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Estimating total body fat using a skinfold prediction equation in Brazilian

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 Annals of Human Biology, March–April 2012; 39(2): 156–160
Copyright q Informa UK, Ltd.
ISSN 0301-4460 print/ISSN 1464-5033 online
DOI: 10.3109/03014460.2012.660989

RESEARCH PAPER

Estimating total body fat using a skinfold prediction equation

in Brazilian children
Daniel J. Hoffman1, Tatiana Toro-Ramos1, Ana Lydia Sawaya2, Susan B. Roberts3 & Patricia Rondo4
1
Department of Nutritional Sciences, Rutgers, the State University of New Jersey, 26 Nichol Avenue, New Brunswick, NJ 08901,
USA, 2Department of Endocrine Physiology, Federal University of São Paulo School of Medicine, Rua Botucatu, 862, São Paulo,
SP, Brazil 04023-900, 3Energy Metabolism Laboratory, Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts
University, 711 Washington St., Boston, MA 02111, USA, and 4Department of Nutrition, School of Public Health, University of
Ann Hum Biol Downloaded from informahealthcare.com by Loughborough University on 04/18/12

São Paulo, Avenida Dr Arnaldo, 715, São Paulo, Brazil 01246-904

Background: The double burden of obesity and underweight is
increasing in developing countries and simple methods for the
assessment of fat mass in children are needed.
Aim: To develop and validate a new anthropometric
predication equation for assessment of fat mass in children.
Subjects and methods: Body composition was assessed in 145
children aged 9.8 ^ 1.3 (SD) years from São Paulo, Brazil using
For personal use only.
at risk of excess body fat generally relies on simpler and
cheaper techniques, such as BMI or skinfolds. While BMI is
a useful index of adiposity for populations, skinfold
prediction equations have generally been developed and
validated in cohorts that are not similar in terms of race or
past nutritional experience to cohorts in developing
countries (Goran et al. 1996; Huang et al. 2003; Hoffman

dual energy X-ray absorptiometry (DEXA) and skinfold
measurements. The study sample was divided into
development and validation sub-sets to develop a new
prediction equation for FM (PE).
Results: Using multiple linear regression analyses, the best
equation for predicting FM (R 2 ¼ 0.77) included body weight,
triceps skinfold, height, gender and age as independent
variables. When cross-validated, the new PE was valid in this
sample (R 2 ¼ 0.80), while previously published equations
were not.
Conclusion: The PE was more valid for Brazilian children that
existing equations, but further studies are needed to assess
the validity of this PE in other populations.
Keywords: Anthropometry, body composition, skinfolds,
stunting, developing countries
INTRODUCTION
The prevalence of overweight continues to increase in many
developing countries, even as the prevalence of under-
nutrition remains relatively high (Doak et al. 2000; Kapoor
and Anand 2002; Caballero 2005). Access to body
composition techniques available in wealthier countries,
such as dual energy x-ray absorptiometry (DEXA) or
bioelectrical impedance (BIA) (Eisenmann et al. 2004;
Ramirez-Zea et al. 2006), is limited and assessment of those
et al. 2006). Thus, developing and validating new skinfold
prediction equations is needed for more accurate estimates
of body fatness in developing and transitional economies.
Anthropometric measures are among the cheapest and
most common methods available to assess human body
composition, especially in developing countries (Ball et al.
2004). However, the use of skinfolds to estimate body fatness
(BF) has not been without criticism (Slaughter et al. 1988;
Dezenberg et al. 1999; Ellis 2001; Kapoor and Anand 2002;
Walker et al. 2002; Yao et al. 2002). Much of the criticism for
skinfold prediction equations is focused on the outcome
variable estimated, the population in which the equations
are derived and the validity of the equation in other cohorts
or populations (Bernal-Orozco et al. 2010). First, fat mass
(FM) is the univariate variable estimated with prediction
equations and has been reported to minimize some of the
complexity introduced into the prediction model process
and increase the predictive power of body-composition
models (Slaughter et al. 1988). Thus, equations that estimate
%BF have limited predictive power and contribute to
potential bias of the prediction equation. Second, the
population in which the prediction equation is derived is
important as equations derived from adult cohorts may
over-estimate body fatness by 3 –6% (Dezenberg et al. 1999)
and few of the many skinfold prediction equations
published have been found to be valid across populations

