REVIEW

CURRENT
OPINION Segmental bioelectrical impedance analysis:
an update
Leigh C. Ward

Purpose of review
Bioelectrical impedance analysis is a popular, noninvasive and practical method for assessment of body
composition. The last decade has seen the development of impedance analyzers designed to assess the
composition of body segments as well as the whole body. This review outlines the theoretical basis for
segmental impedance analysis, validity and use in practice.
Recent findings
Segmental impedance analysis tends to underestimate fat-free mass and overestimate fat mass when
compared to reference techniques, although the magnitude of these differences can be small. Performance
is improved with population-specific prediction equations; algorithms in-built into instrument firmware should
not be relied upon. Prediction of whole-body composition from the sum of the individual segments, although
theoretically preferable, shows little advantage over whole body wrist to ankle impedance approaches.
Prediction of appendicular skeletal muscle mass, although promising, requires further research. The use of
measured impedance data directly as indices of composition, rather than for prediction, has not found
extensive application in nutritional research despite its success in other fields.
Summary
Segmental bioimpedance techniques have advanced substantially in recent years due to availability of
simple-to-use analyzers and simplified measurement protocols. The method has been well validated and
increasingly adopted in nutritional and clinical practice. Segmental impedance, like conventional whole
body impedance approaches, provides indirect prediction of body composition whose accuracy is yet to
achieve that of reference techniques such as magnetic reference imaging. This lack of accuracy, however,
is outweighed by the method’s practicality of use in many settings.
Keywords
body composition, eight-electrodes, fat-free mass, fluid distribution, segmental bioelectrical impedance,
skeletal muscle

INTRODUCTION growth in its use for nutritional assessment [3],

Knowledge of body composition parameters such as
total body water, fat-free mass (FFM) and fat mass is
of importance in studies of nutritional status. Var-
ious methods have been developed to measure,
accompanied by advances in impedance technology
[4]. Impedance technology has also found its way
into health monitoring in the general population
with the availability of low-cost impedance body fat
&

either directly or indirectly, these compartments.
Garrow [1], while reviewing the available tech-
niques for measuring body composition, stated that
the ideal method should ‘be relatively inexpensive,
require little inconvenience for the individual, be
operated by unskilled technicians and yield highly
reproducible and accurate results’. Few methods
meet these requirements, one being bioelectrical
impedance analysis (BIA).
BIA first came to prominence in the mid-1980s
with the first commercial availability of impedance
analyzers and following the seminal publication of
Lukaski et al. [2]. Since then there has been rapid
analyzers [5 ]. Despite the wide variety of equipment
and measurement methodologies now available, the
basic measurement principles remain the same.
School of Chemistry and Molecular Biosciences, The University of
Queensland, St. Lucia, Brisbane, Australia
Correspondence to Associate Professor Leigh C. Ward, School of
Chemistry and Molecular Biosciences, The University of Queensland,
St Lucia, Brisbane QLD 4072, Australia. Tel: +61 7 3365 4633; fax: +61
7 3365 4699; e-mail: l.ward@uq.edu.au
Curr Opin Clin Nutr Metab Care 2012, 15:424–429
DOI:10.1097/MCO.0b013e328356b944

www.co-clinicalnutrition.com Volume 15
Number 5
September 2012

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KEY POINTS

Segmental bioelectrical impedance analysis offers a
simple practical method for assessing the fat and
fat-free mass of body segments and of body fluid
distribution.

Its accuracy and precision is generally acceptable for
population level studies, but where accuracy is
paramount, reference methods should still be used.

