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Comparison of ultrasound and skinfold measurements in assessment of subcutaneous and total fatness.

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AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 58307-313 (1982)
Comparison of Ultrasound and Skinfold Measurements in
Assessment of Subcutaneous and Total Fatness
GARY A. BORKAN, DAVID E. HULTS, J O H N CARDARELLI. A N D
BELTON A. BURROWS
Normative Aging Study, VA Outpatient Clinic, Boston, Massachusetts 02108
(G.A.B.,D.E.H.), and Department of Nuclear Medicine, VA Medical Center,
Boston, Massachusetts 02130 (J.C., B.A.B.)
KEY WORDS
Anthropometry
Body composition, Obesity, Skinfolds, Ultrasound,
ABSTRACT
Ultrasound (A-scanmode) and skinfold methods were evaluated
in the measurement of subcutaneous fat thickness and prediction of total fat
weight (by whole body potassium counting). Based on intraobserver correlations
on 39 men at 15 body sites, skinfold caliper measurements were more reproducible
than ones obtained by ultrasound. Measurements made with the two techniques
at the same site typically produced different mean estimates of fat thickness.
However, scores were often highly correlated with each other, indicating similar
relative rankings of subjects by each technique. Skinfolds were more highly correlated with total fat weight than were ultrasound measurements, but body
weight and anthropometric measures had even higher correlations with total fat
weight. Anthropometric measurements were highly correlated with fatness because of their association with body weight, and when this relationship was statistically controlled for, they typically lost their predictive effectiveness. Multiple
regression analyses revealed that the best predictors of fat weight were body
weight along with skinfold and ultrasound measurements. These results suggest
that skinfolds are a more effective means of assessing subcutaneous fat than ultrasound, especially when the large difference in cost of equipment is considered.
For the past several decades, the skinfold
caliper has been the most frequent method of
measuring subcutaneous fat thickness. This
device has many distinct advantages, especially in field situations: it is painless, noninvasive, simple to use, portable, and does not
require elaborate electronic technology. Moreover, a very substantial literature exists on
skinfold measurements and on subcutaneous
fat as an index of total body fat (Durnin and
Rahaman, 1967; Fletcher, 1962; Keys and
Brozek, 1953; Newman, 1956). Disadvantages
of skinfolds are that they compress the fat
tissue, that they are only useful at certain body
sites, and that they may be ineffective in the
very obese (Brozek and Kinzey, 1960; Burkinshaw et al., 1973; Durnin et al., 1971). Softtissue radiography represents an alternative
and more accurate measure of subcutaneous
fat (Garn, 1954; Reynolds, 1944; Stuart et al.,
1940). However, this technique is relatively
0002-9483/82/5803-0307$02.500 1982 ALAN R. LISS, INC.
cumbersome, and has been less widely
adopted. Tissue magnification, radiation exposure, and subject positioning must be carefully monitored in soft tissue radiography
(Tanner, 1962).
The value of ultrasound in measuring subcutaneous fat thickness has not yet been fully investigated. Ultrasound devices can produce internal images of tissue configuration (B-scan
mode) or depth readings of changes of tissue
density (A-scanmode). Ultrasound involves no
radiation exposure, and is safe and painless to
use. This technique has been employed for
assessment of body composition of livestock
(Stouffer, 1969; Wallace et al., 1977) and
validations of ultrasound determinations have
been published (Booth et al., 1966; Bullen et
al., 1965; Haymes et al., 1976).More recently a
Received August 10, 1981; accepted January 21, 1982
308
G.A. BORKAN, D.E. HUUI'S, J. CARDARELLI. AND B.A. BURROWS
small portable ultrasound device (Body Composition Meter) has been introduced which is
designed specifically for assessment of subcutaneous fat using the A-scan mode.
Preliminary reports demonstrate the accuracy
of this device through measurements of
cadavers (Sanchez and Jacobson, 1978) and
surgical patients (Balta et al., 1981).
The present study compares subcutaneous
fat thickness measurements using a skinfold
caliper and Body Composition Meter. Intraobserver reliability was assessed, and site-by-site
comparisons were made of fat thicknesses obtained by the two methods. We have also compared ultrasound and skinfolds with traditional anthropometry in how well they predict
total fat weight (by potassium counting),both
at individual sites and in combination.
MATERIALS AND METHODS
Subjects
Subjects were 39 males recruited from the
participants in the Normative Aging Study of
the Veterans Administration Outpatient
Clinic, Boston, Massachusetts. These men,
along with almost 2000 other active participants, have been enrolled in a comprehensive
longitudinal aging study for an average of 18
years. To gain entry into the Normative Aging
Study, men were screened for good health (Bell
et al., 1972), although in the succeeding years
there has been considerable differentiation in
health within the sample.