Correspondence: Daniel J. Hoffman, Department of Nutritional Sciences, Rutgers, the State University of New Jersey, 26 Nichol Avenue, New
Brunswick, NJ 08901, USA. E-mail: dhoffman@aesop.rutgers.edu
(Received 12 August 2011; accepted 23 January 2012 )

156

(Brook 1971; Reilly et al. 1995) and contribute to random or
systematic errors (Durnin and Rahaman 1967; Brook 1971;
Reilly et al. 1995; Dezenberg et al. 1999). Still, while some
equations derived from multi-racial cohorts exist (Dezen-
berg et al. 1999), they have not been found to be valid for
Latino children, in whom new equations have been
developed (Huang et al. 2003). Third, the specific predictive
variables to be included in skinfold prediction equation is
open to debate and some authors have suggested that
measures of body size (e.g. height) should be included along
with measures of body mass (e.g. weight) to account for
difference in the predictive capacity of skinfold measures
between the shortest and tallest individuals of a population
(Burton and Cameron 2009).
It is important and necessary to continue to develop novel
skinfold prediction equations for use in transitional
Ann Hum Biol Downloaded from informahealthcare.com by Loughborough University on 04/18/12
countries, especially as the prevalence of obesity continues
to increase in these less-developed and non-Western
countries. By convention, such equations are best charac-
terized by the use of acceptable reference methods to obtain
criterion measures of body composition (e.g. DEXA or
stable isotopes), the use of large, randomly selected samples
(n . 100), a high correlation between the reference measure
and predicted scores (R . 0.80) and cross-validation of the
Equation (Fields and Goran 2000). However, given that no
skinfold prediction equations exist for populations in
For personal use only.
developing countries, the focus of this project was to
develop and evaluate a new prediction equation for
estimating FM in children from developing countries.
METHODS
Study cohorts
Three independent cohorts were included in this study. The
first two were composed of children, studied at the Federal
University of São Paulo, who had been volunteers in studies
of metabolism and growth retardation. The third cohort was
composed of children from Jundiai, São Paulo as part of a
study on maternal diet and growth conducted by the
University of São Paulo. All children were examined by a
paediatrician prior to enrolling in theses studies and were
free from acute or chronic diseases. Informed consent was
obtained from the parents of the children and the protocols
were approved by the ethical committees at each participat-
ing university.
Body composition
Body composition was assessed using skinfold measure-
ments as well as dual energy x-ray absorptiometry (DEXA).
Anthropometric measurements were made in the mornings,
with the children wearing shorts and t-shirts. Each cohort
had a single research assistant conduct the measurements on
all of the children in that particular cohort. Height was
measured to the nearest 0.5 cm using a mounted measuring
stick (Stadi-o-meter, Country Technologies, Green Bay, WI).
Weight was measured using a digital electronic scale
(Country Technologies) accurate to within 0.1 kg. Skinfold
measurements were made on both sides of the body at the
q Informa UK, Ltd.
SKINFOLD PREDICTION EQUATIONS IN CHILDREN 157
bicep, tricep, subscapular, suprailiac, thigh and calf sites
using a Harpenden skinfold caliper (Country Technologies)
according to the protocol of Lohman and Martorell (1988).
Measurements were made in triplicate using a standardized
protocol and the mean value were used in all analyses.
The development of a new prediction equation was
compared to previously published child-specific prediction
equations to calculate FM (in kg) using skinfold thickness
(in millimetres), as follows:
. Goran et al. (1996), both genders:
FM ¼ 0:18* weight þ 0:23* subscapular þ 0:13* tricep 2 3:0;
. Slaughter et al. (1988):
Boys : FM ¼ weight* ½ð1:21* SUMTRSB
2 0:008* ðSUMTRSBÞ2 2 1:7Þ=100
;
Girls : FM ¼ weight* ½ð1:33* SUMTRSB
2 0:013* ðSUMTRSBÞ2 2 2:5Þ=100
;
where SUMTRSB is the sum of the tricep and
subscapular skinfolds.
. Huang et al. (2003):
FM ¼ ð0:632*weightÞ2ð1:606*ageÞ2ð1:882*genderÞþ3:330;
FMa ¼ ð0:764* weightÞ 2 ð0:471* heightÞ þ 45:955:
Body fat and FFM were measured with a Hologic
QDR – 4500A DXA (Hologic Inc., Bedford, MA) for the
two cohorts in São Paulo and a Lunar Prodigy (General
Electic, Inc., Chalfont St. Giles, UK) for the cohort in
Jundiai using adult quick-scan software programs and the
children positioned according to standard protocols.
Phantoms were used to calibrate the DXA before each
measurement.
Statistical analyses and development of prediction
equations
To develop the prediction equation studied, the data from
the three cohorts were combined into one dataset. From this
dataset, using the random sample command in Systat, a
random sample of 30 subjects was selected. The randomly
selected subjects formed the Validation sample while those
not selected formed the Development sample. According to
Student’s t-test, there were no significant differences
between the two samples with respect to the proportion of
boys and girls, age, body weight, percentage fat mass or lean
body mass. Using the Development sample, forward stepwise
linear regression analyses were conducted to determine
which variables, including weight, tripceps skinfolds, height,
gender and age, best predicted FM. The final equation
developed (model R 2 ¼ 0.77) and used in the subsequent
analyses and comparisons included the independent
 158 D. J. HOFFMAN ET AL .

