CHAPTER II

LITERATURE REVIEW

II.1 Overview about Body Mass Index (BMI)

Body Mass Index (BMI) is a simple tool or way to determine adult
nutritional status. Weight loss may increase the risk of infectious diseases while
weight gain will increase the risk of degenerative diseases (Pranadji, 1997).
BMI's use only applies to adults over 18 years of age. BMI cannot be applied
to infants, cannot be applied children, cannot be applied for adolescents, cannot
be applied for pregnant women and cannot be applied athletes. In addition, BMI
cannot be applied to other special circumstances such as edema, ascites and
hepatomegaly Body mass index is the ratio between weight and square of height
in meters (Sirajuddin, et al., 2018).
The effectiveness of interventions for overweight and obesity in children and
adolescents has been reviewed in several systematic reviews. How they are
selected for implementation and their post implementation effects at the
population level are rarely investigated. For this reason, there is no systematic
information on the determinants of the divergent trends in BMI in children and
adolescents and in adults, be it on food environments and behavior or on policies
that affect them. The plateau of children’s and adolescents’ BMI in high-income
countries as adult BMI continues to increase might be due to specific initiatives
by governments, community groups, schools, and notable individuals that have
increased public awareness about overweight and obesity in children, leading to
changes in nutrition and activity that are sufficient to curb the rise in mean BMI
(Lancent, 2017).
Weight (Kg)
Body Mass Indeks ( BMI ) =
Height ( m ) x Height (m)
       BMI classification based on clinical experience and research results in some
developing countries with the following conditions:
 Table 11.1 Category IMT (WHO 2000)
Classification BMI (kg/m2)
Underweight < 18.50
- Severe thinness < 16.00
- Moderate thinness 16.00 – 16.99
- Mild thinness 17.00 – 18.49
Normal 18.50 – 24.99
Overweight ≥ 25.00
- Pre-obesitas 25.00 – 29.99
Obesity ≥ 30.00
- Obese Class I 30.00 – 34.99
- Obese Class II 35.00 – 39.99
- Obese Class III ≥ 40.00
(Source : Sirajuddin, et al., 2018)

II.2 Overview about Body Height based on Knee Height

Estimates of pharmacokinetic parameters and nutritional status evaluation
depend on accurate measurement not only weight but height. However, a number
of diseases can cause difficulty in measuring height accurately. Therefore,
various unaltered bone-based formulas have been developed. The methods
developed include high knee, arm length, and half hand span (Sirajuddin, et al.,
2018).
Body height is an indicator component of nutritional status so accurate
measurement is very important to determine the value of BMI (Body Mass
Index). BMI is useful as an indicator to determine the indication of cases Chronic
Energy Deficiency and obesity. But to obtain appropriate measurement in the
elderly is quite difficult because of posture problems, spinal damage, or causal
paralysis should be seated in a wheelchair or in bed. Therefore, the measurement
of elderly height cannot be measured properly so that to know the height of
elderly can be done an estimation with formula based on several parameters such
as knee height, arm length, and length. Knee height can be used to estimate
elderly and disabled height. The aging process does not affect bone length in the
hands, feet, and height of the vertebral bone. Furthermore, elderly height
 prediction is considered as a sufficiently valid indicator in developing an
anthropometric index and interpretation of body composition measurement
(Wiryani, et al., 2010).
Knee height is measured from below the lateral malaeolus of the fibula to
the heel. This step is used for individuals who are ≥60 years old or unable to
stand or have a spinal deformity. The high prediction formula based on knee
height as follows (Sirajuddin, et al., 2018).
Female = 84.88-(0.24 x age (year)) + (1.83 x knee height) -
(75 - age/5) x 1.2
Male = 64.19 - (0.04 x age (year)) + (2.02 x knee height)

II.3 Overview about Waist To Hip Ratio (WHR)

