Assessing the Validity of Body Mass Index
Standards in Early Postmenopausal Women
Robert M. Blew,* Luis B. Sardinha,† Laura A. Milliken,‡ Pedro J. Teixeira,†§ Scott B. Going,§
Dawna L. Ferreira,* Margaret M. Harris,* Linda B. Houtkooper,§ and Timothy G. Lohman*§
Abstract
BLEW, ROBERT M., LUIS B. SARDINHA, LAURA A.
MILLIKEN, PEDRO J. TEIXEIRA, SCOTT B. GOING,
DAWNA L. FERREIRA, MARGARET M. HARRIS,
LINDA B. HOUTKOOPER, AND TIMOTHY G.
LOHMAN. Assessing the validity of body mass index
standards in early postmenopausal women. Obes Res.
2002;10:799 – 808.
Objective: To examine the relationship between percentage
of total body fat (%Fat) and body mass index (BMI) in early
postmenopausal women and to evaluate the validity of the
BMI standards for obesity established by the NIH.
Research Methods and Procedures: Three hundred seven-
teen healthy, sedentary, postmenopausal women (ages, 40
to 66 years; BMI, 18 to 35 kg/m2; 3 to 10 years postmeno-
pausal) participated in the study. Height, weight, BMI, and
%Fat, as assessed by DXA, were measured. Receiver oper-
ating characteristic analysis was performed to evaluate the
ability of BMI to discriminate obesity from non-obesity
using 38%Fat as the criterion value.
Results: A moderately high relationship was observed
between BMI and %Fat (r ⫽ 0.81; y ⫽ 1.41x ⫹ 2.65)
with a SE of estimate of 3.9%. Eighty-one percent of
other studies examined fell within 1 SE of estimate as
derived from our study. Receiver operating characteristic
analysis showed that BMI is a good diagnostic test for
obesity. The cutoff for BMI corresponding to the crite-
rion value of 38%Fat that maximized the sum of the
sensitivity and specificity was 24.9 kg/m2. The true-
positive (sensitivity) and false-positive (1 ⫺ specificity)
Received for review January 19, 2002.
Accepted for publication in final form April 9, 2002.
*Department of Physiology, University of Arizona, Tucson, Arizona; †Exercise and Health
Laboratory, Faculty of Human Movement, Technical University of Lisbon, Lisbon, Portu-
gal; ‡Department of Exercise Science and Physical Activity, University of Massachusetts,
Boston, Massachusetts; and §Department of Nutritional Sciences, University of Arizona,
Tucson, Arizona.
Address correspondence to Timothy G. Lohman, Ph.D., Department of Physiology, Ina
Gittings Building #93, University of Arizona, Tucson, AZ 85721.
E-mail: lohman@u.arizona.edu
Copyright © 2002 NAASO
rates were 84.4% and 14.6%, respectively. The area
under the curve estimate for BMI was 0.914.
Discussion: There is a strong association between %Fat and
BMI in postmenopausal women. Current NIH BMI-based
classifications for obesity may be misleading based on
currently proposed %Fat standards. BMI ⬎25 kg/m2 rather
than BMI ⬎30 kg/m2 may be superior for diagnosing obe-
sity in postmenopausal women.
Key words: body mass index, percentage of fat, post-
menopausal women, receiver operating characteristic
analysis
Introduction
The NIH have established cut-off points using body mass
index (BMI) for overweight and obesity at 25 kg/m2 and 30
kg/m2, respectively (1). According to preliminary data from
the 1999 National Health and Nutrition Examination Survey
(NHANES 1999), the prevalence of overweight (BMI 25.0
to 29.9 kg/m2) in adults ages 20 to 74 years increased by
⬃2% between the NHANES II and NHANES 1999 surveys,
whereas obesity (BMI ⱖ 30.0 kg/m2) nearly doubled from
⬃15% to 27% during the same period (2). In women ages
50 to 59 (typically the early menopausal years), the percent-
age considered obese (BMI ⱖ 30.0 kg/m2) has increased by
47.3% between 1991 and 1998 (3). Overweight and obesity
are known risk factors for insulin resistance, glucose intol-
erance, diabetes mellitus, hypertension, dyslipidemia, sleep
apnea, arthritis, hyperuricemia, gall bladder disease, and
certain types of cancer (4). This increase is an alarming
statistic and emphasizes the importance of accurately as-
sessing body composition, because it is expected that a
significant extent of the risk of excess weight is caused by
the contribution of excess fat to body mass. Therefore, it is
important to determine the relationship between BMI and
percentage of total body fat (%Fat).
DXA and underwater weighing (UWW) are accurate
methods to estimate body fat. However, these methods are
costly, difficult to access, and often impractical. Other, less
OBESITY RESEARCH Vol. 10 No. 8 August 2002 799
BMI Standards in Postmenopausal Women, Blew et al.
expensive, but more accessible methods, such as bioelectri-
cal impedance analysis (BIA) and skinfold thickness (SKF)
have their own limitations. SKF measurements are depen-
dent on the skill of the examiner and may vary widely when
measured by different examiners (5,6). BIA may not be
accurate in severely obese individuals and is not useful for
tracking short-term changes in body fat brought about by
diet or exercise (7,8). A weight-for-height measure such as
BMI is a simple inexpensive method of determining overall
fatness, although it is not a direct measure of body fat.
Consequently, the use of BMI to predict body fatness would
offer significant advantages, and in fact, several studies
suggest that BMI is an acceptable predictor of body fatness
(9 –13). However, the use of BMI to predict %Fat and
diagnose obesity has also been shown to have several lim-
itations. Previous studies have shown that ethnicity, age,