Table I. Physical characteristics of the development and validation slope statistically different from the line of identity or an
samples (mean ^ SD). intercept different from 0 (Table III).
Variable Development Validation Neither the Goran, Slaughter nor Huang equations was
n 115 30 successfully cross-validated in our sample and the mean
Age (years) 9.8 ^ 1.3 10.1 ^ 1.5 differences in estimated BF compared with DEXA are
Weight (kg) 25.48 ^ 6.00 25.52 ^ 7.03 depicted in Figure 1.
Height (cm) 1.25 ^ 0.10 1.25 ^ 0.11
Fat Mass (kg) 4.84 ^ 2.34 4.82 ^ 2.90
Fat-Free Mass 20.64 ^ 4.37 20.70 ^ 5.00
Fat Mass (% weight) 18.4 ^ 5.9 18.06 ^ 6.21 DISCUSSION
Gender 42% M and 58% F 40% M and 60% F
As the global prevalence of overweight among children
continues to increase, the need for a simple method to
variables weight, sex, age, tricep skinfolds and height. estimate FM is great, especially for less developed countries
This equation was applied to the Validation sample for that lack the infrastructure or technology to use more
accuracy using paired Student’s t-test and deviation from advanced techniques. Anthropometric prediction equations
the line of identity in which a multiple linear regression have often been used for both individual and population
model was created with predicted FM entered as the
Ann Hum Biol Downloaded from informahealthcare.com by Loughborough University on 04/18/12

assessments of body composition in developing countries.

dependent variable and measured FM was entered as the
independent variable. The equation was found to not
deviate from the line of identity if the model had a
statistically significant X-intercept at 0 and the slope of the
regression was equal to one. Student’s t-tests were conducted
to determine statistically significant differences between
measured FM and predicted FM. Each equation, published
and developed, was considered valid if it was not
significantly different from the measured FM and did not
deviate from the line of identity. Statistical significance was
For personal use only.
However, such equations have generally been developed
and/or validated in well-nourished Caucasian children in
developed countries and may not be appropriate for
different racial groups or populations with broad variations
in height associated with nutritional stunting. The focus of
this study was to use body composition data from DEXA to
develop and validate a paediatric skinfold prediction
equation in racially-mixed children from a developing
country and compare it to existing equations. Briefly, in our
group of Brazilian pre-pubertal children, the novel skinfold