Volunteers from the Normative Aging
Study were recruited for a special series of
body composition examinations at the VA
Medical Center, Boston, and a total of 39 men
had all the examinations described below.
These men ranged in age from 41 to 76 years,
and had a mean age of 57.6 years.
TABLE 1. Intraobserver reliability correlations of
subcutaneous fat measurement tecniques by sitea
Skinfold
1-r2
r
Site
Arm
Anterior (biceps)
Lateral
Posterior (triceps)
Medial
Chest
Anterior
(juxt a-nipple)
Mid anterior
Lateral (axillary)
Posterior
(subscapular1
Abdomen
Anterior (umbilicus)
Lateral (suprailiac)
Posterior
(dorsal iliac)
Leg
Anterior
Lateral
Ultrasound
r
I-r2
.I1
.81
.83
.I4
.41
.34
.31
.45
.I8
.45
.81
.48.
.39
.90
.19
.I1
.41
.85
34
.96
.28
.80
.43
.I3
.36
.29
.08
.41
.11
.14
.24
.64
.48
.62
.59
.I1
.62
.I6
.I9
(n=25)
.42
.38
.I2
.I1
.48
50
-
-
.I8
.74
.39
.45
.91
.93
.87
Posterior
Medial
.80
.34
.I1
.82
> .32 significant at .05 level.
Ultrasound: Ultrasound measurements of
subcutaneous fat thickness (including skin
thickness) were taken at the same 15 body
sites using portable ultrasound equipment
(Body Composition Meter, Ithaco, Inc.,
Ithaca, New York). This lightweight device,
designed expressly for assessment of subcutaneous fat thickness, utilizes the A-scan (linear)
mode as opposed to the B-scan (two-dimensional) mode. Rather than use the 2.5 MHz transducer supplied with the meter, we used a 3.5
MHz transducer with a 0.5 diameter for
greater tissue resolution. Readout from the instrument utilizes a series of light emitting
Measurements
diodes (LEDs) that allows measurements in
Skinfolds: A Lange skinfold caliper (Cam- millimeter intervals to a depth of 100 mm. We
bridge Scientific Industries, Cambridge, held the transducer to the skin manually, using
Maryland) was used to measure skinfold thick- ultrasound transmission gel, and were able to
ness at each of 15 sites located at the levels of maintain good skin contact without depressthe chest at the nipples, umbilicus, and mid- ing the skin surface. Tissue thicknesses less
point of the upper leg (halfway between the than 3 mm could not be differentiated due to
pubis and middle of the patella). These sites are the blind spot in front of the transducer. We
listed in Table 1. Standard anthropometric did not judge this to be a problem, however,
techniques were used and all measurements because 3 mm is essentially the lower limit
were replicated at the end of the patient exami- of fat and skin thickness encountered. During
nation (a 30-minute interval). All measure- the examinations we routinely checked the
ments were made by an experienced anthro- calibration of the Body Composition Meter
pometrist (G.A.B.),with the subject standing. using a plastic phantom supplied by the
Posterior and medial leg skinfolds could not be manufacturer .
taken due to skin tautness and lateral leg skinAlthough the recommended mode of utilizfolds could be made on only 25 individuals.
ing the Body Compositition Meter is to reduce
309
ULTRASOUND AND SKINFOLD ASSESSMENT OF FATNESS
the gain control until only a single diode remains lit (corresponding to the fat-muscle interface), in practice several adjacent or nearby
LEDs may remain lit even at low gains (due to
spurious echos, or fascial layers). We found
that the use of the Body Composition Meter required greater knowledge of underlying anatomy than did skinfold calipers. The anthropometrist was trained on this instrument under the
direction of individuals experienced in its use.
Whole body potassium counting: Each patient had a single potassium-40 measurement
in a whole body counter. The low level counting
facility at the VA Medical Center, Boston, consists of two matched 4 x 8 inch sodium iodide
crystal detectors mounted in a scanning geometry in a 8 x 8 x 8 foot room with 9-inch steel
walls. The subject lay supine on a bed between
the two detectors for two 20-minute traverses
of the counter assembly. Details of counters of
this type, as well as scanning geometry and
calibration have been published (Tyson et al.,
1970).