and sex may significantly influence the relation between
%Fat and BMI (14 –17). This suggests that %Fat and BMI
may be more closely related within specific populations,
and hence clearer definitions of obesity should be estab-
lished for those groups. A recent report from a Centers for
Disease Control and Prevention workshop recognized the
potential differences between populations but reiterated the
importance of BMI in population-based health promotion
(18). It proposed that BMI can be an effective method on
three levels: self-monitoring by the individual, identifying
subpopulations where chronic disease is prevalent, and al-
lowing population trends to be tracked and characterized.
However, BMI’s effectiveness is dependent on cut-off
points that apply to all populations, something that currently
recommended cut-off points may not do (18).
Indeed, there is evidence to suggest that in certain sub-
groups of a population, BMI may be more predictive of
body fatness than in other subgroups. Wellens et al. showed
a significantly higher correlation between BMI and %Fat in
the upper BMI tertile than in lower tertiles in white women
ages 20 to 45 years (19). Receiver operating characteristic
(ROC) analysis suggested a BMI of 23 kg/m2 in white
women might provide better diagnostic screening cut-offs
for obesity (19). Whether the cut-off applies to postmeno-
pausal women is not known. More recently, a large-scale
study of elderly Italian women showed that BMI is an
acceptable surrogate measure of body fatness for population
studies, but it was deemed inadequate to replace a direct
measure of body fatness at the individual level (20). Be-
cause postmenopausal women are likely to have increased
fat mass and decreased fat-free mass (21), the relationship
between %Fat and BMI may be different for this population.
The change in this relationship might suggest that lower
levels of BMI may be superior for predicting obesity. There-
fore, the aim of this paper is to address the relationship
between %Fat and BMI in a population of early postmeno-
pausal women and moreover, consider the extent to which
this relationship agrees with data from other studies. Also,
800 OBESITY RESEARCH Vol. 10 No. 8 August 2002
given the aforementioned changes in fat and fat-free mass in
postmenopausal women, the study uses ROC analysis to
determine if there are more appropriate values for diagnos-
ing obesity than those currently recommended by the NIH.
Research Methods and Procedures
Subjects
Three hundred seventeen healthy, sedentary, postmeno-
pausal women participating in the Bone Estrogen Strength
Training study were included in the present study (22). The
University of Arizona’s Human Subjects Institutional Re-
view Board approved the study and all participants gave
written informed consent before participation in the study.
The women were 3 to 10 years postmenopausal (40 to 66
years old). Menopause was defined as 12 consecutive
months without a menstrual period. The sample included
surgical as well as nonsurgical menopause. At entry into the
study, they had a self-reported BMI ⬎5th percentile and
⬍95th percentile, were nonsmokers, and were either using
hormone replacement therapy (HRT) for 1 to 6 years or had
not used HRT in the preceding year. Subjects did not take
any other medications known to affect bone metabolism and
body composition and were not exercising or dieting before
entering the study.
DXA
Participants’ %Fat was measured by DXA using a total-
body scanner (model DPX-L; Lunar Radiation Corp., Mad-
ison, WI). DXA uses a constant potential X-ray source of 78
kVp and a rare-earth k-edge filter to achieve a congruent
beam of stable dual-energy radiation with effective energies
of 40 and 70 KeV. The scanner was calibrated daily against
a standard calibration block supplied by the manufacturer.
Subject position for the total body was standardized and
identical to those described by Mazess et al. (23). All total
body scans were completed in medium scan mode to ensure
appropriate image resolution. All subjects were scanned
twice within ⬃2 weeks to improve accuracy by reducing
potential day-to-day variability. The mean of the two scans
was used in all statistical analysis. Initial scan analysis,
including the placement of baselines distinguishing bone
and soft tissue, edge detection, and regional demarcations,
was performed by computer algorithms (version 1.3y; Lu-
nar Corp.). Subsequently, the technician visually inspected
all scans and adjustments were made as necessary. The
%Fat coefficient of variation for repeated measure-
ments was 2.8%.
Anthropometry
Standing height (HT) and weight (WT) measurements
were completed with subjects wearing light-weight clothing
and no shoes. HT was measured to the nearest 0.1 cm using
a Schorr measuring board (Schorr Products, Olney, MD).
BMI Standards in Postmenopausal Women, Blew et al.
Subjects were asked to stand with their arms hanging freely
at their sides, ankles or knees touching, and their weight
distributed evenly on both feet. The mid-axillary plane was
aligned perpendicular to the floor with the scapulae and
buttocks in contact with the vertical board if possible, or
whichever part touched the board first. The head was posi-
tioned in the Frankfurt Horizontal plane, and HT was mea-
sured during a maximal inhalation. WT was measured on a
