Relationships Between the Body Mass Index
and Body Composition
Rita 1. Wellens*, Alex F. Roche*, Harry J. Khamisr t, Andrew S. Jacksons;
Michael L. Pollock§, Roger M. Siervogel*
Abstract
WELLENS, RITA I, ALEX F ROCHE, HARRY J
KHAMIS, ANDREW S JACKSON, MICHAEL L
POLLOCK AND ROGER M SIERVOGEL.
Relationships between the body mass index and body
composition. Obes Res. 1996;4:35-44.
The aims of this study were to evaluate the Body
Mass Index (BMI) (welght/stature-i) as a proxy for
percent body fat (%BF) and to determine its associa-
tion with fat-free mass (FFM). Multivariate analysis
of variance and partial correlations were used to
examine relationships between BMI and %BF and
FFM from densitometry for 504 men and 511
women, aged 20 to 45 years. Sensitivity/specificity
analyses used cut offs of 28 kg/m2 in men and 26
kglm 2 in women for BMI, and 25% in men and 33%
in women for %BF. Significantly higher associations
existed in each gender between BMI and %BF in the
upper BMI tertile than in the lower BMI tertiles. In
the lower BMI tertiles, correlations between BMI
and FFM were approximately twice as large as those
between BMI and %BF. The BMI correctly identi-
fied about 44% of obese men, and 52% of obese
women when obesity was determined from %BF.
BMI is an uncertain diagnostic index of obesity.
Results of Receiver Operator Characteristic (ROC)
analyses using %BF and total body fat, both provid-
ed a BMI of 25 kg/m 2 in men and 23 kg/m 2 in
women as diagnostic screening cut offs for obesity.
Submitted for publication February 23, 1995.
Accepted for publication in final form July 20, 1995.
From the *Division of Human Biology, Department of Community Health,
Wright State University, School of Medicine, Dayton OH 45387, tStatistical
Consulting Center, Wright State University, Dayton, OH 45435, :j:Department
of Health, Physical Education and Recreation, University of Houston, Houston,
TX 77004, and the §Center for Exercise Science, Department of Medicine and
Exercise Science, University of Florida, Gainesville, FL 32611.
Reprint requests to Dr. Wellens, Washington State University, Department of
Kinesiology and Leisure Studies, Pullman WA 99164-1410. Tel: 509-335-
6211; Fax 509-335-4594.
Copyright ©1996 NAASO.
Key words: Body Mass Index, fatness, fat-free mass,
body composition
Introduction
Numerous studies have reported associations of
obesity with increased morbidity and mortality (28,35).
The Body Mass Index (BMI) is widely used in epidemi-
ological research and, commonly, high BMI values
(weightlstature2; kg/m2) are interpreted as evidence of
overweight or obesity. Somewhat arbitrary BMI cut off
levels based on associations with mortality and morbidi-
ty in large population surveys have been suggested as
guidelines for desirable weights (8).
Obesity is defined as an excess of adipose tissue.
An evident problem is that the amount of body fat is
usually not measured in epidemiological surveys
because direct methods such as densitometry are diffi-
cult to apply. Unlike for BMI, there is a lack of reports
that allow the selection of a "cut off' level for body fat-
ness derived from body density above which morbidity
and mortality rates are increased. Since methods for the
direct measurement of body fat are time-consuming and
expensive, their application is limited to research set-
tings and typically they are applied to. small samples.
Weight and stature can be measured easily in large sam-
ples with high precision. Validation of BMI values
against direct measures is needed, however, to justify
the use of the BMI as an index of body composition.
The BMI has been criticized because the numerator
(weight) does not discriminate between muscle, fat,
bone or vital organs and, therefore, an individual with
high fat-free mass (FFM) relative to stature might have
a high BMI value but not be obese (3).
A valid index of body composition that is easily
available would be important for health professionals so
that persons at risk for developing obesity-related dis-
eases could be successfully screened. The present study
was conducted to evaluate BMI as a proxy for body fat-
ness versus direct measurements of percent body fat
OBESITY RESEARCH Vol. 4 No.1 Jan. 1996 35