determined using a p-value of 0.05 and all statistical analyses
were conducted using Systat 12 (SPSS Inc, Evanston, IL).
RESULTS
Selected physical characteristics of the children from this
study subjects used in this study appear as means ^ SD in
Table I. The mean values for the validation group were not
significantly different from the development group.
Table II shows the model developed with the variables
entered for each step of the forward stepwise regression.
Weight accounted for only 62% of the variance of fat mass.
The introduction of tricep skinfolds accounted for another
7%, while height accounted for an additional 5%. The
introduction of gender and age accounted for an additional
1% and 2% of the variance of fat mass, respectively.
The new equations were more accurate than the
equations of Slaughter et al. (1988), Goran et al. (1996),
and Huang et al. (2003) in predicting FM (Table III) when
regressed against measured FM. When the novel and
published prediction equations were regressed against
measured body fat, only the novel equation did not have a
prediction equation performed better than standard
published equations, even those developed for ‘Latino’
populations (Slaughter et al. 1988; Goran et al. 1996; Huang
et al. 2003). These results emphasize the need for continued
development of skinfold prediction equations for different
populations to minimize bias when assessing adiposity in
less developed regions of the world.
The validity of our proposed prediction equation differed
in agreement with established equations and two potential
areas are likely to have contributed to these differences. First,
technical issues remain a threat to the internal validity of
anthropometric measurements. For example, investigator
error (i.e. improperly chosen physical landmarks, not
following standard protocols, etc.) is a common issue that is
usually minimized through the use of a small number of
well-trained investigators and frequent quality control
measures. However, if the development of one equation is
biased as a result of investigator error, that bias will persist
when the equation is used in different cohorts. Also, the use
of different gold standards used to develop the prediction
Equation (e.g. using hydrostatic weighing vs the four-
compartment model) may influence the equation, as each
method may produce an inherent bias in the estimation of

Table II. Stepwise regression analysis for the determination of total fat mass (FM) as measured by dual energy X-ray absorptiometry.
Step and variable Regression equation for FM (kg) Model R 2 Model SEE (kg)
1. Weight 2 3.019 þ 0.308 * weight 0.62 1.453
2. Triceps 2 3.790 þ 0.266 * weight þ0.196 * triceps 0.69 1.325
3. Height 6.583 þ 0.460 * weight þ 0.183 * triceps – 12.110 * height 0.74 1.202
4. Gender 6.921 þ 0.464 * weight þ 0.157 * triceps (12.548 * height þ 0.580 * gender 0.75 1.180
5. Age 6.371 þ 0.488 * weight þ 0.128 * triceps (11.138 * height þ 0.645 * gender – 0.188 * age 0.77 1.204
Units for variables are as follows: Weight (kg), Triceps (mm), Height (m), Gender as Male ¼ 0 and Female ¼ 1, Age (years).