calibrated digital scale (model 770; SECA, Hamburg, Ger-
many), accurate to 0.1 kg, while subjects stood with their
weight evenly distributed and their arms hanging freely at
their sides. The average of two measurements for both HT
and WT were used as the criterion measurements. BMI was
calculated as WT (kilograms) divided by HT squared
(meters squared).
Statistical Analysis
Statistical analyses were conducted using the SPSS/PC
(SPSS for Windows, V.9.0; SPSS Inc., Chicago, IL).
Means, SDs, and Pearson’s product moment correlations
were calculated. Independent sample Student’s t tests were
used to compare age, years past menopause, height, weight,
BMI, and %Fat between women who used HRT and women
who did not use HRT. Linear regression analyses were
performed to evaluate the relationship between %Fat by
DXA and BMI. The slopes of the regression lines for the
two groups were not different (p ⬎ 0.05). Therefore, data
from the two groups were combined for further analysis.
Significance was inferred at p ⬍ 0.05. All results were
expressed as means and SDs.
ROC analysis is a way of evaluating the accuracy of a
diagnostic test by summarizing the potential of the test to
discriminate between the absence and presence of a health
condition (24,25). In this study, ROC analysis examined the
ability of BMI to discriminate obesity from non-obesity
using ⱖ38%Fat as the criterion value for obesity, based on
the recent recommendation for older women by Lohman et
al. (26,27). The slightly higher %Fat value of 38% (30% to
35% is usually recommended for obesity in women) allows
for a small increase in fatness with age without a concom-
itant increase in risk factors (26,27). By this delineation,
obese women (ⱖ38% fat) who are correctly classified as
obese by BMI represent true-positive cases, whereas obese
subjects classified as non-obese represent false-negative
cases. Non-obese women correctly classified as non-obese
represent true-negative cases, whereas non-obese subjects
classified as obese represent false-positive cases. These
assessments of BMI’s screening performance were repeated
using slightly lower and higher %Fat cut-off values (35%
and 40%) to address alternative definitions of obesity.
The sensitivity of BMI refers to the probability that BMI
will classify a subject as obese when the subject is truly
obese. The specificity is the probability that BMI will clas-
sify a subject as non-obese when the subject is truly non-
obese (true-negative). The true-positive rate (sensitivity)
was plotted against the false-positive rate (1 ⫺ specificity)
across a range of BMI values. This relationship gives an
estimate of BMI that yields the minimal number of false-
negative and false-positive cases (e.g., the BMI best able to
discriminate between obese and non-obese subjects). This
estimate is selected by determining the BMI value that
maximizes the sum of sensitivity and specificity. The sum
of sensitivity and specificity gives the overall performance
of the cut-off point, with higher sums indicating superior
performance (28).
Another index provided by ROC analysis is the area
under the curve (AUC), which reflects the overall accuracy
of BMI in predicting obesity. The closer the AUC is to 1.0,
the greater the chance that any given obese subject will have
a higher BMI than that of any given non-obese subject.
Conversely, if BMI is unable to distinguish between obese
and non-obese (i.e., where there is no difference between
the two distributions), the AUC will be close to 0.5, and the
ROC curve will approach a diagonal line.
Study Comparison
A literature review was performed based on a compre-
hensive MEDLINE search and a search for articles cross-
referenced in related published reports. Only studies that
presented both BMI and %Fat by DXA, hydrodensitometry,
or a four-component model (4CM) in healthy postmeno-
pausal-aged women (range of mean ages, 42 to 75 years)
were included. In cases where only mean values of HT and
WT were presented, a BMI score was calculated using these
values. Twenty-six studies were then examined in two ways
to determine the extent to which our sample could be
generalized. First, the mean values of BMI and %Fat were
plotted against our regression line to determine whether
their results supported the relationship between BMI and
%Fat that we found. This was accomplished by determining
whether their mean values fell within 1 SE of estimate
(SEE) from the regression line derived in our study. Second,
the mean values of BMI and %Fat for each of the studies
were plotted, and a regression line was created. This regres-
sion line was then plotted against the regression line of the
present study. In the event that a single study examined
multiple populations (i.e., different age, ethnicity, or gen-
der), only those fitting our criteria were used. In cases where
multiple populations within a given study fit our criteria,
each population was treated as an independent sample for
comparison. Thus, a single study may have been used more
than once in comparing it with our study. In cases where
both UWW and DXA %Fat were presented, only the DXA
measure was included in our analysis.
Results
Table 1 presents the means, SDs, and ranges of physical
characteristics by HRT status and all subjects combined.
OBESITY RESEARCH Vol. 10 No. 8 August 2002 801
BMI Standards in Postmenopausal Women, Blew et al.