The amount of fat in the abdomen suggests there are some changes in
metabolism, including to insulin and increased free fatty acid production,
compared with the amount of fat under the skin of the feet and hands. Changes in
metabolism provide an illustration of the examination of diseases associated with
differences in the distribution of body fat. The commonly used measure is the
waist to hip ratio. Measurement of waist and hip circumference should be
performed by trained personnel and the measurement position must be precise,
since different measurement positions give different results (Sirajuddin, et al.,
2018).
The waist circumference shows fat deposits. The fat content contained in
around the abdomen indicates a change of metabolism in the body. Change
metabolism can be a decrease in the effectiveness of insulin because of the load
work that is too heavy. An increase in the amount of fat around the abdomen can
also show the increased production of free radical fatty acids. The high fat
content around the abdomen describes the risk of obesity. Size of waist
circumference will be easy to change depending on the amount of fat content
inside the body. In contrast, the size of the pelvis in healthy individuals is
 relatively stable. The size of the pelvis a 40-year-old would be the same as the
size of the person's pelvis when 22 years old. Therefore, the waist to hip ratio can
describe obesity (Thamaria, 2017).
Measurement of waist circumference and waist-to-hip ratio is used to
determine central obesity whereas body mass index measurements are used to
measure obesity throughout the body. Measurement of waist circumference more
correlated with intra abdominal fat when compared with waist-to-hip ratio
measurement (Sari, et al 2015).
A prospective study showed that waist-to-hip ratio was associated with
cardiovascular disease. As for the formula in determine Waist to hip ratio (WHR)
ratio of waist circumference and hip are:

Waist Circumferrence
Formulation of WHR =
Hip Circumferrence

Table II.3 Interpretation of Waist and Pelvic Waist Measurements

Risk
Gender Age Very
Low Moderate High
High
20- 29 < 0.83 0.83-0.88 0.89-0.94 > 0.94
30-39 < 0.84 0.84-0.91 0.92-0.96 > 0.96
Male 40-49 < 0.88 0.88-0.95 0.96-1.00 > 1.00
50-59 < 0.90 0.90-0.96 0.87-1.02 > 1.02
60-69 < 0.91 0.91-0.96 0.99-1.03 > 1.03
20-29 < 0. 71 0.71-0.77 0.78-0.82 > 0.82
30-39 < 0.72 0.72-0.78 0.79-0.84 > 0.84
Female 40-49 < 0.73 0.73-0.79 0.80-0.87 > 0.87
50-59 < 0.74 0.74-0.81 0.82-0.88 > 0.88
60-69 < 0.76 0.76-0.83 0.84-0.90 > 0. 90
(Source : Sirajuddin, et al., 2018)

II.4 Overview about Waist circumference

 There are two types of obesity, namely general obesity and waist
Obesity/central. General obesity can be measured using the Body Mass Index,
whereas central obesity can be measured by waist circumference (WC). The
value of BMI is obtained by dividing the weight (in kg) by the square of the
height (in meters) or W/H2, while the value of WC is obtained from the
measurement of WC (in cm). 3 In community-based surveys, obesity rates are
measured more by using BMI. The value of BMI obtained does not depend on
age and sex. WC is used more clinically to assess waist obesity, by measuring fat
concentrated in the abdomen. Some research shows, WC is the best predictor for
the risk of degenerative diseases (Triwono, et al 2012).
Another common way to monitor the risk of obesity is to measure waist
circumference. Good stomach size is not more than 90 cm for men and not more
than 80 cm for women. Measurement of waist circumference is more meaningful
than BMI in determining fat deposits in the waist cavity (central obesity) due to
increased fat deposits in the stomach is reflected from the increase in waist
circumference. Below is the table of waist circumference threshold values
according to various countries (Sirajuddin, et al., 2018).
Table II.4 Abdominal Threshold Boundary Value by Various Countries
Male Female
Country
(cm) (cm)
USA (ATP III) 102 (90) 88 (85)
Europeans 94 80
Middle Eastern, Eastern
94 80
European, North African
Sub-Saharan Africans 94 80
Asian (Including Chinese,
90 80
South Asia, and Japanese)
Ethnic south and Central
90 80
Americans
Indonesia 90 80
(Source: Sirajuddin, et al.,2018)