Segmental impedance methodology has the potential to
predict appendicular skeletal muscle volume but further
research is required.
BASIC THEORY OF SEGMENTAL
BIOELECTRICAL IMPEDANCE ANALYSIS
The theory of biological impedance measurements
for body composition assessment has been well
described elsewhere [4,6]. Briefly, when an alternat-
ing potential is applied to the body, the resulting
current passes predominantly through the conduc-
tive water-containing tissues, that is the FFM. The
volume of the conductive compartment is described
by the following expression:
l2
v ¼ r
R athletic population. Marked differences in predicted
wherein v is volume, r is resistivity, l is conductor
length and R is the resistance. Eq. (1) is the basis
of prediction equations for body composition
parameters based upon whole body, wrist to ankle,
or segmental impedance measurements. This pre-
diction equation may incorporate other predictor
variables such as weight, age and sex in a multiple
regression.
Eq. (1) is based upon the electrical properties of a
cylinder. The human body is not a single cylinder
but is considered to comprise five interconnected
cylinders (segments): two arms and legs and the
trunk. If the resistance of the body segments is
measured separately then total volume is computed
from the following equation:
Vtotal ¼ 2Varm þ 2Vleg þ Vtrunk
Substituting from Eq. (1) yields the following
equation
l2 l2 l2
V total ¼ 2ðr Þ þ 2ðr Þ þ ðr Þ
R arm R leg R trunk
Eq. (3) can be used to predict whole body
volumes from the sum of the respective segments
impedance measurements. This assumes that the
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Segmental bioelectrical impedance analysis: an update Ward
resistivities (r) of the individual segments are the
same, which may not be the case as discussed later.
WHOLE BODY VERSUS SEGMENTAL
BIOELECTRICAL IMPEDANCE ANALYSIS
It is difficult to reconcile the simplified Eq. (1) with
the more theoretically correct Eq. (3). Although the
sum of the resistance of the three segments, arm,
trunk and leg may equal the wrist to ankle value, the
total fluid volume is given by Eq. (3) not Eq. (1). This
highlights some of the criticisms of conventional
wrist-to-ankle methodology.
First, it is relatively insensitive to changes in the
water content of the trunk yet this is the largest
single water compartment in the body. This is of
importance in clinical states wherein ascites or
central edema may be present.
Second, predictive algorithms based upon
Eq. (1) assume that all individuals have similar
relative distribution of water between the limbs
and the trunk. This is highly unlikely in disease
states or disturbances of water balance necessitating
population-specific prediction algorithms.
An additional consideration is that many of the
commercially available impedance analyzers have
different modes of operation for different popu-
(1) lation groups, for example general population or
body composition have been observed between
modes [7]. Because the selection of operating mode
is the choice of the operator, the potential for inap-
propriate choice, either by omission or commission,
exists leading to inaccurate reporting of results.
IMPLEMENTATION OF SEGMENTAL
BIOELECTRICAL IMPEDANCE ANALYSIS
Early segmental measurements were made by
moving both the current drive and voltage sense
electrodes as electrode pairs to different anatomical
locations spanning the segment of interest. Impre-
cision in locating these electrodes incurs error in
the measurements as evidenced by the sum of the
segmental impedances not equalling those of the
(2) wrist-to-ankle measurement.
With modern segmental analyzers, the indivi-
dual stands upon pairs of electrodes and grips
handles in which additional pairs of electrodes are
embedded, the so-called octapolar or eight-elec-
trode method. Sequential measurements between
(3)
pairs of sense electrodes, according to the principle
of equipotentials [8], are made to measure impedan-
ces of all body segments.
Recently, this method has been compared with
&
the older paired electrode approach [9,10,11 ]. An
www.co-clinicalnutrition.com 425
 Assessment of nutritional status and analytical methods
important outcome of this study was that the equi-
potential approaches overestimates limb resistance
by between 3 and 8% when compared to the paired
electrode approach. This implies that the equipo-
tential method determines the resistance of a
‘virtual’ limb that includes a small contribution
of the trunk. Nevertheless, the convenience of
stand-on impedance devices that do not require
the individual to undress outweighs this small
source of error. Furthermore, as long as these over-
estimations are reasonably constant between
individuals, the consequential error in predicting
segmental FFM is automatically corrected for
when the method is calibrated against techniques
such as dual-energy X-ray absorptiometry (DXA)
or MRI.
PREDICTING BODY COMPOSITION FROM
SEGMENTAL IMPEDANCE
MEASUREMENTS
Impedance measurements are most appropriately
used to predict body fluid volumes or immediately
derived values such as FFM. Consequently, predic-
tions of segmental composition are typically derived
using an algorithm based on Eq. (1), wherein v
represents the volume of tissue water or FFM. In
practice, Eq. (1) is rarely solved directly. Instead, Eq
(1) is ‘calibrated’ empirically by regressing the impe-
dance quotient (l2/R) against measurements of
segment composition obtained from DXA or MRI,
the slope of the regression line equating to the
‘apparent’ resistivity.
In segmental analysis, length should be that of