Table 1. Descriptive statistics of postmenopausal women by HRT status and independent of HRT status
HRT (n ⴝ 155) No HRT (n ⴝ 162) HRT ⴙ No HRT (n ⴝ 317)
Mean ⴞ SD Range Mean ⴞ SD Range Mean ⴞ SD Range
Age (years) 54.2 ⫾ 4.5* 40 to 66 55.4 ⫾ 5.0* 45 to 66 54.8 ⫾ 4.8 40 to 66
Years past
menopause 5.3 ⫾ 3.7† 1.0 to 33.8 6.5 ⫾ 3.2† 3.0 to 20.0 5.9 ⫾ 3.5 1.0 to 33.8
Height (cm) 163.1 ⫾ 6.9 144.0 to 185.6 162.9 ⫾ 6.2 146.0 to 180.0 163.0 ⫾ 6.6 144.0 to 185.6
Weight (kg) 67.7 ⫾ 11.8 45.5 to 110.7 68.6 ⫾ 11.1 46.1 to 98.6 68.2 ⫾ 11.5 45.5 to 110.7
BMI (kg/m2) 25.4 ⫾ 4.1 18.4 to 35.5 25.8 ⫾ 3.5 17.9 to 34.1 25.6 ⫾ 3.8 17.9 to 35.5
FFM (kg) 40.5 ⫾ 5.0 19.9 to 53.7 40.3 ⫾ 4.8 20.1 to 54.7 40.4 ⫾ 4.9 19.9 to 54.7
Percentage of fat 38.3 ⫾ 6.7 16.8 to 53.1 39.3 ⫾ 6.5 13.5 to 54.3 38.8 ⫾ 6.6 13.5 to 54.3

