intracellular water ratio; FFM-DXA, fat-free mass from dual-energy
heights and larger TBW, FFM, and PA values (all P , 0.001).
X-ray absorptiometry; FFM-TBW, fat-free mass from total body water;
FFM-UWW, fat-free mass from underwater weighing; FM-DXA, fat mass The women had larger ECW:ICW ratios and all FM measures
from dual-energy X-ray absorptiometry; FM-TBW, fat mass from total body than those of the men (all P , 0.001).
water; FM-UWW, fat mass from underwater weighing; TBW, total-body Pearson correlation values between the PA and the other an-
water. thropometric and body-composition variables are presented in
714 GONZALEZ ET AL.
TABLE 3 method that exhibited the best correlation with the PA. Table 3
Significant phase-angle determinants as observed with the use of presents the results for this analysis for the men and women.
multivariate linear regression modeling1 Age, race, height, ECW:ICW, and FFM were associated with the
Men (n = 599)2 Women (n = 843)3 PA in men and women. By contrast, BMI was associated with PA
only in men. In addition to race, the only variable that was positively
b h2 P b h2 P associated in men was FFM. Greater age, height, BMI, and ECW:
Age, y 20.029 13.45 ,0.001 20.020 10.48 ,0.001 ICW were associated with a lower PA, and the largest negative b
Race4 value was for the ECW:ICW ratio (b = 20.847). African American
African American 0.276 0.84 0.001 0.315 1.79 ,0.001 men had PA values that were 0.2768 higher than those of Caucasian
Hispanic 0.072 0.02 0.601 0.210 0.25 0.06 men although all other characteristics were similar.
Asian 20.090 0.05 0.425 20.379 1.17 ,0.001 In women, BMI was not statistically associated with the PA.
Other 0.044 0.02 0.621 0.002 0.001 0.98 The ECW:ICW ratio, height, and age also had negative b values
Height, cm 20.059 6.29 ,0.001 20.039 5.41 ,0.001
and, thus, a negative relation with the PA. African American
BMI, kg/m2 20.024 0.39 0.025 — — —

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ECW:ICW 20.847 1.15 ,0.001 20.826 2.38
FFM-UWW, kg 0.062 6.68 ,0.001 0.048 8.14
1
ECW:ICW, extracellular water:intracellular water ratio; FFM-UWW,
fat-free mass obtained from underwater weighing.
2
Adjusted R2 = 0.539.
3
Adjusted R2 = 0.421.
4
Caucasians were considered the reference race.
Table 2. All correlations were significant. The highest positive
correlation was shown between the PA and FFM obtained with
the use of UWW (r = 0.43 and 0.45 for men and women, re-
spectively). The highest negative correlation was shown be-
tween the PA and ECW:ICW (r = 20.39 and 20.20 for men and
women, respectively). A negative correlation between the PA
and FM was observed in men (r varied from 20.10 to 20.18
according to the method), whereas this correlation was positive
in women (r varied from 0.17 to 0.23).
Multivariate linear regression analyses were performed sep-
arately for men and women. The following variables were tested
in these analyses: age, weight, height, BMI, race, TBW, ECW:
ICW, and FFM obtained with the use of UWW, which is the
,0.001 women had, on average, PA values that were 0.3158 larger than
,0.001 those of Caucasian women, whereas Asian women had, on av-
erage, a 0.3798 lower PA than that of Caucasian women.
After all of the previously noted evaluated variables were
controlled for, one-half of the PA variability was explained in men
(adjusted R2 = 0.539), and the explained variance was even less in
women (adjusted R2 = 0.421). Table 3 also presents h2 values that
explain how much (the percentage) each variable contributed to
the total variability explained by the final model. Age explained
the highest variability on the PA in both men and women followed
by FFM and height. Figure 1 presents, in a graph, the pro-
portional contribution of each variable to the total variance of this
model that was obtained from the multivariate linear regression
analysis. As shown, .0% of the variance of the model for both
sexes was explained by the 3 variables previously mentioned.
DISCUSSION
Although its biological meaning is not completely understood,
the PA has been used extensively as an important prognostic
marker in several clinical situations. In a recently published
review, several studies that used the PA as a prognostic marker in

FIGURE 1 Total variance proportion (R2 proportion) observed for each variable with the use of a multiple linear regression analysis in phase-angle
prediction models for men and women according to h2 values. For men, age, race, height, the ECW:ICW, FFM-UWW, and BMI together accounted for ,55%
of the phase-angle variance (R2-men = 0.546). For women, age, race, height, the ECW:ICW, and FFM-UWW together explained ,43% of the phase-
angle variance (R2-men = 0.426). Afr Am, African Americans; ECW:ICW, extracellular water:intracellular water ratio; FFM-UWW, fat-free mass obtained
from underwater weighing.