BMI and Body Composition, Wellens et al.
(%BF) and total body fat (TBF) estimated from densito-
metry in a large sample of healthy men and women and
within tertiles of the BMI distribution. In addition, the
utility of BMI in the diagnosis of obesity (high %BF)
was evaluated and associations of BMI values with fat-
free mass (FFM) were explored.
Methods and Procedures
Subjects
The subjects were enrolled in one of three separate
studies. All were white and aged 20 to 45 years. The
procedures for each study were approved by the
Institutional Review Boards of the respective institu-
tions. The Fels sample consisted of 153 men and 162
women from the Fels Longitudinal Study for whom data
from their most recent examinations were used. These
Fels subjects were from a wide range of social and eco-
nomic strata with distributions of socio-economic status
similar to those in national surveys (29). The Jackson
sample included 282 men and 194 women measured at
Wake Forest University, Winston-Salem (NC), the
Institute for Aerobics Research, Dallas (TX), or the
Mount Sinai Medical Center, Milwaukee (WI). These
data have been used previously by Jackson et al. (17-18)
in the development of predictive equations for body
density based on anthropometry. The Pollock sample
provided data for 69 men and 155 women measured at
the University of Florida, Gainesville (FL). These data
have been used to develop predictive equations for body
composition based on ultrasound (1,13).
Anthropometry and Densitometry
In each study, weight and stature were measured
using the techniques described in the Anthropometric
Standardization Reference Manual (23). BMI was cal-
culated as weight divided by stature squared (kg/m2).
To avoid the problem of fluid retention before and
during menstruation, the subjects were not tested from 5
days before until after their menstrual periods. Percent
body fat was estimated from body density with a correc-
tion for residual lung volume. For underwater weight,
the subjects from the Fels Longitudinal Study sat on a
chair suspended from four load cells while subjects
from the Jackson and Pollock studies were seated on a
chair suspended from a scale. In the Fels Longitudinal
Study, the average of the largest three weights in a
series of 10 trials - indicative of maximum exhalation -
was used to calculate body density. The Jackson and
Pollock studies repeated underwater weighing six to 10
times until three similar readings, to the nearest 20 g,
were obtained. If this was not achieved, the average of
the three largest weights was used. The Siri two-com-
ponent model (34) was applied in each study to calcu-
late FFM from body density (BD). From the Siri model
36 OBESITY RESEARCH Vol. 4 No.1 Jan. 1996
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%BF = (4.95 1 BD - 4.5) x 100 with total body fat (TBF)
and FFM calculated from %BF and weight (W) as fol-
lows: TBF (kg) =(%BF x W) 1100 and FFM (kg) =W -
TBF.
Statistical Analysis
The Statistical Analysis System (SAS) was used for
data analysis (33). Multivariate analysis of variance
(MANOVA) was applied to examine whether there
were significant differences among the data from the
three study populations with respect to age, BMI, and
body composition variables. Selected percentiles were
calculated for the total data set (data from the three studies
combined) in order to compare these with percentiles
from a nationally representative sample. Partial
Spearman correlation analyses (adjusting for age) were
conducted on the total data set and on BMI tertiles of the
total data set. Multiple comparisons among the age-
adjusted partial correlations were conducted across these
tertiles within gender using a Bonferroniadjustmentwith a
95% family confidence coefficient for three comparisons.
The BMI was evaluated as a diagnostic index for
obesity by examining its sensitivity and specificity ver-
sus %BF from densitometry (20). These analyses
required the selection of cut off levels; values derived
from published recommendations were used. Obesity
by BMI was defined as a value> 28 kg/m2 in men and
> 26 kg/m 2 in women since long term follow-up studies
beginning at about 35 years show increases in mortality
when BMI at entry is larger than these values (11,35).
The chosen cut off levels for obesity by %BF were> 25
% in men and > 33% in women; these match recent rec-
ommendations (2,4). The cut off levels for obesity by
TBF were calculated from applying these %BF cut offs to
the 85th percentiles for weight for the corresponding age
groups from the Second National Health Examination
Survey (26). These resulted in > 22.0 kg for men and>
24.8 kg in women. Receiver Operator Characteristic
(ROC) curve analysis was applied, as an alternative to
using published BMI cut off levels, in order to identify
cut off levels of BMI that would lead to a good trade-off
between high sensitivity and low specificity or vice
versa (16). The ROC curve is a plot of the sensitivity
(proportion of true positives) versus l-specificity (pro-
portion of false positives) associated with fatness, as
indicated by %BF, for a range of BMI cut off values.
The choice of a BMI cut off value is based on a balance
between high sensitivity and low specificity.
Results
Age, weight, stature, BMI, and body composition
estimates for the three samples are presented in Table 1.
A multivariate analysis of variance (MANOV A)
showed some significant (p < 0.001) differences among
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BMI and Body Composition, Wellens et al.