the segment, however, this is rarely used; instead,
segment length is assumed to be proportional to
height and this approach is used in eight-electrode
style analyzers. The validity of this assumption
across all populations is open to question and
may contribute to the relatively poor performance
of segmental impedance in some populations.
An additional problem presents itself when
calculating total body composition using Eq. (3).
In most studies, the resistivity of segments is
assumed to be constant. Owing to the different
tissue composition of body segments, this is
unlikely to be the case, and Zhu et al. [12] have
noted that the use of segment-specific resistivity
values can improve prediction of fluid volumes in
dialysis patients.
SEGMENTAL IMPEDANCE ANALYSIS AND
BODY COMPOSITION
Gibson et al. [13] validated, in a large multiethnic
study, two octapolar analyzers against a four-
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component model of body composition. They
reported high correlations between the two
methods for percentage total body fat with no sig-
nificant difference in group mean values for men
but significant underestimation (2.5–3.0%) by BIA
in women. The standard errors of estimation ranged
from 2.8 to 3.5% body fat.
A mean difference in whole-body FFM, com-
puted from segmental analyses, of 1.6 kg and wide
limits of agreement (1.8 to 4.9 kg) between BIA and
DXA was reported by Chao et al. [14] in young men.
This difference was decreased to 0.04 kg (3.2 to
3.2 kg) when a population-specific segmental
equation was used.
&&
Ling et al. [15 ] compared segmental BIA with
DXA in 484 middle-aged men and women. They
reported excellent agreement (intraclass correlation
coefficients >0.93) between the two methods.
Difference in whole body lean mass was only
0.2 kg in normal weight individuals, although lean
mass was underestimated by 1.24 and 4.1 kg in the
overweight and obese, respectively. In contrast,
body fat mass was overestimated in the overweight
and obese by 1.98 and 4.85 kg, respectively. Limits of
agreement (2 SD) were approximately more or less
than 4.5 kg (approximately  10 and  25% of lean
and fat masses, respectively) in both men and
women suggesting that, although performing well
at a group level, segmental BIA may have limited
value for predicting body fat in an individual.
The segmental approach for predicting whole
body composition has also been applied to children
[16]. FFM was significantly underestimated
(P < 0.003) by BIA compared to FFM measured by
deuterium oxide dilution, irrespective of sex and
age, in a large group of Gambian children aged from
5 to 18 years. Although the differences were signifi-
cant, the absolute magnitude was relatively small,
approximately 4%.
Despite the main advantage of segmental BIA
being the ability to predict the composition of
the individual body segments, there have been
relatively few studies validating this approach.
&&
Ling et al. [15 ] observed that BIA generally
underestimated the lean masses of all body seg-
ments (arms, legs and trunk) when compared to
DXA measurements. These underestimates were
smaller for the arms (approximately 5%) than legs
(7%) and, particularly, the trunk (12%). Similar
observations were made by Chao et al. [14] who
determined the limits of agreement as approxi-
mately more or less than 0.6 kg (20%) and  1.9 kg
kg (17%) for the arms and legs, respectively. Mally
&
et al. [17 ] also found underestimation (6–18%) of
appendicular lean mass in older men but overesti-
mated in the arms of women (13%); the reverse
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 Segmental bioelectrical impedance analysis: an update Ward
was found for fat mass, particularly for truncal fat
(60% overestimation).
As the prevalence of obesity has increased across
the world, interest has focussed on measuring body
fat mass rather than the FFM. It is easy to estimate fat
mass from BIA-derived measures of whole body FFM
by subtracting FFM from total body mass. This is
readily achieved since most commercially available
segmental analyzers are incorporated into a digital
stand-on weighing scale. Determination of segment
weight is, however, extremely difficult, yet, most
analyzers provide estimates of segmental fat mass.
The methods by which this is achieved are largely
unknown as the algorithms used are proprietary to
the manufacturers [18]; however, it is likely that
they are based on a notional ‘weight of the segment’
derived from the predicted segment FFM and per-
centage of fat mass derived from regression formulae
determined in independent DXA studies of body
composition [19].
&&
Leahy et al. [20 ] in a large study of young adults
(167 women and 236 men aged 18–29 years) com-
pared fat mass measurements predicted by segmen-
tal BIA with DXA measurements. Total body fat was
underestimated by approximately 2%, although this
increased to more than 4% in men and women with
greater than 24.6 and 32% body fat, respectively. Fat
mass was significantly overestimated in the trunk in
men (2.1 kg, 31%) but underestimated in women
(0.4 kg, 5.6%). There were also significant differ-
ences for appendicular fat, overestimating leg fat
mass by as much as 1.6 kg (31.4%) in men. These
authors urged caution in the use of BIA for segmen-
tal body composition analysis, particularly for the
trunk.
In an earlier review of segmental impedance
analysis in this journal, De Lorenzo and Andreoli
[21] speculated that segmental BIA techniques may
be used to quantify regional skeletal muscle mass,
replacing imaging techniques such as MRI or com-