 PHASE-ANGLE DETERMINANTS
cancer, HIV, dialysis, and other clinical situations associated
smaller PA values with a poor prognosis or a shorter survival time
(2). Thus, the PA has been considered to be a general health or
nutritional status marker (9, 10). Nevertheless, to our knowledge,
no previous study has investigated PA determinants in healthy
subjects with the use of body-composition components obtained
from methods that are considered reference methods. With this
rationale, our study provided us the opportunity to assess directly
the association between the PA and associated factors.
The importance of age in PA variation has been shown
previously in other population-based studies in which a trend of
a decreasing PA could be seen in both men and women (4, 5).
During clinical situations, age also appeared to be an important
determinant of the PA even in the presence of an infection
or malnutrition (6). This study showed that age is the most
important biological determinant of PA variation. Aging, by
itself, is associated with other determinant PA variables such
as a smaller body cell mass followed by a compensatory in-
crease in the extracellular volume leading to a higher ECW:
ICW ratio (8).
An interesting finding was the contribution of race as a sig-
nificant determinant of the PA. This finding confirmed that it is
not possible to use universal reference values for the PA. Other
studies have suggested that different populations should have
their own reference PA values although the different populations
showed the same trend of variation according to sex and age (4,
5). This finding reinforces the idea that each population should
use its specific risk cutoffs that are based on its specific reference
PA values with the use of a standardized PA. This approach
should be preferred to the use of unique fixed cutoff values for
each disease as several authors have suggested (11–13).
Stature was a PA determinant with a negative b value even
after adjustment for all other variables. This observation implies
that a PA is smaller in magnitude with greater height. Note that
even in the presence of height as a covariate, BMI was also
a significant PA determinant in men. To our knowledge, no
previous study has related this biological variable as a PA de-
terminant. One hypothesis is that the importance of height is
related to the FFM component, suggesting that similar amounts
of FFM could determine the variation in PA according to the
subject’s height. This idea is similar to the concept of a fat-free
mass index (FFMI), which is an important prognostic factor that
is based on body composition. A recent published study from
our group showed that a low FFMI was associated with a greater
mortality rate in cancer patients regardless of BMI or FM (14).
The ECW:ICW ratio has been examined previously and shown
to be one determinant of PA variation. The authors related PA
variability to alterations in the cell size, the permeability of the
cell membrane, or differences in the distribution of fluids in the
tissues (15). Our results confirm that the ECW:ICW ratio is
a significant determinant of the PA. The alterations in the PA
associated with disease, malnutrition, and physical inactivity
could be justified by modifications in FFM that have been
commonly shown in these clinical scenarios. However, even in
situations when FFM loss has not occurred, extracellular fluid
expansion can lead to an increase in the ECW:ICW ratio. This
outcome could occur in sepsis and the early phases of malnu-
trition leading to a decrease in the PA. Therefore, a periodic
assessment of the PA in severely ill patients could be an auxiliary
tool in the early diagnosis of these clinical conditions.
715
Because of the limitation of the use of a 2-compartment model,
FM and FFM obtained by the same methods could not be ana-
lyzed simultaneously in the regression models. However, the
lower PA shown in obese subjects with BMI . 35, as shown by
Bosy-Westphal et al. (5), could be explained by other variables
included in our model. Dittmar (16) suggested that obese
subjects have greater hydration and fluids in the extracellular
compartments, which could lead to a larger ECW:ICW ratio.
This increased ECW:ICW ratio could be the reason for the lower
PA in the overweight and obese subjects. Mazariegos et al. (17)
showed that severely obese patients in the preoperative period of
bariatric surgery had an increased ECW:ICW ratio compared
with that of a control group. Moreover, this alteration did not
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reverse even after surgery. Thus, the excessive adipose tissue
influences, in a definitive way, the hemodynamic or fluid, thereby
maintaining these abnormalities.
Even after the inclusion of all body-composition variables, only
slightly .50% of PA variability could be explained in the men,
and even a smaller amount could be explained in the women.
Some studies have shown that smaller PA values are also associ-
ated with a decrease in function as assessed by handgrip strength
(18, 19). Some recently published studies have suggested that
the PA might be inversely related not only to muscle mass but
also to strength in elderly subjects (20). Therefore, the PA could
be an auxiliary tool in the diagnosis of sarcopenia. The inclusion
of functional variables in the analysis could further increase our
knowledge of PA variability in healthy subjects.
In conclusion, we showed that age and the combination of
FFM and height were the most important variables that explain
PA variability in healthy subjects. The ECW:ICW ratio may
justify the variations shown in PA in several clinical situations
and severe obesity. Race has only a small relation with PA vari-
ation, but this relation justifies the need for specific reference
values for each population. Future studies that use functional
variables could further increase our knowledge of the biological
importance of the PA in healthy and diseased patients.
The authors’ responsibilities were as follows—MCG: conceived the study,
participated in the design and coordination of the study, performed the data
analysis, and wrote the manuscript; TGB-S and RMB: participated in the
data analysis and reviewed the manuscript; DG: coordinated the data collec-
tion, and reviewed the manuscript; SBH: participated in the study design,
coordinated the data collection, and reviewed the manuscript; and all au-
thors: read and approved the final manuscript. None of the authors reported
a conflict of interest related to the study.
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