Table 1. Descriptive statistics of age, weight, stature, body mass index (BMI), percent body fat (%BF),
total body fat (TBF), and fat-free mass (FFM) by densitometry

FELS Sample Jackson Sample Pollock Sample

MEN (n= 153) (n = 282) (n = 69)

MEAN SD MEAN SD MEAN SD

Age (y) 32.1 7.7 31.3 7.8 32.7 7.6
Weight (kg) 79.4 13.6 79.6 11.8 79.7 12.7
Stature (em) 180.5* 7.6 179.0 6.2 179.1 6.7
BMI (kg/m 2) 24.3 3.6 25.0 3.3 24.8 3.2
%BF 20.3* 7.6 18.9 7.4 18.3 7.8
TBF (kg) 16.8* 8.8 15.6 7.7 15.1 8.1
FFM (kg) 62.5* 7.6 64.1 7.3 64.6 8.8

WOMEN (n= 162) (n = 194) (n = 155)

MEAN SD MEAN SD MEAN SD

Age (y) 31.2 7.6 30.0 8.6 29.9 8.1
Weight (kg) 66.3* 13.8 56.6 7.2 61.5 11.4
Stature (em) 166.0 6.4 165.1 5.7 166.6 6.4
BMI (kg/m2) 24.1* 5.1 20.8 2.3 22.1 3.6
%BF 31.4* 8.9 23.2 7.0 24.6 7.8
TBF (kg) 21.8* 10.5 13.4 5.5 15.7 8.2
FFM (kg) 44.6* 5.7 43.1 4.1 45.8 5.7

* differences (p < 0.001) among the 3 groups

the three populations (Fels, Jackson, and Pollock) after
adjustment for the effects of gender (Table 1). Based on
Fisher's LSD multiple comparison procedure (7) at the
0.05 level of significance, several of the variables dif-
fered among the three groups, especially for women.
Among men, the Fels sample had significantly larger
mean values for stature and smaller values for FFM in
comparison to the Jackson sample.
Among women, the means for weight, BMI, and
TBF are higher in the Fels sample than in the Pollock
sample, and higher in the Pollock sample than in the
Jackson sample; similarly, the mean for FFM is ranked
(highest to lowest): Pollock, Fels, and Jackson. The
mean stature for Pollock women is higher than for
Jackson women. Finally, the mean %BF is higher in
Fels women than in either of the other two samples.
A comparison of percentiles for weight, stature, and
BMI from the pooled sample (Fels, Pollock, and
Jackson combined) with percentiles from national data
(26) is presented in Table 2. Although the three popula-
tions differ with regard to some variables, as indicated
in the results from the multivariate analysis of variance,
the percentiles from the pooled sample may nevertheless
be comparable to national values. There are important
advantages to pooling the data, including the enhanced
sample size and an increase in the validity of the conclu-
sions. Deviations (in absolute value) between the sam-
ple percentiles and the national values for each gender
and each of the four samples (Fels, Jackson, Pollock and
the pooled sample) were computed for the three vari-
ables (weight, stature, and BMI) and averaged for each
of five percentile levels (10, 25, 50, 75, and 90). This
average absolute deviation was used as a measure of the
extent to which the combined sample matched the gen-
eral U.S. population (the lower the average absolute
deviation, the closer the match). While each of the indi-
vidual samples has the highest mean absolute deviation
in at least one instance, the pooled sample never has the
highest mean absolute deviation (data not shown). So,
while none of the four samples is ideally representative
of the general population based on this comparison, the
pooled sample appears to be at least as representative as
any of the individual samples. This fact, combined with
its much larger sample size, makes the pooled sample
the best choice for purposes of analysis.
Table 3 shows the Spearman rank correlations,

OBESITY RESEARCH Vol. 4 No.1 Jan. 1996 37

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BMI and Body Composition, Wellens et al.