* p ⬍ 0.05.
† p ⬍ 0.01.
HRT, hormone replacement therapy; BMI, body mass index; FFM, fat-free mass.

Our sample was 87.7% white (n ⫽ 278), 9.5% Hispanic Twenty-six studies were examined that resulted in 36
(n ⫽ 30), 1.6% Asian American (n ⫽ 5), 0.9% African samples. Their BMI and %Fat values were plotted against
American (n ⫽ 3), and 0.3% Native American (n ⫽ 1). our regression line (Table 2; Figure 2). Eighty-one percent
Forty-nine percent of the subjects were using some form of of the studies selected from the literature review fell within
HRT. Age and years past menopause were significantly 1 SEE from the regression equation in our study.
different (p ⬍ 0.05) between women using HRT and women A comparison of the BMI cut-off point for classifying
not using HRT, but no significant differences were observed obesity as suggested by the NIH and that proposed by this
when comparing height, weight, BMI, and %Fat. Conse- study is presented in Table 3. ROC analysis was used to
quently, the results that follow are based on all subjects
combined and not by HRT status.
Based on BMI classifications suggested by the NIH (1),
1.6% were underweight, 45.1% were within the healthy
weight range, 38.5% were overweight, and 14.8% were
obese. Linear regression analysis showed that %Fat and
BMI were highly correlated (r ⫽ 0.81) with a SEE of 3.9%.
Figure 1 illustrates the relationship and shows the resulting
regression line [%Fat ⫽ 1.41(BMI) ⫹ 2.65]. The associa-
tion between BMI and %Fat was not altered by adjusting for
years past menopause or years on HRT. Using this equation
to estimate the %Fat values associated with the NIH BMI
classifications, the following was found: BMI of 19 kg/m2
equals 29.4%Fat, BMI of 25 kg/m2 equals 37.9%Fat, BMI
of 30 kg/m2 equals 45.0%Fat, and BMI of 35 kg/m2
equals 52.0%Fat.
Gallagher et al. (29) have proposed the use of the inverse
of BMI to predict body fatness because a curvilinear rela-
tionship may exist between BMI and %Fat. Linear regres- Figure 1: Percentage of total body fat (%Fat) measured by DXA
sion using the inverse of BMI to predict %Fat in our sample vs. body mass index (BMI) in postmenopausal women (n ⫽ 317;
resulted in r ⫽ 0.83, SEE ⫽ 3.7%, and %Fat ⫽ r2 ⫽ 0.64; SE of estimate ⫽ 3.9%). Horizontal line indicates the
cut-off value for %Fat (38%). Vertical lines indicate NIH-recom-
⫺951.7(BMI) ⫹ 76.8. Using this equation to predict %Fat
mended classifications (1). Vertical line on the left (short dash)
values associated with the BMI classifications, the follow- indicates underweight cut-off (19 kg/m2), middle vertical line
ing was found: BMI of 19 kg/m2 equals 26.7%Fat, BMI of (long dash) indicates overweight cut-off (25 kg/m2), and vertical
25 kg/m2 equals 38.7%Fat, BMI of 30 kg/m2 equals line on the right (solid) indicates obesity cut-off (30 kg/m2).
45.1%Fat, and BMI of 35 kg/m2 equals 49.6%Fat.

