Published online: 2020-04-30
Nutrition
Phase Angle is Determined by Body Composition and
Cardiorespiratory Fitness in Adolescents
Authors
Raquel David Langer1 , Roseane de Fatima Guimarães2, Ezequiel Moreira Gonçalves1, Gil Guerra-Junior1,
Anderson Marques de Moraes3
Affiliations
1 Faculty of Medical Sciences, Growth and Development
Laboratory – Center for Investigation in Pediatrics
(CIPED), State University of Campinas, Campinas, Brazil
2 School of Kinesiology and Physical Activity Sciences,
Universite de Montreal, Montreal, Canada
3 Department of Sports Science, Pontifical Catholic
University of Campinas, Campinas, Brazil
Key words
bioelectrical impedance analysis, fat mass, fat-free mass,
physical activity
accepted 18.03.2020
Bibliography
DOI https://doi.org/10.1055/a-1152-4865
Published online: 2020
Int J Sports Med
© Georg Thieme Verlag KG Stuttgart · New York
ISSN 0172-4622
Correspondence:
Raquel David Langer
Faculty of Medical Sciences, Growth and Development
Laboratory – Center for Investigation in Pediatrics (CIPED)
State University of Campinas
126 Street Tessalia Vieira de Camargo
13083-887 Campinas
Brazil
Tel.: + 551935219097, Fax : + 551935219097
raqueldlanger@gmail.com
Introduction
Adolescence is marked by several changes in body composition,
including the quantity and distribution of fat mass, bone mass, and
lean soft tissue [1, 2]. Early studies show that the proportion of
body adiposity and fat-free mass (FFM) hydration changes over the
process of growth, both in boys and girls [3, 4]. In boys, the percent
of fat mass ( %FM) can increase from 13.7 % in infancy to 25.4 % at
6 months of age, and in girls increases from 14.9 % in infancy to
26.4 % at 6 months of age. Similarly, the percentage of FFM hydra-
tion also differs in boys (75.1 ± 2.5 %) and in girls (75.5 ± 1.8 %) [4].
Additionally, changes also occur in the total body weight, such as
Langer RD et al. Phase Angle is Determined … Int J Sports Med
Thieme
Abs trac t
The phase angle is used to evaluate nutritional status and is an
indicator of cellular health. Cardiorespiratory fitness and body
composition are strong indicators of health during adoles-
cence. We aimed to evaluate if body composition and cardi-
orespiratory fitness have an association with phase angle
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among adolescents. 203 girls and 220 boys (12.8 ± 1.3 years)
were evaluated. Peak height velocity, percentage fat mass, fat-
free mass, cardiorespiratory fitness, and phase angle measure-
ments were collected. Linear regression adjusted by peak
height velocity was used to verify if predictor variables were
associated with phase angle among adolescents. Phase angle
showed correlation with fat-free mass (girls: r = 0.42 and boys:
r = 0.37); with percent fat mass (girls: r = 0.23); and with cardi-
orespiratory fitness (boys: r = 0.19). Linear regression showed
that percentage fat mass (in girls) and cardiorespiratory fitness
(in boys) had an effect of 11 and 17 % in phase angle, respec-
tively, while fat-free mass had an effect of 22 and 26 % in phase
angle for girls and boys, respectively. Changes in phase angle
seem to be more associated with the percentage fat mass in
girls, cardiorespiratory fitness in boys, and fat-free mass in both
when controlled by peak height velocity.
an increase or a decrease in weight [3]. Furthermore, a higher body
mass index (BMI) during adolescence can increase the prevalence
of obesity and related cardiovascular disease risk factors through-
out adult life [5].
Bioelectrical impedance analysis (BIA) is a widely used technique
to estimate the body composition of children, adolescents, and
adults showing different health and disease conditions. This is due
to its usability, non-invasiveness, speed, and relative cost-effective-
ness [6]. BIA measures whole-body impedance using two compo-
nents: resistance (i. e., the pure opposition of a biological conduc-
tor to the flow of an alternate electric current) and reactance (i. e.,
 Nutrition
effect of capacitance produced by tissue interfaces and cell mem-
branes) [7]. Using these two components, it is possible to calculate
the phase angle (PhA) [7]. PhA is used as an indicator of cellular
health in relation to imbalance of cellular water and integrity of the
cell membrane [8]. However, the PhA value can be negatively in-
fluenced by several clinical diseases, such as malnutrition [9], dia-
betes [10], human immunodeficiency virus infection (HIV infec-
tion) [11], and some types of cancer [12, 13]. Healthy individuals
show higher values of PhA (higher than 5º), indicating better cel-
lular health and cell membrane integrity compared to malnour-
ished patients [9]. In addition, improvements in the PhA value can
be seen in early studies with young adults following a period of re-
sistance training [14] and in soccer players [15].
It is well known that being physically active and having higher
levels of cardiorespiratory fitness benefit health, functional ability,
quality of life, and longevity [16, 17]. Furthermore, a recent meta-
analysis showed that children who participated in exercise inter-
ventions presented significant reductions in BMI, waist circumfer-
ence, and %FM as well as increases in cardiorespiratory fitness, low-
er-body strength, and speed-agility compared to controls [18].
Additionally, adolescents who are physically active present higher
levels of cardiovascular fitness, a better blood lipid profile, and
lower body adiposity [16]. Overall, evidence seems to indicate that
being physically active during adolescence can minimize these var-
ious health risks [19]. Hence, it is necessary to evaluate body com-
position with accurate methods to evaluate and follow the chang-
es occurring during this stage of life. Thus, we hypothesized that
adolescents with higher values of PhA would present with lower