Table 2. Comparisons by gender of selected percentiles of weight, stature and BM! from the combined
dataset used in the present study with percentiles from national data

Percentiles
Source 10 25 50 75 90

Men
Weight Present study 66.0 70.6 78.1 86.7 95.7
NCHSa 63.6 69.2 76.8 84.8 95.0
Stature Present study 170.8 174.8 179.6 183.5 188.5
NCHS 167.8 172.5 177.0 181.7 185.9
BM! Present study 21.0 22.3 24.4 26.7 29.2
NCHS 20.7 22.4 24.5 26.9 29.5

Women
Weight Present study 50.1 53.2 58.9 66.0 75.2
NCHS 50.3 54.5 60.3 68.5 80.5
Stature Present study 158.3 161.3 165.7 169.7 173.9
NCHS 155.6 158.9 163.3 167.5 171.5
BM! Present study 18.7 19.7 21.2 23.5 26.7
NCHS 19.0 20.4 22.4 25.5 30.2

a NCHS: National Center for Health Statistics (18)

adjusted for age, of BMI with %BF and FFM by BMI and women respectively, using a large BMI as an indi-
tertiles from the three samples combined and for the cator of obesity. The BM! cut off level was increment-
total data set. In men, the middle tertile BM! limits ed by steps of 0.5 from 18 to 33 kg/m 2. The curves for
were 22.8 kg/m2 (lower bound) and 25.6 kg/m 2 (upper both men and women increase, but are concave down-
bound); and in women they were 20.4 kg/m2 (lower ward. The choice of the optimum cut off point - where
bound) and 22.7 kg/m 2 (upper bound). In men, the cor- there is a good trade-off between sensitivity and the
relation between %BF and BMI in the upper tertile was false positive rate - is necessarily subjective and
significantly higher than the correlation for the lower depends upon the relative importance attributed to sensi-
tertile (p < 0.02), and in women the correlation in the tivity and specificity. This choice will be near where
upper tertile was significantly higher than the correla- the ROC curve "turns the comer" (16). For this study,
tions in the middle and lower tertiles (p < 0.001). The sensitivity was given more importance than specificity
correlation between BM! and FFM was significantly
Table 3. Spearman rank correlations adjusted for
higher in the lower than the middle BMI tertile in men
age, of BMI with percent body fat (%BF) and fat-
(p < 0.02) and in women (p < 0.0001).
free mass (FFM) from densitometry by BMI ter-
When BMI was used as a diagnostic index for obe-
tiles and for the total group by gender
sity in the total sample, sensitivity was 43.6% for men
and 51.8% for women (Table 4). Specificity (% of true
BMI Tertiles Total group
negatives) of BMI was close to 100% in each gender.
The positive predictive values were high in men, 67% of
%BF Men O.l9 L 0.27M 0.42U 0.65
those who are diagnosed as obese (using BM!) actually
have high %BF; in women, 86% of those who test posi- Women 0.19 M 0.20 L 0.69 U 0.79
tive actually have high %BF. The negative predictive
values were high in each gender. In men, 85% of those FFM Men 0.19 M 0.31 U 0.43 L 0.54
who test negative (using BMI) for high %BF actually do
not have high %BF; in women, 88% of those who test Women 0.16 M 0.36 U 0.43 L 0.46
negative actually do not have high %BF.
Figures 1 and 2 show ROC plots of sensitivity ver- L Lower tertile; M Middle tertile; U Upper tertile
sus one minus specificity (or false positive rate) for men Values connected by lines do not differ significantly at a =0.05.

38 OBESITY RESEARCH Vol. 4 No.1 Jan. 1996

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BMI and Body Composition, Wellens et al.

Table 4. Diagnostic value (%) of BMI versus %BF from densitometry by gender using BMI cut offs
from the literature and from the ROC analysis applied in the present study

Literature Present study

Men Women Men Women
(BMI > 28 kglm2) (BMI > 26 kglm2) (BMI > 25 kglm2) (BMI > 23 kglm2)