puted tomography. Unfortunately, this has not
transpired to be the case. Various authors have
developed methods for prediction of skeletal muscle
volume (e.g. [22]). Biases in prediction ranged from
2 to 6% compared to standard error of approxi-
mately 9% when predicting whole-body skeletal
muscle volume from wrist–ankle impedance
measurements. Despite the promise of these studies,
little work appears to have been undertaken recently
[23]. The ability of segmental BIA to predict skeletal
muscle mass specifically would extend significantly
the utility of the technique and be of great value and
relevance to those wishing to monitor sarcopenia in
the aged.
Segmental impedance measurements are not
confined to whole limbs. Localized impedance
1363-1950 ß 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
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measurements have come to prominence in a num-
ber of fields. The measurement of impedance of a
sublimb segment, the calf, has become the method
of choice when impedance is used to monitor fluid
status during dialysis [24,25]. This technique is more
sensitive and precise than whole body or limb
measurements. Typical coefficients of variation
were reported as less than 0.5%. The technique
has recently been adapted to assess body compo-
sition of dialysis patients based on measurement of
arm impedance to predict muscle and subcutaneous
adipose tissue [26]. This technique should find wider
application in nutritional investigations that
involve changes in body water volumes or distri-
bution between cellular compartments or body
regions [27].
Highly localized impedance measurements
focussing on small segment volume are also being
used to provide qualitative information on the com-
position and architecture of muscle in a variety of
disease states [28]. This approach, known as electri-
cal impedance myography, promises to be useful as
an indicator of disease state and efficacy of treat-
ment. To date, its application has been primarily to
evaluate neuromuscular disease, but because it pro-
vides information on the composition of muscle
including the presence of edema, fat and connective
tissue, it is likely to be of value in nutritional studies.
The prediction of body composition from impe-
dance data includes many potential sources of error.
Recognition of this has led some to question the
value of predicting body composition parameters
per se and, alternatively, to propose that clinically
useful information can be equally gained from
consideration of the measured impedance alone
&& &
[29 ,30 ]. This approach has been successfully used
to monitor the development of postsurgical edema
localized to the leg [31]. Accumulation of extra-
cellular fluid in lymphoedema of the arm or leg is
routinely monitored using impedance indices only
&
[32,33 ], although prediction of absolute fluid
volumes is possible [34]. The application of this
method to assess edema from other causes including
nutritional perturbation is yet to be realized.
Segmental BIA has only recently begun to move
into routine clinical practice. Determination of fluid
distributions in body segments has been shown to
be useful in palliative care of patients with cancer
[35] as prognostic indicators with the potential to
predict survival time.
Patients undergoing peritoneal dialysis, at risk of
developing protein–energy wasting, routinely have
nutritional assessments. Segmental BIA measure-
ments are strongly correlated with DXA measure-
ments in such patients [36,37] and may be a more
practical alternative.
www.co-clinicalnutrition.com 427
 Assessment of nutritional status and analytical methods
CONCLUSION
The advent of commercially available stand-on style
segmental analyzers has allayed many of the con-
cerns previously raised regarding standardization of
the measurement technique. Unlike conventional
wrist to ankle BIA, the segmental analyzers provide
much greater convenience for the individual,
although a stand-on device is not suitable for use
in the bed-bound patient. Available data suggest
that its predictive performance is not markedly
better than conventional BIA when used to predict
the composition of the whole body. This is disap-
pointing given the early hopes to the contrary. The
real value of segmental impedance lies in its ability
to measure the composition of discrete body seg-
ments. Recent studies reviewed here suggest that it
achieves this aim, although it would be desirable to
see the accuracy of the technique improved; typi-
cally, FFM is underestimated and fat mass overesti-
mated. In many studies, however, the lack of
absolute accuracy may be of secondary concern to
the ability to assess fat, lean and fluid distribution.
Equally, in longitudinal studies the ability to
measure small changes in body composition is of
more importance. Data on the use of segmental BIA
systems in such studies are currently lacking.
Despite these observations, segmental BIA has
proved useful for predicting FFM, fat mass, skeletal
muscle volume and fluid distribution in different
populations in various settings.
In summary, segmental BIAs provide a simple,
convenient, inexpensive practical alternative to
reference techniques for the assessment of body
composition at the population level but accuracy
concerns may limit its use for predicting body com-
position in an individual.
Acknowledgements
None.
Conflicts of interest
Author L.C.W. has consulted to ImpediMed Ltd. Imped-
iMed Ltd. had no involvement in the conception, execu-
tion or in the preparation of the manuscript.
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