levels of %FM and a high level of physical activity. Therefore, the
aims of the current study were to: 1) evaluate the relationship be-
tween PhA and body composition including cardiorespiratory fit-
ness, and 2) predict how PhA variability can be explained by body
composition and cardiorespiratory fitness among adolescents from
both sexes.
Materials and Methods
Sample
The sample comprised 423 adolescents aged 10–16 years from a
local school in São Paulo, Brazil, who fulfilled the inclusion criteria
of: i) not having any cardiovascular risk and physical limitation to
participate in the procedures, or ii) returning the Informed Consent
Form signed. All adolescents, both boys (52 %) and girls (48 %) per-
formed the regular school routine of two days a week. Each section
lasted 45 minutes distributed by periodic sections consisting of
physical exercises (i. e., aerobic fitness, endurance, and flexibility)
and collective sports.
Ethical aspects
In this cross-sectional study, all adolescents and their guardians/
parents who agreed to participate in the study were adequately in-
formed about the research proposal and the procedures to which
they would be subjected. The research was approved by the Ethics
Committee of the School of Medical Sciences (number 797/08),
University of Campinas. All procedures followed Resolution No. 466
of 2012 of the National Health Council of the Ministry of Health of
Thieme
Brazil and were conducted in accordance with the Declaration of
Helsinki. The present study meets the ethical standards of the “In-
ternational Journal of Sports Medicine” [20].
Anthropometry
The total body weight (kg) was determined using a digital scale to
the nearest 0.1 kg and the total body height (cm) using a vertical
stadiometer to the nearest 0.1 cm. The body mass index (BMI, kg/
m2) was calculated.
Peak height velocity (PHV)
The total age (years) and total body height (cm) were used to pre-
dict the PHV (in years). Using the individual classification and ac-
cording to sex, participants with negative predictive PHV were clas-
sified as pre-PHV, and positive predictive values of PHV were clas-
sified as post-PHV. The following published equation [21] was used:
PHV girls= − 7.709133 + ⎡⎣0.0042232 × ( age × height ) ⎤⎦
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PHV boys= − 7.999994 + ⎡⎣0.0036124 × ( age × height ) ⎤⎦
Phase angle (PhA)
PhA was assessed using tetrapolar bioelectrical impedance analy-
sis (BIA), single frequency (50 kHz), model Quantum II (RJL Systems,
Detroit, MI, USA), which has been previously validated in adoles-
cents [22]. Participants were instructed to remove all metallic ob-
jects before a BIA measurement was taken. Participants were laid
barefoot, in a supine position, with legs abducted at a 45º angle,
arms far from the trunk, and hands pronated on a table isolated
from electrical conductors. After five minutes of rest, the adoles-
cents’ skin was cleaned with alcohol and two electrodes were
placed on the surface of the right hand and two on the surface of
the right foot, according to the recommended protocol [7]. The
evaluation lasted approximately one minute. BIA provided meas-
urements with parameters of resistance (R) and reactance (Xc),
both given in Ohms (Ω). Using these variables, the PhA was calcu-
lated using the following published equation [7]:
⎛ Xc ⎞ ⎛ 180 ⎞
PhA = arc-tang⎜ ⎟ × ⎜ ⎟
⎝ R ⎠ ⎝ π ⎠
The reproducibility of the parameters provided by BIA was deter-
mined by the coefficient of variation and the technical error of
measurement, based on the test-retest method as performed in
23 participants of the study population of an another study [22].
Fat-free mass (FFM)
The FFM was calculated separately for girls and boys, according to
the published equation [23] for children and adolescents aged 7–25
years:
FFM = 0.438 × (H2/Z ) + ( 0.308 × Wt ) + (1.6 × Sex ) + ( 7.04 × H) × 8.50
where, H is height (cm), Z is impedance (Ω), Wt is weight (kg), and
Sex is 0 (girl) or 1 (boy).
Langer RD et al. Phase Angle is Determined … Int J Sports Med
Skinfold thickness
To calculate the percentage fat mass ( %FM), the measurements of
the tricipital and calf skinfold in mm were evaluated using a Sanny®
caliper and followed the recommendations of the ACSM [24]. Using
the published equation [25] for children and adolescents aged 8–18
years, the %FM was calculated as follows:
%FMGirls = 0.610 × ( TRICIPITAL + CALF ) + 5.1
%FMBoys = 0.735 × ( TRICIPITAL + CALF ) + 1.0
Cardiorespiratory fitness (VO2 peak)
The VO2 peak was assessed using the progressive effort test proposed
in the literature [26]. To calculate the VO2 peak, the following pub-
lished equation was used [26]:
VO2 peak = 31.025 + ( 3.238 × S ) − ( 3.248 × A ) + ⎡⎣0.1536 × ( S × A ) ⎤⎦
Results
More than one-half of the subjects (52 %) were boys. The mean age
was 13 years (IQR: 10–16). Participants’ body composition, BIA
measurements, and VO2 peak are presented in ▶Table 1. All meas-
urements except for the weight and BMI were significantly differ-
ent between boys and girls (p < 0.05). Boys had larger heights
(∆ = 3.22 cm), FFM (∆ = 5.3 kg), PhA (∆ = 0.4º), and VO2 peak (∆ = 2.5
ml · kg · min) compared to girls (p < 0.05). On the other hand, girls
tended to be closer to their age of PHV compared to boys and had
higher %FM (∆ = 2.9 %), R (∆ = 61.2 Ω), and Xc (∆ = 2.2 Ω) values
than boys (p < 0.05).
The PHV showed a significant association with PhA (girls:
r = 0.22, p < 0.01, and boys: r = 0.42, p < 0.001) and with the predic-
tor variables, such as %FM only in girls (r = 0.22, p < 0.01) and FFM
(girls: r = 0.60, p < 0.001, and boys: r = 0.81, p < 0.001), and an in-
verse association with VO2 peak (girls: r = –0.55, p < 0.001, and boys:
r = –0.18, p < 0.01). For this reason, the PHV was used as a control
variable for further analysis.