Sensitivity (%) 43.6±4.6 51.8 ± 4.8 78.6± 3.8 81.5 ± 3.7

Specificity (%) 93.5 ± 1.2 97.8±O.7 69.8 ± 2.3 84.4 ± 1.8

since a false positive is not considered as serious as a
false negative. Therefore a cut off level toward the
upper end of where the curve "turns the corner" was
chosen. These levels were 25 kg/m 2 for men (78.6%
sensitivity and 69.8% specificity) and 23 kg/m2 for
women (81.5% sensitivity and 84.4% specificity). The
cut offs suggested in the literature (28 kg/m 2 for men,
26 kg/m 2 for women) would result in 43.6% sensitivity
and 93.5% specificity for men, and 51.8% sensitivity
and 97.8% specificity for women. The cut offs derived
from the ROC analysis are marked on the figures
together with the cut offs obtained from the literature.
Because the ROC curve for women extends further into
the left upper corner of the plot (i.e., has higher curva-
ture) than that for men, the specificity for women is
larger than that for men for a given sensitivity (and con-
versely, for a given specificity, the sensitivity is larger
for women than for men). ROC analysis was also con-
ducted using TBF instead of %BF and these resulted in
ROC curves (not shown) with cut offs identical to the
ones observed for %BF, namely 25 kg/m 2 for men
(88.6% sensitivity and 71% specificity) and 23 kg/m 2
for women (97.2% sensitivity and 81.5% specificity).
Based on the ROC analysis, the BMI levels cho-
sen in the present study were 25 kg/m2 for men and
23 kg/m2 for women. In the study by Hortobagyi et aI.

1.0
0.9
0.8
0.7
~ 25 kg/m2 (A)
-
--
~
0

>.
.s; 0.5
0.6

'';:::;
'wc:
0.4
~ 28 kg/m2 (8)
Q)
CJ)

0.3
0.2 Men

0.1
o. 0 -+-r.....-T"'T""T""T""T'"T""T""~r-T'"I-rT"'T""T""T""T'"T""T"""I'"T"1-rT"'T""T""T""T'"T""T"""I'"T"1r-r-T"'T""T"T""T'",..,-,...,...,r-rT""1
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
1 - Specificity (%)
Figure 1: Receiver Operator Characteristic (ROC) curve for men.
Note: (A) BMI cut off level from ROC analysis with sensitivity of 78.6% and one minus specificity of 31.2% (B)
BMI cut off level from literature with sensitivity of 43.6% and one minus specificity of 6.5%

OBESITY RESEARCH Vol. 4 No.1 Jan. 1996 39

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BMI and Body Composition, Wellens et al.

1.0
0.9

0.8

0.7

--
~
0

>.
+-'
'S;
0.6

0.5
~
26 kg/m2 (8)
+:
'00
c:
Q) 0.4
CJ)

0.3
0.2
Women
0.1

o.0 -+-r""""'TT""rT""IrT"T"T"T"T"T"1r-rT-r-rT'"'T""1'"T""T""""T"T"~rT"T"""""T""T"'1r-r-T-r-rT"T"""r-T'"T""'I""T""'t
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
1 - Specificity (%)
Figure 2: Receiver Operator Characteristic (ROC) curve for women.
Note: (A) BMI cut off level from ROC analysis with sensitivity of 81.5% and one minus specificity of 15.6% (B)
BMI cut off level from literature with sensitivity of 51.8% and one minus specificity of 2.2%

(14), BMI levels of 24.5 kg/m 2 for men and 22 kg/m2
for women were derived from ROC curve analysis.
These lower BMI cut off levels coincide with a reversal
in sensitivity and specificity values. Table 5 shows that
compared to the study by Hortobagyi et aI., sensitivity
in the present study represents a 14% decrease in men
and a 3% increase in women, and the specificity repre-
sents a 48% increase in men and a 21 % increase in
women. The gender differences are also much smaller
in the present study (Table 5).
Discussion
The age range of the subjects was limited to 20 to
45 years because in this age range the density of FFM is
close to 1.1 g/mL (13), which is the assumed value in
the Siri two-component model (34). The BMI cut off
values were based on the findings from long term fol-
lOW-Up studies showing increases in mortality for BMI
values greater than 28 kg/m 2 for men and greater than
26 kg/m 2 for women (35). These values are similar to
the BMI levels ( men, ;;::: 27.8 kg/m 2 ; women, ;;::: 27.3
kg/m 2) used to calculate the prevalence of overweight
in national U.S. surveys (4). The latter levels are based
on the 85th percentile values for men and women aged
20 to 29 years. There is a lack of long-term studies relat-
ing %BF to morbidity and mortality. Although the sup-
porting research is limited, cut off points for %BF of >
25% in men and > 33 % in women have been suggested(3).
Sensitivity and specificity reflect the proportion of
true positive and negative test results respectively in
homogeneous populations, that is, either those that are
truly obese (for sensitivity) or truly not obese (for speci-
ficity). As such, these estimates are not influenced by
the ratio of obese to non-obese individuals in the study
sample (20). Notwithstanding the strong correlations in
the present study between %BF and BMI for the total
group (0.65 in men and 0.79 in women), our findings
using published cut off levels indicate low sensitivities
(44% in men and 52% in women) and high specificities
(93% in men and 98% in women). This indicates that
only about 44% to 52% of the truly obese adults as indi-
cated by %BF from densitometry are identified by BMI
as being obese while almost all non-obese adults are
classified as such by BMI.