Annals of Human Biology


Table III. Cross-validation of previously published fat mass prediction equations and the new equations DEXA FM vs predicted FM.
Equation n R2
Novel equation 30 0.80
Goran et al.a 30 0.67
Slaughter et al.b 30 0.51
Huang et al.c 30 0.33
Huang et al.c ‘simple’ 30 0.23
* Slope significantly different from 1.0; ** intercept significantly different.
a
Goran et al. (1996); b Slaughter et al. (1988); c Huang et al. (2003).
FFM or FM. It was reported that FM from skinfold
prediction equations compared to estimates from five
precise body composition methods (DXA, total body
potassium, total body water, whole body electrical
conductivity and BIA), the mean difference in FM varied
from 2.72 to (0.14 kg (Ellis 2001). Thus, inconsistent use of
gold standards as newer and more valid techniques have
Ann Hum Biol Downloaded from informahealthcare.com by Loughborough University on 04/18/12
been developed, such as DEXA or stable isotopes, will most
likely generate bias in the development and subsequent use
of prediction equations.
Second, established equations have been developed in
racially homogeneous groups of children from developed
countries (Slaughter et al. 1988; Goran et al. 1996). A
number of studies have reported that racial/ethnic
differences in either body composition or body fat
distribution exists, both of which can bias the accuracy of
skinfold prediction equations from one racial/ethnic
For personal use only.
group to another. For example, in a study with Guatemalan
adults, equations developed specifically for this cohort
performed better than equations developed from other
ethnic groups (Ramirez-Zea et al. 2006). Dezenberg et al.
(1999) reported that neither the Goran nor the Slaughter
equation were valid in a heterogeneous population of Black
and White children in the US. Several studies have reported
differences in body composition and body fat distribution
between ethnic groups, such that Hispanic boys have more
body fat mass than White and Black boys (Ellis 1997).
Another group reported that, despite having similar total
body fat mass, Black girls had more adipose tissue in the
arms and trunk compared to White girls (Yanovski et al.
1996). This highlights the importance of developing
10
8 in height contributes greatly to the existing literature
Fat mass (kg)
6
4 or public health relevance of the results. First, the
2 by different technicians. However, the protocol used by each
0
DEXA Slaughter Goran Latino
Technique to estimate fat mass
Figure 1. Comparison of published prediction equations with an
equation developed in pre-pubertal children from Brazil.
q Informa UK, Ltd.
SKINFOLD PREDICTION EQUATIONS IN CHILDREN 159
Slope (kg) Intercept Measured-Predicted (kg)
1.152 ^ 0.109 2 0.630 ^ 0.571 0.088
1.365 ^ 0.180* 2 0.621 ^ 0.781** 0.834**
1.317 ^ 0.846 0.760 ^ 0.846** 1.736**
0.471 ^ 0.127* 2.692 ^ 0.722 0.304
0.694 ^ 0.239 0.279 ^ 1.635** 1.722**
new prediction equations for FM, mostly due to differences
in the distribution of subcutaneous fat in different
populations. Furthermore, differences between specific
equations may also arise from the fact that not all prediction
equations include the Tanner Stage of the children studied
(Dezenberg et al. 1999). Not only does FM and fat
distribution change through pubertal development, but the
density and hydration of FFM are also influenced by age and
maturation (Ortiz et al. 1992). Therefore, the inclusion of
Tanner Stage in regression equations used to determine
predictive factors of FM in cohorts of children can increase
not only the specificity of the equation, but also control for
confounding factors that may lead to bias between cohorts.
Moreover, beyond the fact that the skinfold prediction
equation developed in our cohort of low-income, racially
diverse children in Brazil, it is worth noting that height was a
major predictor in the validated equation. A review of the
most widely used skinfold prediction equations shows that
height has been used as a predictive variable in only one
Equation (Huang et al. 2003). This is of concern given the
relatively recent paper in which the use of height to better
predict body fat mass relative to body size, rather than body
mass, is described (Burton and Cameron 2009). Briefly, the
authors reported that including a term for height2 improved
the estimates of fat mass for the tallest and shortest persons.
This observation is of particular relevance for developing
regions where the prevalence of growth faltering (i.e.
stunting) remains high. Thus, developing a skinfold
prediction equation that incorporates height may markedly
improve the ability for investigators in transitional countries
to better monitor changes in adiposity, rather than just BMI.
There has been a marked paucity of prediction equations
from cohorts in transitional countries and the validation of
an equation that may also accommodate large variations
on methods to assess adiposity in developing regions of the
world.
There were two limitations to our study that merit
discussion, neither of which compromise the interpretation
anthropometric data were collected at different locations
technician was the same and the same procedures and
equipment were used for establishing landmarks and taking
Novel skinfold measurements. Second, the time between the data
collection of one cohort was , 6 years before that of the
second cohort. Still, it is unlikely that this time difference
would influence any aspect of body composition in two
cohorts of the same age. Finally, the population in which our
 160 D. J. HOFFMAN ET AL .
equation was derived is a heterogeneous group living in the
shantytowns of São Paulo and Jundiai. As with most
shantytowns in urban areas of São Paulo state, most families
originate from the northeastern region of Brazil and are of
mixed ethnicity (e.g. Portuguese, African and Indigenous).
Thus, there may be limited generalizability to children from
Asian or European families, perhaps more so for children of
mixed ancestry, but the novel prediction equation can be
validated in other cohorts in Latin America and elsewhere.
CONCLUSION
Based on the data from the cohorts studied, the use of the
new prediction equation is more valid compared to
equations developed in the US or other developed nations.
Thus, this equation may better serve investigators in
Ann Hum Biol Downloaded from informahealthcare.com by Loughborough University on 04/18/12
developing nations as our novel equation was developed
using advanced body composition techniques and from
cohorts of racially mixed children. Future studies should
focus on testing the novel prediction equation on children in
other developing countries and/or combining data from
different ethnic groups to develop additional equations that
could be used across cultures and ethnic groups.
Declaration of interest: The authors report no conflict of
interest. The authors alone are responsible for the content
For personal use only.
and writing of the paper.
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Annals of Human Biology