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where S is the last running speed completed and A is age in years.
Due to its reliability and validity, this method has been widely used
as a cardiorespiratory fitness marker when an individual’s maxi-
mum oxygen uptake cannot be assessed in a laboratory-based test
[27, 28].
Statistical analysis
The SPSS software version 21.0 (IBM Corp., Armonk, NY, USA) was
used to analyze the data. The Shapiro-Wilk test was used to verify
the normality of the data. All analyses were performed separately
for each sex group. Descriptive analysis of data, mean, and SD val-
ues were used to characterize the sample. The Student’s t-test and
Mann-Whitney U test were used to test for differences between the
sexes, depending on the sample distribution. Bivariate (Pearson’s)
correlation (r) was conducted to determine the relationship be-
tween PhA with body composition ( %FM and FFM) and VO2 peak.
Linear regression analysis was performed to identify the effects on
PhA. The variance inflation factor (VIF) was tested to verify the mul-
ticollinearity symptoms between the predictor’s variables. Values
presented are medians [interquartile range (IQR)], unless other-
wise specified. P < 0.05 was set as the level of significance.
In girls, a positive association between PhA and %FM was ob-
served (▶Fig. 1a), whereas in boys, PhA showed a positive associ-
ation with VO2 peak (▶ Fig. 1b). In both girls and boys, a positive as-
sociation between PhA and FFM was observed (▶ Fig. 1c and d, re-
spectively).
Linear regression analyses were performed separately for girls
and boys to verify the determinant factors for PhA, controlled by
PHV (▶Table 2). The variables that presented the best correlation
with PhA were tested as predictors. In addition, we found no mul-
ticollinearity symptoms between predicted variables of weight
(VIF = 1.000 in both girls and boys), BMI (VIF = 1.000 in girls and
boys), FFM (VIF = 1.000 in girls and boys), %FM (VIF = 1.000 in girls
and boys), or in VO2 peak (VIF = 1.000 in girls and boys). Among girls,
BMI was the strongest predictor of variance in PhA (27 %), followed
by FFM (22 %), weight (19 %), and %FM (11 %) (p < 0.05). Similarly,
in boys the FFM was the strongest predictor of variance in PhA
(26 %), followed by BMI (23 %), weight (21 %), and VO2 peak (17 %)
(p < 0.05). Interestingly, VO 2 peak was not associated with PhA
among girls (p = 0.814) or %FM among boys (p = 0.811).