40 OBESITY RESEARCH Vol. 4 No.1 Jan. 1996

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BMI and Body Composition, Wellens et al.

Table 5. Diagnostic value of the BMI versus %BF from densitometry by gender derived from ROC
analyses

Gender Study Age range BMlcutoff Sensitivity Specificity

(y) level (kg/m2) (%) (%)

Men Present study 20-45 25 78.6 69.8

Hortobagyi et aI. (1994) 19-77 24.5 91.0 47.0

Women Present study 20-45 23 81.5 84.4

Hortobagyi et aI. (1994) 19-77 22 79.0 70.0

These results are in accordance with those from the best (Table 5). The levels chosen in the present
another study of adults using similar cut off levels for study were 25 kg/m2 for men and 23 kg/m 2 for women.
BMI (BMI ~ 27.8 kg/m 2 in men and ~ 27.3 kg/m2 in In the study by Hortobagyi et al. (15) BMI levels of 24.5
women), but lower cut off levels for %BF from densito- kg/m2 for men and 22 kg/m 2 for women were derived
metry, namely> 20% in men and > 25% in women (36). from ROC curve analysis (Table 5). These differences
In the latter study, slightly stronger correlations were between the findings from the present study and those
reported between %BF and BMI in women (n= 213, r= from the study by Hortobagyi might be due to the fact
.84) as compared to men (n=150, r= .70); a similar gen- that the age range in the present study was restricted to
der difference was observed in the present study. A ages 20 to 45 years to avoid errors in estimating %BF
study of 1280 men and 365 women, aged 19 to 77 years, for older adults due to FFM density values deviating
reported sensitivity values of 54.5% in men and 26.9% from the assumed 1.1 g/mL, but the age range in the
in women and specificity values of 91.8% in men and Hortobagyi study was 19 to 77 years. The implication
98.2% in women (15) when the obesity cut off points of the greater extension of the ROC curve into the left
for BMI were ~ 28 kg/m 2 in men and ~ 27 kg/m 2 in upper comer of the plot in women, compared to men in
women, and the cut off levels for %BF from densitome- the present study, is that identification of high %BF
try were ~ 25% in men and ~ 30% in women. using BMI is more accurate for women than for men
Data from the Rosetta Study using cutpoints for (Figures 1 and 2).
BMI > 27.8 kg/m 2 in men and> 27.3 kg/m2 in women, The correlations in the present study between BMI
and cutpoints for %BF from densitometry similar to the and %BF by BMI tertiles in the combined samples
ones used in the present study (> 25% in men and > might help explain the low sensitivity of BMI when
30% in women), reported sensitivity values in men of using recommended BMI cut offs (5). Our results
45% in the younger age group (average age 33.7) and showed strong correlations (.65 in men and .79 in
40% in the middle aged group (average age 54.6) while women) between BMI and %BF for the total group
in women sensitivity was 47% in the younger age group (Table 3) with the highest correlations observed in the
(average age 31.8) and 45% in the middle aged group upper BMI tertile for each gender (.42 in men and .69 in
(average age 55.2) with specificity values in each gen- women). A similar trend was noted in a report of BMI
der being greater than 93% (2). These three studies are correlations with %BF and TBF from densitometry by
in agreement with the present findings that the BMI is BMI quartiles showing the highest correlations in the
an excellent diagnostic index for classifying the non- upper quartiles in men (r=.56 for %BF and r=.76 for
obese, but is rather insensitive for classifying the obese. TBF) and women (r=.42 for %BF and r=.77 for TBF)
The findings that correlations between %BF and BMI . versus correlations in the lower quartiles ranging from
are higher in women, and that sensitivity values in .07 to .33 for %BF and from .21 to .44 for TBF (15). In
women are generally higher and specificities lower rela- summary, these studies document that BMI is highly
tive to the values found in men, are generally explained correlated with %BF only for adults in the upper part of
as due to the observation that women have a greater fat the BMI distribution. The higher correlations of BMI
mass and fat percentage than men for any given BMI (2). with TBF, compared with %BF, would be expected due
When ROC curve analysis was applied to derive a to the inclusion of weight in both variables (9,12,15).
reasonable trade-off between sensitivity and one minus Similarly, results of the ROC analysis show that sensi-
specificity, instead of using recommended cut off levels, tivity values are higher in both men (by 10%) and
substantially lower BMI cut off levels were selected as women (by 15%) when using TBF instead of %BF.