Total millequivalents of potassium-40 were
converted to total body potassium based on
the known relationship of potassium-40 to
total potassium in the body, and based on the
previous calibration of the counter with
potassium-42. A correction was also made for
differential counting efficiency related to body
size. Body fat weight was calculated using the
formula of Forbes and Lewis (1956): Fat
weight = Weight - (Meq K/68.1).
Anthropometry: A battery of 44 anthropometric measurements was also taken, including height, weight, a variety of length,
breadth, and circumference measures, all using
standard anthropometric sites and techniques
(Damon et al., 1972).This is the same test battery used from the inception of the Normative
Aging Study. The anthropometry was taken
only once during the examination.
RESULTS
Intraobserver correlation coefficients (r)and
the proportion of variance attributable to intraobserver error (1 - r2) are presented in
Table 1 for each body site and technique. The
correlations for skinfolds were higher than for
ultrasound for every site except the anterior
arm. Four of the seven sites in the trunk
achieved correlations of 0.90 or greater for
skinfolds. Ultrasound, on the other hand, did
not achieve any reliability greater than 0.81
and four sites had correlations less than 0.5.
The only sites where reliability of ultrasound
compared favorably with skinfolds were on the
leg, but this is a part of the body where there is
very little fat.
Mean fat thicknesses by site and technique
are compared in Table 2. For this comparison
skinfolds were divided in half, because they
TABLE 2. Mean skinfold and ultrasound values b y site for 39 males
Site
______
Arm
Anterior
Lateral
Posterior
Medial
Chest
Anterior
Midanterior
Lateral
Posterior
Abdomen
Anterior
Lateral
Posterior
Leg
Anterior
Lateral
Posterior
Medial
X
Skinfoldsa
adj
SD
SD
cv
X
Ultrasound
adj
SD
SD
2.0
8.4
5.8
2.6
0.7
2.6
1.8
1.0
0.54
2.11
1.49
0.74
0.27
0.25
0.26
0.28
4.1
7.7
6.6
4.9
1.0
2.2
1.8
1.5
0.78
1.0
1.49
0.72
0.19
0.13
0.23
0.15
16.7
16.2
10.9
11.5
4.7
5.2
4.1
4.5
4.23
4.42
3.44
4.31
0.25
0.27
0.31
0.38
32.6
32.3
19.5
9.8
6.7
7.7
6.9
2.4
5.16
6.16
2.97
1.76
14.0
11.8
18.6
3.9
4.5
5.0
3.55
4.19
4.35
0.25
0.35
0.23
27.7
18.5
13.0
8.0
7.0
5.0
7.7
5.3
2.2
2.2
1.67
1.74
0.21
0.34
-
-
7.2
4.7
5.9
9.2
1.8
1.5
1.8
2.8
-
-
askinfold divided by 2 for comparability with ultrasound.
bt > 2.02 significant at .05 level.
cr > .32 significant at .05 level.
adj
adj
cv
tb
rc
15.4
4.7
12.5
0.56
0.71
0.81
0.65
0.16
0.19
0.15
0.18
16.0
18.4
9.0
-4.4
0.45
0.70
0.52
0.81
5.12
3.36
3.10
0.18
0.18
0.24
13.7
7.0
- 5.5
0.66
0.53
0.18
1.30
1.07
1.40
2.07
0.18
0.23
0.24
0.23
- 2.4
- 1.6
-
0.76
0.83
- 2.3
-
310
G.A. BORKAN, D.E. HULTS. J. CARDARELLI, AND B.A. BURROWS
theoretically represent a double fold of fat, and
ultrasound measures a single thickness. Adjusted standard deviations (corrected for intraobserver bias) are included, as are coefficients
of variation (based on the adjusted standard
deviation). For all sites except the lateral leg,
the mean scores between the two techniques
were significantly different. Because we had no
criterion measure of actual fat thickness, it is
not clear which technique yields scores which
are closer to the actual fat thickness at each
site. Taking the adjusted coefficient of variation as a measure of dispersion of the data,
ultrasound generally produced a more limited
range of scores than skinfolds.
Correlations between ultrasound and skinfolds were strongly positive at many sites, indicating that relative rankings of individuals
were similar, even if measurement scales
varied. Posterior arm, posterior chest, and lateral leg had correlations greater than 0.80 (i.e.,
64% of variance explained). At other sites
agreement was much lower, though all but one
had significant correlations. There was no apparent systematic relationship between the
t-statistics (absolute comparisons) and the
correlations (comparison of relative ranking of
individuals).
To determine whether these techniques are
equally effective in predicting overall adiposity, we compared the skinfold and ultrasound
sites individually with total fat weight from
the whole body counting (Table 3). At all but
the anterior arm site, skinfolds had higher correlations with fat weight than did ultrasound.