802 OBESITY RESEARCH Vol. 10 No. 8 August 2002

BMI Standards in Postmenopausal Women, Blew et al.

Table 2. Mean body mass index and mean total body fat percentage in postmenopausal age populations
Anthropometry Percent fat

Population Age Weight (kg) Height (m) BMI % Fat

Study (reference) n Ethnicity Mean SD Range Mean SD Mean SD Mean SD Mean SD Method

Aloia et al. 1999 (30) 162 Black 42.2 ⫾12.1 65.8 ⫾8.2 1.64 ⫾0.06 24.6 ⫾2.9 36.4 ⫾7.2 DXA
203 White 47.7 ⫾12.9 62.8 ⫾8.3 1.64 ⫾0.06 23.2 ⫾2.6 35.1 ⫾7.2 DXA
Baumgartner et al. 1995 (31) 50 White 60 to 70 67.2 ⫾11.6 1.61 ⫾0.05 26.0 ⫾4.5 38.3 ⫾7.8 DXA
82 White 71 to 80 63.1 ⫾10.9 1.58 ⫾0.06 25.1 ⫾3.6 38.0 ⫾6.8 DXA
56 White ⬎80 59.0 ⫾8.5 1.56 ⫾0.06 24.2 ⫾3.3 35.1 ⫾3.2 DXA
Bedgoni et al. 2001 (20) 1423 White 67 ⫾5.0 60 to 88 65.0 ⫾9.0 1.57 ⫾0.06 26.2 ⫾3.5 37.7 ⫾6.0 DXA
Bergsma-Kadijk et al. 1996 (32) 18 White 71.6 ⫾3.8 65 to 78 65.0 ⫾8.5 1.60 ⫾0.05 25.4 ⫾3.9 38.8 ⫾5.9 4-Component
model
Brodowicz et al. 1994 (33) 31 * 71.1 ⫾4.6 65 to 85 65.1 ⫾10.1 1.61 ⫾0.06 25.0 ⫾3.5 39.0§ DXA
44.5§ UWW
Broekhoff et al. 1992 (34) 28 * 72.0 ⫾4.0 67 to 78 68.4 ⫾9.9 1.61 ⫾0.07 26.3 ⫾3.4 39.6 ⫾5.6 UWW
Clasey et al. 1999 (35) 19 White 65.8 ⫾1.4 * * * * * 26.4 ⫾4.4 41.2 DXA
41.6 UWW
Deurenberg et al. 1989 (36) 37 * 68.0 ⫾5.2 60 to 83 68.5 ⫾8.7 1.63 ⫾0.06 25.9 ⫾3.2 43.9 ⫾4.3 UWW
Gallagher et al. 1996 (15) 104 Black 49.6 ⫾16.2 * 71.2 ⫾12.3 1.62 ⫾0.06 27.0 ⫾4.3 35.6 ⫾8.5 4-Component
290 White 50.3 ⫾18.7 * 61.8 ⫾10.0 1.63 ⫾0.07 23.3 ⫾3.7 30.3 ⫾8.6 model
Gallagher et al. 2000 (29) 155 Black 56.2 ⫾16.8 * 71.5 ⫾12.5 1.62 ⫾0.07 27.1 ⫾4.3 37.6† 4-Component
225 White 48.8 ⫾17.6 * 62.7 ⫾10.4 1.63 ⫾0.07 24.5 ⫾4.5 33.8† model
Gruber et al. 1998 (37) 20 * 51.7 ⫾1.9 * 68.9 ⫾13.1 1.65 ⫾0.02 24.8 ⫾4.3 38.2 ⫾7.9 DXA
19 * 52.2 ⫾1.3 * 69.1 ⫾9.6 1.66 ⫾0.12 25.1 ⫾3.6 39.2 ⫾6.5
Harris et al. 1996 (38) 261 White 63.5 ⫾5.2 47 to 76 67.5 ⫾11.8 1.61 ⫾0.07 26.1 ⫾4.1 39.9† DXA
Kirchengast et al. 1998 (39) 278 White 55.8 * 44 to 67 71.3 ⫾9.1 1.65 ⫾0.05 26.3 ⫾3.1 41.5 ⫾6.1 DXA
Nelson et al. 1991 (40) 41 White 60.2 ⫾1.1 PM, ⬍70 64.0 ⫾1.4 1.62 ⫾0.01 24.4 ⫾0.5 42.1 ⫾0.9 UWW
Rankinen et al. 1999 (41) 200 White 52.0 ⫾6.8 18 to 72 69.8 ⫾16.1 1.58 ⫾0.06 27.9 ⫾6.8 37.4 ⫾8.6 UWW
Ravn et al. 1999 (42) 417 * 53.0 ⫾3.6 45 to 59 66.7 ⫾10.4 1.62 ⫾0.07 25.4 ⫾3.6 40.1 ⫾6.7 DXA
403 * 53.4 ⫾3.8 66.6 ⫾10.2 1.62 ⫾0.07 25.4 ⫾3.5 40.1 ⫾6.6
Reilly et al. 1994 (43)‡ 16 * 70.4 ⫾4.2 66 to 78 60.3 ⫾8.4 1.57 ⫾0.05 24.4 ⫾3.0 39.0 ⫾8.8 UWW
Sardinha et al. 2000 (44) 383 White 60.5 ⫾7.1 50 to 80 65.4 ⫾10.9 1.54 ⫾0.06 27.8 ⫾4.2 42.6 ⫾6.9 DXA
Snead et al. 1993 (45) 62 * 66.3 ⫾3.1 60 to 81 64.6 ⫾11.6 1.62 ⫾6.6 24.6† 34.5 ⫾6.6 DXA
39.9 ⫾6.3 UWW
Svendsen et al. 1991 (46) 23 * 75 ⫾0.0 75 65.5 ⫾11.6 1.59 ⫾0.07 25.9 ⫾4.3 33.7 ⫾9.9 DXA
Svendsen et al. 1995 (47) 196 White 50 to 59 66.1 ⫾10.7 1.63 ⫾0.06 24.9 ⫾3.9 35.1 ⫾6.8 DXA
26 60 to 69 64.2 ⫾9.5 1.60 ⫾0.06 25.3 ⫾4.0 36.8 ⫾8.0
32 70 to 79 63.9 ⫾10.4 1.60 ⫾0.07 25.1 ⫾4.3 33.8 ⫾9.0
Tremollieres et al. 1996 (48) 100 White 53.8 ⫾3.1 46 to 60 55.9 ⫹5.4 1.60 ⫾0.06 21.8 ⫾1.8 31.6† DXA
37 White 64.1 ⫾4.0 60 to 70 56.6 ⫾5.6 1.58 ⫾0.06 22.6 ⫾2.0 34.6†
Visser et al. 1999 (49) 30 * 73.6 ⫾2.3 67.9 ⫾12.6 1.59 ⫾0.06 26.9 ⫾5.2 38.9 ⫾6.7 4-Component
Model
Williams et al. 1995 (50) 23 White 65.0 ⫾9.4 64.4 ⫾8.1 1.61 ⫾0.06 24.9 ⫾3.6 40.1 ⫾5.8 UWW
Xie et al. 1999 (51) 124 * 56.4 ⫾2.9 51 to 63 66.0 ⫾11.5 1.64 ⫾0.06 24.5 ⫾4.1 30.4 DXA
Zamboni et al. 1999 (52) 144 * 72.0 ⫾2.2 68 to 75 64.7 ⫾11.4 1.57 ⫾0.06 26.4 ⫾4.5 41.1 ⫾6.1 DXA