▶Table 1 Characteristics of girls and boys who participated in the study.

Variables TOTAL (n = 423) GIRLS (n = 203) BOYS (n = 220) p-value

Median (IQR) Median (IQR) Median (IQR)
Weight (kg) 49.50 (25.70–98.80) 48.70 (25.70–85.00) 50.00 (29.40–98.80) 0.124
Height (cm) 155.38 ± 10.68 * 153.70 ± 8.84 * 156.92 ± 11.95 * 0.002
BMI (kg/m2) 19.87 (14.31–43.61) 17.74 (14.31–43.61) 20.03 (14.50–37.65) 0.759
PHV (years) −0.03 (−2.76–3.43) 0.47 (−1.89–3.43) −0.76 (−2.76–2.60) 0.000
%FM 22.14 (8.64–58.33) 23.58 (13.21–45.24) 20.11 (8.64–58.33) 0.000
FFM (kg) 34.76 (17.70–67.13) 33.41 (17.70–52.53) 36.64 (22.37–67.13) 0.000
R (Ω) 626.42 ± 80.60 * 658.16 ± 72.35 * 597.14 ± 76.78 * 0.000
Xc (Ω) 61.00 (44.00–79.00) 62.00 (46.00–79.00) 59.00 (44.00–79.00) 0.002
PhA (º) 5.53 (3.70–8.35) 5.34 (3.86–8.24) 5.66 (3.70–8.35) 0.000
VO2 peak (ml · kg · min) 41.15 (31.35–54.24) 40.32 (32.18–51.96) 42.13 (31.35–54.24) 0.000

Abbreviations: BMI, body mass index; PHV, peak of height velocity; %FM, percent of fat mass; FFM, fat-free mass; R, resistance; Xc, reactance; PhA,
phase angle. * Mean ± SD.