Posterior chest (subscapular) skinfold was the
only site that had a correlation with total fat
greater than 0.60. The average correlation of
skinfold sites with total fat was 0.51, compared
to an average of 0.35 for ultrasound. Skinfolds
also had higher correlations with body weight
than ultrasound for most sites. At the majority of ultrasound and skinfold sites, the correlations with fat weight were greater than those
for total weight. A number of skinfold and ultrasound sites remained significant in predicting fat weight, even when their association
with body weight was controlled by partial
correlation. In particular, significant partial
correlations were found for ultrasound and
skinfolds of the arms, and skinfolds of the
chest.
A variety of anthropometric variables were
also compared with total fat (Table 4) and
several of these were better predictors than
any subcutaneous fat measurement. Body
weight, with a correlation of 0.72, was more
predictive of total fat weight than was any
other anthropometric measurement. Abdominal circumference did almost as well, followed
by hip breadth and two chest circumferences.
In contrast to the subcutaneous fat measures
TABLE 3. Correlation coefficients of subcutaneous fat measurements by site with fat weight /from 40K/, body weight
and fat wbight partialling for body weight IN = 39)"
Site
Fat weight
SkinF-~
Ultrafold
sound
Arm
Anterior
Lateral
Posterior
Medial
Chest
Anterior
Mid anterior
Lateral
Posterior
Abdomen
Anterior
Lateral
Posterior
Leg
Anterior
Lateral
Posterior
Medial
> .32 significant at .05 level.
Body weight
Ultrafold
sound
~~~
~
~
Skin-
Fat wt
partialling
for body wt
-~ __
SkinUltrafold
sound
~~~
.44
.54
.42
.54
.55
.39
.31
.48
.3 1
.34
.12
.31
.32
.21
- .03
20
.33
.46
.48
.47
.48
.36
.48
.49
.53
.53
.59
.63
.38
.47
.46
.44
.50
.38
.39
.56
.27
.54
29
.35
28
.40
.49
.40
.28
.13
.37
.29
.52
.53
.57
.30
.64
.6 1
.55
.49
.ll
.17
.ll
.16
.31
- .09
.21
- .02
.17
25
- .05
.21
-
29
.33
.39
27
27
.I8
-
.18
.40
23
-
.17
-
-
.28
.09
.02
311
ULTRASOUND AND SKINFOLD ASSESSMENT OF FATNESS
TABLE 4. Correlation coefficients of anthropometric measurements with fat weight, body weight and fat weight
partialling for body weight (N = 39)a
Site
Fat weight
Weight
Height
Arm Span
Chest depth
Hip breadth
Maximum chest circumference
Resting chest circumference
Abdomen circumference
Calf circumference
Wrist circumference
Upper arm circumference
.72
.22
.I1
.55
.69
.68
.66
.71
.47
.27
Body
weight
-
-
.47
.33
.38
.78
- .19
.79
25
.24
.43
- .08
- .28
- .05
.77
.68
.71
.59
.64
.44
Fat wt
partialling
for body wt
-.la
.41
29
ar > 3 2 significant a t .05 level
TABLE 5. Prediction o f fat weight lkg) using various sets o f independent variables
Predictors by
site and method
Skinfold
Ultrasound
Anthropometric
circumference
Anthropometric
length and breadth
All predictors
multiple r. r2
Prediction equation
Fat weight = 2 8 6 chest posterior + ,961 arm
anterior
,780 arm medial + ,148 abdomen
4.38
posterior
F a t weight = 3.428 arm anterior + ,374 chest mid
anterior + 2.759 leg lateral - ,623 leg medial
- ,981 leg anterior - 1.981
Fat weight = ,617 abdomen circumference + ,784
calf circumference - 1.687 wrist circumference
- 32.705
Fat weight = 1.786 hip breadth + 1.741 chest
depth - ,361 arm span + .87 wall height
-79.192
Fat weight = ,600 weight
2.008 medial arm
ultrasound + ,266 lateral chest skinfold -.420
anterior abdomen skinfold + 1.373 anterior arm
,261 lateral chest ultrasound - ,915
skinfold
upper arm circumference - 8.657
+
+
+
r = .71
r2 = .50
r = .76
r2 = .58
r = .75
r' = .56
r = .78
r2 = .60
r = .92
r2 = .85
+
in Table 3, the anthropometric measures tended to correlate even more highly with body
weight than with fat weight. Consequently,
their partial correlations with fat weight, after
controlling for body weight, were nonsignificant for most measurements.