* Not specified in this paper.

† Calculated from height and weight group means or using a prediction equation.
‡ Calculated from individual subject data presented in paper.
§ Means are estimated from a graph.
UWW, underwater weighing; PM, postmenopausal.

OBESITY RESEARCH Vol. 10 No. 8 August 2002 803

BMI Standards in Postmenopausal Women, Blew et al.

Figure 3: Receiver operating characteristic (ROC) curve of body

Figure 2: Mean percentage of total body fat (%Fat) and body mass
index (BMI) values from other studies that used a similar sample
(see Table 2). Solid line represents regression line of %Fat on BMI
using all other studies as data points. Dashed lines and mixed
dotted and dashed lines represent the regression line and 1 SE of
estimate, respectively, as derived in this study.
mass index (BMI) vs. DXA obesity (ⱖ38%Fat), where 24.9 is the
cut-off that corresponds to the best tradeoff between sensitivity
and 100 ⫺ specificity (e.g., the most accurate cut-off point for
discrimination between obese and non-obese postmenopausal
women).

a greater BMI than a randomly selected non-obese sub-

examine the ability of BMI to discriminate obesity from
non-obesity using ⱖ38%Fat as the criterion value for obe-
sity. The ROC curve depicted in Figure 3 shows the cut-off
point for BMI that maximized the sum of the sensitivity and
specificity for detecting obesity defined as 38%Fat was 24.9
kg/m2. The true-positive (sensitivity) and false-positive
(1 ⫺ specificity) rates corresponding to the cut-off value
were 84.4% and 14.6%, respectively, which means BMI
will classify a subject as obese 84.4% of the time when the
subject is truly obese but will misclassify them as obese
14.6% of the time. The AUC estimate was 0.914, mean-
ing that a randomly selected obese subject will have
ject 91% of the time. The 95% confidence interval was
0.877 to 0.942. The lower limit of 0.877 is high, suggesting
good diagnostic performance by BMI. Using the NIH cutoff
for obesity of 30 kg/m2, the sensitivity was 25.6 and the
specificity was 99.3.
Discussion
BMI-based classification of overweight and obesity has
been widely accepted by the research community but has
not yet been broadly adopted by primary care practitioners
(18). The weak relation of BMI to important health out-
comes in a varied range of populations and the inability of

Table 3. Performance comparison of BMI-based cutoffs for diagnosing obesity using 35%, 38%, and 40% body fat, NIH (1)
vs. present study

35% Body fat 38% Body fat 40% Body fat

NIH Present study NIH Present study NIH Present study
2
Proposed BMI cut-off point (kg/m ) 30.0 24.0 30.0 24.9 30.0 25.3
True-positive rate (%)† 20.4 87.2 25.6 84.4 28.8 87.6
False-positive rate (%)‡ 0.0 14.3 0.7 14.6 1.2 14.6
Overall performance 124.4 172.9 124.9 169.8 127.6 173.0
(⌺ Sensitivity and specificity)

†True-positive rate ⫽ sensitivity.