Langer RD et al. Phase Angle is Determined … Int J Sports Med

 Nutrition Thieme

a Girls b Boys
10 10

8 8

PhA (°)
PhA (°)

6 6

4 4

r = 0.233
r = 0.189
p = 0.001
p = 0.005
2 2
10 20 30 40 50 25 30 35 40 45 50 55 60
%FM VO2 peak (ml . kg . min)

c Girls d Boys
10 10

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8 8
PhA (°)

PhA (°)

6 6

4 4

r = 0.419 r = 0.369
p = 0.000 p = 0.000
2 2
10 20 30 40 50 60 10 20 30 40 50 60 70
FFM (kg) FFM (kg)

▶Fig. 1 Pearson’s correlation between phase angle and a percent of fat mass in girls, b cardiorespiratory fitness in boys, c fat-free mass in girls, and
d fat-free mass in boys.

Discussion calculated from the R and Xc values; it expresses changes in the

The main and novel findings of this study were that PhA, when con-
trolled by PHV, was directly associated with %FM only in girls, VO2 peak
only in boys, and FFM in both sexes.
The study demonstrated that the mean PhA values of boys were
significantly higher than that of girls. Similar results were reported
in other studies using a large sample of healthy or unhealthy par-
ticipants [8, 29–31]. Higher means of PhA values were observed in
boys. This result might be explained by the higher amount of rela-
tive FFM present in the total body in boys. Because the PhA is cal-
culated by an equation, the whole-body resistance is inversely pro-
portional to the PhA value, which means that the lower the value
of resistance, the higher the PhA value [31].
Despite no significant association between PhA and body height,
a positive association between PhA and BMI was found. A high cor-
relation between PhA and BMI has been described in several stud-
ies with adults [29, 30], but it is still understudied in the adolescent
population. In the present study, the linear regression analyses
demonstrated that body weight and BMI are statistically significant
explanatory variables for the variation in PhA in adolescents of both
sexes. An explanation for this association is that the PhA is directly
amount of soft tissue mass (related to the hydration) and the ca-
pacity of body cell mass (related to cell membrane permeability),
respectively [29]. Additionally, the PhA value can also be affected
by the total body mass; in this sample, girls had less body weight
compared to boys (∆ = –2.8 kg). These findings have also been de-
scribed in other studies carried out on large samples comprising
children and adult subjects [29, 30]. The association between PhA
and body weight can be explained by the current flow through
physiological fluids, such that the higher the body mass volume,
the lower the body resistance [8, 29].
Even though the PhA is not completely understood biologically,
it has been widely used as an important prognostic marker tool in
several clinical contexts [29]. Several studies have associated lower
levels of PhA as a prognostic indicator for malnutrition, cancer, HIV-
infected and liver cirrhosis as well as a poor indicator of survival
time [8]. The prevalence of obesity in adolescent girls and boys has
increased globally between 1975 and 2016, becoming a challenge
of the 21st century [32, 33]. Previous studies carried out in obese
women found an inverse association between PhA and biochemi-
cal parameters as well as with blood adipocytokine levels, indicat-

Langer RD et al. Phase Angle is Determined … Int J Sports Med

▶Table 2 Linear regression analyses between phase angle and determinant factors.