II.5 Overview about the Upper Arm Circumference

 The important role of nutrition during pregnancy makes the nutritional status
of pregnant women get great attention. Chronic energy deficiency status (CED)
before pregnancy affects fetal growth and becomes a consideration of weight
gain achievement during pregnancy. In Indonesia, prenatal weight is generally
unknown so that upper arm circumference is used as an indicator of risk in
pregnant women. To the extent that, the threshold used to determine a pregnant
woman at risk for CED is 23.5 cm (Eva, et al., 2012).
The Upper Arm Circumference is a way to determine the risk of chronic
energy deficiency in Fertile Women. Measurement of upper arm circumference
can not be used to monitor changes in nutritional status in the short term.
Maternal nutrition is the food or nutrients that are in need by a mother who is
pregnant both in trimester I, second trimester, and third trimester and must
enough amount and quality and must be fulfilled from requirement of everyday
meal so that the fetus that contained can grow well and do not experience trouble
and trouble (Kamariah & musyarofah 2010).
The UAC is a much simpler anthropometric measure than the BMI, as its use
eliminates the need for expensive equipment, such as height charts and scales,
and the need for calculations. It is also much easier to perform on a patient who
is acutely unwell, bed bound or sedentary. Another important advantage of using
UAC is that there is minimal change in the UAC during pregnancy, because it
may be a better indicator of pre-pregnancy body fat and nutrition than the BMI.
It is measured midway between the olecranon of the elbow and the acromion
process of the shoulder of the non dominant arm, using a standard tape measure
(Fakier, et al., 2017)
Upper Arm Circumference is one of the options for determining nutritional
status. Does not require age data that is sometimes difficult to obtain. Provides an
overview of the state of muscle tissue and the subcutaneous fat layer. The UAC
reflects the energy reserves, so it can reflect the LPI on toddlers, CED in fertility
 women, mothers and pregnant women, and the risk of LBW infants (Sirajuddin,
et al., 2018).
Table II.5Classification of the Upper Arm Circumference
Classification Measurement limit
women of childbearing age
CED < 23,5 cm
Normal ≥ 23,5 cm
Baby age 0-30 day
CED < 9,5 cm
Normal ≥ 9,5 cm
Toddler
CED < 12,5 cm
Normal ≥ 12,5 cm
(Source: Sirajuddin, et al., 2018)

II.6 Overview About Percent Body Fat

Measurement of body fat through measurement of skin fat thickness
(skinfold) is done on several parts of the body, such as the upper arm (triceps and
biceps), forearm, scapular (subscapular), middle of the armpit (midaxilarry),
breast side (pectoral ), abdominal, suprailiaka, thighs, kneecap (suprapatellar),
mid-lower limbs (medial calv) (Sirajuddin, et al., 2018).
Many people generally use ordinary weight gauges as an indicator of their
body weight, whereas ordinary weight gauges can not distinguish between fat
and non fat periods. If the body is excess fat then it will increase the likelihood of
disease, such as type two diabetes, heart problems and cancer. Body of any
deficiency will cause things that are not good for the body, especially in women,
among others, breast cancer. If known well the Body composition will make it
easier to decide patterns and further actions to maintain health (Nugraha, Riyadi
& Prakoso 2012).
Fat can be measured in absolute and relative to total body weight. the
amount of body fat varies greatly by sex and age. the thickness of the skin fold is
a measure of body fat content because about half of the total body fat reserves
are found directly under the skin. measurement of skin fold thickness is an
important model to determine body composition as well as body fat percentage
and to determine anthropometric nutritional status (Sirajuddin, et al., 2018).
Table II.6.1 Formula of Body Fat Percent Calculation
Male ( year 18-27 )
Db = 1,0913 – 0,00116 (∑tricep+scapula)
% Body Fat = [(4,97 / Db) – 4,52] x 100
Female (year 18-23)
Db = 1,0897 – 0,00133 (∑tricep+scapula)
% Body Fat = [(4,76 / Db) – 4,28] x 100
(Source: Sirajuddin,et al., 2018)

Fats can be measured absolute (in kg) and relative (%) to total body weight. The
amount of body fat varies greatly by sex and age. Measurement of thick skin
folds is one important method for determining body composition as well as body
fat percentage and to determine anthropometric nutritional status (Nazire, et al.,
2011).
Table II.6.2 Classification of Percent Body Fat Based on Age and Sex
Sex Underfat Healthy range Overweight Obese
Women (years)
20-40 <21% 21-33% 33-39% >39%
41-60 <23% 23-35% 35-40% >40%
61-79 <24% 24-36% 36-42% >42%
Men (years)
20-40 <8% 8-9% 19-25% >25%
41-60 <11% 11-22% 22-27% >27%
61-79 <13% 13-25% 25-30% >30%
(Source: Sirajuddin,et al.,2018)