Several multiple regression analyses were
performed with fat weight as the dependent
variable and various sets of subcutaneous fat
and anthropometric measures as independent
variables (Table 5). Results were quite similar
(multiple r between 0.71-0.78) between skinfolds, ultrasound, anthropometric circumferences, and lengths. Ultrasound achieved a
higher multiple r than skinfolds, despite its
poorer showing in the individual correlations
in Table 3. The highest predictive effectiveness
was achieved when all skinfold, ultrasound,
and anthropometric parameters were included
as potential independent variables. A multiple
r of 0.92 was achieved with body weight entering first, followed by five ultrasound and skinfold variables, and upper arm circumference.
No other anthropometric parameters entered
the equation significantly, despite their high
individual correlations with fat weight.
DISCUSSION
Results of this study indicate that skinfolds
measured by the Lange caliper are a more effective means of measuring subcutaneous fat
than ultrasound using the Body Composition
Meter. Intraobserver reliability of skinfolds
was higher than for ultrasound. Interobserver
reliability was not tested in this study, and it is
uncertain whether variation in ultrasound
technique between technicians would be
greater than that for skinfolds. Criterion
312
G.A. BORKAN. D.E. HULTS, J. CARDARELLI. AND B.A. BURROWS
methods were not available to assess whether
skinfolds and ultrasound are accurate indications of subcutaneous fat thickness at the sites
they measure. Therefore we cannot state which
provides the best indication of true fat
thickness .
However, we were able to measure total fat
weight, and accuracy of the various site
specific composition techniques was assessed.
When all variables were evaluated individually, neither ultrasound nor skinfolds predicted
fat weight as well as did body weight or several
stand ard anthropometric measurements . This
has also been reported by Wilmore and Behnke
(1970), who found abdomen circumference to
be a better predictor of total body density
(equivalent to percent fat) than any skinfold
measure. In a comparison of ultrasound and
skinfolds with total body density (Haas et al.,
1981)body weight had the highest correlation
with fat mass, and five different anthropometric circumferences had correlations with fat
mass higher than any single skinfold or ultrasound measurement. In an investigation of anthropometric indicators of weight loss, Bray et
al. (1978) showed higher correlations between
anthropometric circumferences and weight
loss than with any skinfold site.
The data in Tables 3-5 may indicate the origins of the findings described above. Anthropometric measures of circumference were more
highly correlated with body weight than with
fat weight. Conversely, subcutaneous fat measures were more highly correlated with fat
weight than with total weight. Once the effect
of body weight was removed using partial correlations, subcutaneous fat measures were
more highly correlated with fat weight than
was anthropometry. This is substantiated in
the last equation in Table 5, which shows that
after body weight entered the equation, the only other variables that contributed significantly to explaining fatness were measures of subcutaneous fat (with the exception of upper arm
circumference which was the last variable to
enter the equation). Thus, while weight proved
a good indicator of total fat (explaining 52% of
the variance), the addition of five other skinfolds and ultrasound measures brought the explained variance up to 82%.
We do not advocate using these equations as
predictors of total body fat in other populations. There is ample evidence that such equations are effective only in the sample on which
they are based or others of very similar composition (Malina, 1980).Age, ethnic affiliation,
sex, economic status, and health must be close-
ly matched, as well as the anthropometric
techniques used. The present sample, while
basically consisting of middle-aged, middleincome white males, is a very small sample size
on which to base predictions for the U.S.
population. In addition, we are not advocating
use of skinfolds and ultrasound in conjuction,
for the information they provide is very
similar.
Results of this study also have bearing on
the relationship of subcutaneous to total fat. It
has been recognized that subcutaneous fat is
not a definitive indicator of total fat. There is a
substantial accumulation of fat in the abdomen, and this may vary considerably between
individuals and with age (Borkan and Norris,
1977). Anthropometrists of adults are well
aware from experience that a large abdomen
and a large abdominal skinfold do not always
occur together. When this factor is combined
with the considerable variability between individuals in fat distribution within the body, it
becomes clear why no single site, or even cornbination of subcutaneous fat sites, gives a truly accurate indication of total fatness.
ACNOWLEDGMENTS
The authors wish to thank the staff of the
Normative Aging Study for their helpful comments in preparing this manuscript. We thank
Beth Dolan and Joan Sodergren for typing,
and Susy Chan for keypunching the data. We
appreciate the assistance of Jere Haas, Ed
Frongillo, and James Stouffer for their assistance using the Body Composition Meter. This
research was supported by the Medical Research Service of the Veterans Administration.
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