Variables Girls Boys

R2 β p-value R2 β p-value
Weight (kg) 0.19 0.429 0.000 0.21 0.360 0.000
BMI (kg/m2) 0.27 0.469 0.000 0.23 0.316 0.000
%FM 0.11 0.230 0.001 0.14 0.015 0.811
FFM (kg) 0.22 0.514 0.000 0.26 0.597 0.000
VO2 peak (ml · kg · min) 0.06 0.020 0.814 0.17 0.180 0.005

BMI, body mass index; %FM, percent of fat mass; FFM, fat-free mass; R2, R-square; β, standardized beta.

ing a higher cardiovascular risk in this sample [34]. However, the
association between PhA and %FM in children has not been ex-
plored at all. In the present study, despite no association being
found between PhA and %FM in boys, the %FM predicted an 11 %
variation in the PhA value of girls. This finding is consistent with
because they may not have correctly provided the data. The cross-
sectional design of the present study does not provide conclusions
relating to causality between PhA and the independent variables;
however, it remains open for future research to explore this rela-
tionship in observational and experimental studies. Thus, longitu-

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previous studies that showed the effect of body fat in girls during
the pubertal phase (10–14 years old), whereas in boys this is small-
er until late adolescence [8, 35]. In addition, cellular adipose tissue
hydration is higher compared to lean soft tissue hydration as a re-
sult of an imbalance in the amount of extra and intracellular water
[36, 37].
Being physically active during childhood and adolescence has
been reported as an important factor in the improvement of meas-
urements related to obesity, insulin sensitivity, and metabolic syn-
drome [17]. In this sample, boys had higher PhA and VO2peak values
compared to girls (∆ = 0.32º and ∆ = 1.81 ml · kg · min, respective-
ly). In addition, in this sample of adolescent boys, the VO2 peak pre-
dicted a 17 % variation in the PhA value. This can be explained be-
cause both PhA and VO 2peak are considered as health markers
[8, 38]; their application in the clinical situation can provide impor-
tant information related to health status in adolescents and adults.
A positive correlation was observed between PhA and FFM in
both girls and boys. This result is consistent with a previous study
[11], and although using a different sample, the authors observed
a relationship between PhA and FFM in HIV-infected children and
adolescents. The PhA is calculated using the ratio of the reactance
and resistance measurements provided by BIA [7]. As mentioned
above, the reactance value reflects the capacitance of cell mem-
branes and tissue interfaces – the delay in the passage of an elec-
trical flow, whereas the resistance value is inversely proportional
to the amount of electrolytes present in the water of tissues (i. e.,
fat and muscle tissue) [6]. Therefore, the better the integrity of the
cell membrane, the higher the reactance value will be; the higher
the amount of intracellular and extracellular water, the smaller the
resistance value of the body [6]. In other words, the association be-
tween PhA and FFM can be explained by the amount of water con-
tent in the FFM component (muscle tissue), which provides less re-
sistance against the current.
One limitation of this study is that the results cannot be extrap-
olated to other population groups, considering the small group of
participants. Furthermore, the BIA values can be skewed by exter-
nal variables such as fluid and food intake prior to evaluation. Even
though other variables were controlled, it was not possible to en-
sure that accurate information was provided by the adolescents,
dinal studies are necessary to verify if changes in PhA can be deter-
mined by changes in body composition and cardiorespiratory fit-
ness. Briefly, these results suggest that PhA obtained through BIA
is a potential technique to evaluate the health status in children
and adolescents in relation to physical activity levels and body com-
position parameters.
Therefore, we conclude that PhA can provide key information
for the measurement and evaluation of nutritional and overall
health status in adolescents, especially because it is a convenient,
easy, and non-invasive method. In this sample of adolescents, when
controlled by somatic maturation, the changes in PhA seem to be
explained by %FM in girls, VO2peak in boys, and FFM in both girls and
boys. These results have important implications for physical activ-
ity behavior and body composition to improve overall health in ad-
olescents.
Acknowledgement
The authors thank the Principal and students of Bradesco Founda-
tion School of Campinas-SP for their authorization and collabora-
tion in this study.
Funding
We also thank the Coordination for the Improvement of Higher Ed-
ucation Personnel—CAPES [grant number: 23001.000422/98-30]
for support this study.
Conflict of Interest
The authors declare that they have no conflict of interest.
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