OBESITY RESEARCH Vol. 4 No.1 Jan. 1996 41


BMI and Body Composition, Wellens et al.
Because in the present study, the partial correlations
between BMI and %BF tend to be higher in the upper
BMI tertiles than in the lower tertiles, one might specu-
late that the predictive capability of BMI is correspond-
ingly higher. This is certainly true with regard to the
proportionate reduction in the %BF variation attribut-
able to BMI and age (coefficientof multiple determination
or R2, data not shown); in fact, for men, the R2 in the
upper tertile is twice what it is in the lower tertiles, and
in women the R2 in the upper tertile is seven times what
it is in the lower tertiles. However, the standard error
(square root of mean square error) ranges from 4.7 to
5.6% and is approximately the same across the three ter-
tiles in each gender, indicating that the predictive capa-
bility would be poor. In fact, the estimated slope (after
adjusting for the effects of age) for %BF plus or minus
the standard error for the first, second, and third tertiles
are, respectively, 0.7 ± 0.35, 1.8 ± 0.53, and 0.9 ± 0.15
for men and l.l± 0.40, 1.6 ± 0.71, and 1.3 ± 0.09 for
women. For PPM they are 2.1 ± 0.36, 1.3 ± 0.52, and
0.9 ± 0.22 for men and 2.0 ± 0.31,1.2 ± 0.57,0.5 ± 0.10 for
women. Further study is needed on the predictive capa-
bility of BMI, especially in light of its relationship with
%BF and PPM over BMI tertiles as discussed above.
Other studies of adults have reported strong correla-
tions between BMI and %BF for groups not selected by
BMI (9, 12, 22, 30, 36, 39), but comparison between the
present results and those from other studies are compli-
cated by differences in statistical methods. Scatterplots
(not shown) of %BF versus BMI and %BF versus PPM
showed that the middle tertile corresponded to a short
BMI-interval while the lower and upper tertiles corre-
sponded to longer BMI-intervals. This poses a serious
problem with the use of the Pearson correlation coeffi-
cient as a measure of the general linear relationship
since the r-value generally increases in absolute value
with the range of the X-variable (in this case, BMI).
Consequently, the Pearson correlations for the lower
and upper tertiles may be artificially high (or artificially
low in the middle tertile) because of the substantially
differing widths of the BMI intervals. In fact, compari-
son of Pearson correlation coefficients would only be
appropriate for tertiles from a uniformly distributed ran-
dom variable. The Spearman rank correlation coeffi-
cient (adjusted for age) is a more appropriate measure
since it is not influenced by the width of the BMI inter-
val and hence allows a more accurate comparison of
correlations. That is, the Spearman coefficient is based
on the ranks of the BMI values, and the range of the
ranks of BMI values is the same for all three tertiles.
The correlation coefficients reported from most other
studies are Pearson coefficients and generally not age-
adjusted. In the present study, the Pearson correlations
(not shown) between BMI and age were .26 in men and
42 OBESITY RESEARCH Vol. 4 No.1 Jan. 1996
15508528, 1996, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/j.1550-8528.1996.tb00510.x by Nat Prov Indonesia, Wiley Online Library on [15/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
.15 in women, and between %BF and age these were .42
in men and .24 in women. The associations between
BMI and %BF are strengthened by adjusting for age and
gender, but adjustments for frame size do not influence
the strengths of these associations (32). Note that the
correlations for the total group tend to be higher than
those associated with the BMI tertiles (Table 3). This is
to be expected since the range associated with the BMI
values for the total group is much larger than for the
BMI tertiles. For this reason it is not appropriate to
compare the total group correlation to the correlations
for the BMI tertiles, however, it is appropriate to com-
pare the correlations for the BMI tertilesamong themselves.
Few have examined the relationship between per-
sons selected by BMI and by PPM. A recent study of
adults, aged 20 to 79 years, reported correlations from
two samples between BMI and PPM from densitometry
of .57 and .61 in men and of .45 and .59 in women (38).
Although these correlations were not age-adjusted, they
are similar to the present findings of .54 in men and .46
in women. In men and women with BMI values in the
lowest tertile, the age-adjusted correlation of BMI with
PPM (r =.43 in both men and women) in the present
study was higher than with measures of %BF (r =.19 in
men and women). Correlations of about 0.6 have been
found between BMI values and PPM from densitometry
in adults not selected by BMI (10, 38). Muscle mass is
a major component of body weight, especially at low
BMI values, and therefore, low BMI values can be used
as an indicator of muscle mass. The association of sar-
copenia, as indexed by low BMI values, with increased
mortality rates has been suggested in a recent review (31).
This study was undertaken to examine the associa-
tion between BMI and the main constituents of body
composition (%BF and FPM) in a group of healthy
young and middle-aged adults. We will also briefly
summarize the contribution that our findings add to the
interpretation of the relationships between BMI and
morbidity and mortality statistics. The f-shaped or U-
shaped curves indicative of increased mortality at the
low and high extreme values of body weight or BMI
have been well documented (6,25,35). However, recent
findings from one follow-up study of 8,828 non-smok-
ing Seventh Day Adventist men showed a lack of excess
mortality at low BMI values (no 'J' in the BMI-mortali-
ty curve) and did not observe an increase in mortality
until a BMI value of 27.5 kg/m2 or greater was reached
(37). Chronic energy deficiency levels have been
defined based on low BMI indices varying from 16 to
18.5 kglm2 (19), but allowance should be made for leg
length when using BMI to assess nutritional status due
to the contribution of Iong-leggedness to low BMI (27).
The measurement of leg length is not likely to be practi-
cal for screening. The I-shaped or U-shaped curve