‡False-positive rate ⫽ (1 ⫺ specificity).
BMI, body mass index.

804 OBESITY RESEARCH Vol. 10 No. 8 August 2002

BMI Standards in Postmenopausal Women, Blew et al.
BMI to accurately assess body composition for the individ-
ual are important limitations of the index that may explain
the dissatisfaction among some clinicians. In fact, the use of
BMI to determine obesity or as a surrogate for body com-
position has been shown to have several limitations (14 –
17,20,53). These studies demonstrate that adjusting a sub-
ject’s body weight for height will not necessarily yield
consistent levels of body fatness. Therefore, two individuals
with identical BMI values may have considerably different
%Fat levels, particularly if they vary in ethnicity, age, or
sex. Although data on the effect of ethnicity have been
mixed, Deurenberg et al. concluded in a meta-analysis that
the relationship between %Fat and BMI does vary among
ethnic groups (14). However, this study did not include
Hispanics, and no studies to date have found that the rela-
tionship between %Fat and BMI in Hispanics is different
from whites. It has also been shown that variations in age
and sex have a significant impact on the relationship be-
tween BMI and adiposity (9,15). When comparing young
and old subjects and men and women, older subjects and
women will have a higher %Fat (for a given weight and
height) despite similar BMIs (15). Consequently, it is likely
that there are populations in which the BMI classifications
proposed by NIH will be misleading.
This study provides a more homogeneous population,
thus eliminating potential inequities associated with age,
sex, or ethnicity. However, this is also a limitation of the
study. The characteristics of this sample may not be fully
representative of all postmenopausal women, particularly
older postmenopausal women. The study is further limited
because all subjects were paid volunteers and may not
characterize a random sampling of all postmenopausal
women. Nevertheless, the current sample size of 317 sub-
jects is large enough to define within narrow limits the
magnitude of the correlation between BMI and %Fat (r ⫽
0.81). Furthermore, we were encouraged to find that other
studies examining this population (Table 2) agree with our
findings and for the most part (81%) fall within 1 SEE from
our regression equation.
There are several reasons why some studies did not fit
within 1 SEE from the regression equation in our study.
First, there were studies that did not specify ethnicity
(36,46), which could affect the relationship between %Fat
and BMI (14). Second, several of the studies had a much
smaller sample size than ours, reducing the precision of
their measures (36,40,46,47). These samples were also older
than the current study sample (36,40,46,47), and although
we found that years past menopause did not alter the rela-
tionship between %Fat and BMI, samples with substantially
older subjects may be affected. Finally, not all of these
studies used DXA to determine %Fat in this population
(36,40,41). Studies using two component models such as
UWW to predict %Fat could potentially be inaccurate be-
cause of variations in the densities of the body constituents.
Postmenopausal women are a population that have experi-
enced changes in the density of their fat-free mass, in
particular, reductions in bone mineral density (21,54,55).
The use of DXA, as in this study, allows a three-component
measure, which, in a population where bone is known
to undergo dramatic changes, may remove inaccuracies
caused by potential component variations. However,
because the evidence suggests that the variability be-
tween the methods (UWW, DXA, and 4CM method)
only ranges from 1% to 3% (35), all were considered for a
more inclusive comparison.
Previous studies have created prediction formulas to es-
timate %Fat based on BMI (9,29,36). Formulas derived
from age- and sex-specific regression equations have been
shown to have an estimation error of about 4% in elderly
men and women (9,36). The equation developed by Deuren-
berg et al. incorporates the confounding variables of age and
sex, but it used densitometry and only included ⬃60 women
in our age range (9). Gallagher et al. (29) also developed an
equation for predicting %Fat (4CM) from the inverse of
BMI that incorporated both age and sex. The sample used to
derive the prediction equation consisted of 671 white and
African-American subjects (380 women and 225 men) and
varied widely in age, but still yielded a high correlation (r ⫽
0.90) and a SEE of 4.3%. The current study sample was
more ethnically and age homogeneous, included only post-
menopausal women (n ⫽ 317), and it resulted in a lower
SEE (3.9%) for the prediction of %Fat from BMI. Accord-
ingly, the results of our study are more directly applicable to
the postmenopausal population.
In this population, it is apparent that BMI is as effective
for predicting %Fat as BIA or SKF. The SEE (3.9%) was
similar to those found in previous studies (9) and compa-
rable with using SKF or BIA with potentially less measurer
error and cost than either of these methods. This does not
necessarily mean that BMI is an effective screening tool for
diagnosing obesity. However, the AUC determined by the
ROC analysis (0.91) does support BMI’s effectiveness at
diagnosing obesity. The AUC in this sample suggests that
any randomly selected obese subject will have a higher BMI
than a randomly selected non-obese subject 91% of the
time. The 95% confidence interval (0.88 to 0.94) demon-
strates that at even the lower limit (0.88), the diagnostic
ability of BMI is good.
With the regression equation from this study, BMI is
disparate from %Fat for the overweight and obese classifi-
cations. According to the current classifications from NIH
(1), a BMI of 25 to 30 kg/m2 indicates overweight and 30 to
35 kg/m2 indicates class I obesity. Our results indicate that
the corresponding ranges for %Fat are 38% to 45% and 45%
to 52% for overweight and class I obesity, respectively. The
relationship for overweight and obesity is linear across the
majority of %Fat and BMI values, but the relationship is not
linear at lower BMIs. The corresponding %Fat for a BMI of
OBESITY RESEARCH Vol. 10 No. 8 August 2002 805
BMI Standards in Postmenopausal Women, Blew et al.
19 kg/m2 is 29.4% (or 26.7% using the inverse of BMI that
relates more linearly to %Fat), an amount of fatness clearly
not associated with underweight health-related risks. How-
ever, this is likely explained by the fact that our sample only
had five subjects (1.6%) ⬍19 kg/m2.
ROC analysis was performed to obtain a more analytical
measure of the effectiveness of BMI for diagnosing obesity
in postmenopausal women. In younger women (20 to 45
years), Wellens et al. (19) showed that BMI provided a
sensitive measure for estimating adiposity based on a
33%Fat criterion measure but did not examine a postmeno-
pausal population. In the absence of a clearly defined rela-
tionship between %Fat and morbidity and mortality in post-
menopausal women, our cut-off of 38%Fat for obesity was
based on the recommendation of Lohman et al. (26,27).
With this criterion value, 24.9 kg/m2 was the most sensitive
and most specific BMI for the present population of post-
menopausal women, meaning that it is the optimal value to
discriminate between obesity and non-obesity. Other com-
monly used %Fat cut-off points for obesity (35% and 40%)
yielded a range of 24.0 to 25.3 kg/m2 when used as criterion
values (Table 3). These values are consistent with the 25.5
kg/m2 determined by Sardinha and Teixeira (44) in a pop-
ulation of women over 50 years, employing similar meth-
odology. It also closely corresponds to the cut-off point
determined by Calle et al. (56) in a large-scale prospective
study showing that women with a BMI higher than 25
kg/m2 had a significantly increased risk of death from
cardiovascular disease.
According to our data, the NIH classification for obesity
of 30 kg/m2 gives a false-positive rate of 0.7 (sensitivity ⫽
99.3) and a true-positive rate (specificity) of 25.6 (Table 3).
This indicates that although a BMI of 30 kg/m2 will likely
not classify a non-obese postmenopausal woman as obese, it
may inaccurately classify many obese women as non-obese.
This is a potentially harmful misclassification because the
prevalence of adult obesity has increased (2), and it is an
important correlate of chronic disease (4). Given the greater
health risks associated with obesity, it is perhaps more
important to classify everyone who is truly obese as obese
even at the risk of increasing the false-positive rate. There-
fore, 25 kg/m2 may be a better obesity criterion value than
30 kg/m2 because it maximizes the sum of sensitivity and
specificity, which seems more appropriate in the case of
predicting obesity as an excess of body fatness and not
merely weight.
Although we support the use of BMI criterion values for
population studies, it is important to remember that the rela-
tionship between BMI and %Fat is not precise and creating
absolute cut-off measures may be unreliable for any given
individual (20). Nevertheless, BMI-based classifications are
still important and necessary in the primary care and public
health settings (18). BMI criterion values such as those pro-
posed here are limited by the lack of clearly defined standards
806 OBESITY RESEARCH Vol. 10 No. 8 August 2002
that establish a relationship between %Fat and risk factors
associated with morbidity and mortality in postmenopausal
women. Even so, our selection of ⱖ38%Fat is likely to be
consistent with an increased health risk for postmenopausal
women, and therefore, the corresponding BMI of ⬎24.9 kg/m2
should be considered when classifying obesity in postmeno-
pausal women. Given that the moderately high relationship
between %Fat and BMI is representative of other studies of
postmenopausal women and that there is a dramatic difference
between our cut-off point (24.9 kg/m2) and that proposed by
the NIH for the population as a whole (30.0 kg/m2), our results
clearly support the need for population-specific BMI classifi-
cations. In conclusion, in the context of recommended health-
related %Fat cut-offs, the results of our study suggest that a
BMI of 30 kg/m2 may be too conservative. The currently
accepted NIH cut-off for the category of overweight (25 kg/
m2) could be a better criterion to diagnose obesity in post-
menopausal women.
Acknowledgments
This study was supported by National Institutes of Health
grant AR39559.
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