BMI and Body Composition, Wellens et al.
indicative of increased mortality at low and high BMI
values might be explained if BMI is a good index of
FFM at low BMI values and of %BF at high BMI as
shown by our findings. Data from the prospective
Established Populations for Epidemiologic Studies of
the Elderly examined the BMI at middle age, at old age,
and weight change between age 50 and old age in rela-
tion to mortality at old age in 6,387 white men and
women (24). The results show that at age 50, relative
mortality was significantly higher in both men and
women for those situated in the heaviest quintile of the
BMI ( ~ 28.4 kg/m2 in men; ~ 29.2 kg/m2 in women)
while the risk of mortality in old age associated with the
BMI showed the opposite trend, namel:r those situated
in the lowest BMI quintile « 22.3 kg/m in men; < 21.0
kg/m 2 in women) had highest relative mortality. A sig-
nificantly increased risk of mortality was associated
with weight loss. The association of increased weight
loss with older age along with the association with poor
health, suggest that most of the weight loss resulted
from a decline in health and not from positive lifestyle
changes (24). If BMI is an index of FFM at low BMI
values, the increased mortality at lower BMI ranges may
be attributed to increased risk for immunoincompetence
and for fractures due to low bone mineral density (31).
The observations in this study that the correlations
between BMI and %BF were substantially higher in the
upper BMI tertile than in the two lower tertiles, and that
BMI correlated higher with FFM than with %BF in the
lower tertile in each gender, might partly explain why
BMI was an insensitive index for the detection of obesi-
ty for the entire group. The insensitivity of the BMI has
implications for identifying the obese. Health profes-
sionals should be cautious when using BMI as an index
of obesity, although BMI correlates well with %BF in
the adults most likely to be easily identified as obese,
namely those in the upper BMI range. Based on the
results of the present ROC curve analysis, lower BMI
values than those commonly recommended for white
adults are suggested, namely 25 kg/m 2 in men and 23
kg/m 2 in women. These lower cut off BMI values (see
Figures 1 and 2) would allow for the successful detec-
tion of obese adults that would be generally missed by
the current recommended standards for overweight (21).
Since the correlations between BMI and %BF have been
shown to vary by ethnic group, the present recommen-
dations apply only to white adults (39).
Acknowledgments
We thank the data collection, data analytical and
secretarial staff from the Division of Human Biology, as
well as Parveen Kapoor from the Statistical Consulting
Center, Wright State University and Linda Garzarella
15508528, 1996, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/j.1550-8528.1996.tb00510.x by Nat Prov Indonesia, Wiley Online Library on [15/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
from the University of Florida, for their assistance with
the many aspects of this study.
This work was supported by grant 0012252 from
the National Institutes of Health, Bethesda, MD and by
grant MV-93-10-YI from the American Heart
Association, Ohio Affiliate.
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