Blood Pressure

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The relationship between mid-upper arm

circumference and blood pressure in Walter Sisulu
University community

Wenzile S Mthethwa, Zuqaqambe M Mampofu, Madigoahle A Mokwena &

Nthai E Ramoshaba

To cite this article: Wenzile S Mthethwa, Zuqaqambe M Mampofu, Madigoahle A Mokwena

& Nthai E Ramoshaba (2024) The relationship between mid-upper arm circumference and
blood pressure in Walter Sisulu University community, Blood Pressure, 33:1, 2296904, DOI:
10.1080/08037051.2023.2296904

To link to this article: https://doi.org/10.1080/08037051.2023.2296904

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Blood Pressure
2024, VOL. 33, NO. 1, 2296904
https://doi.org/10.1080/08037051.2023.2296904

Research Article

The relationship between mid-upper arm circumference and blood

pressure in Walter Sisulu University community
Wenzile S Mthethwa, Zuqaqambe M Mampofu, Madigoahle A Mokwena and Nthai E Ramoshaba
Department of Human Biology, Walter Sisulu University, Nelson Mandela Drive, Mthatha5117, South Africa

ABSTRACT ARTICLE HISTORY

Prevalence of hypertension is increasing to higher levels in South Africa. Anthropometric measures Received 11 October
for obesity are well known to predict the development of hypertension. However, the relationship 2023
between mid-upper arm circumference (MUAC) and blood pressure (BP) is scant in South African Revised 12 December
2023
communities such as universities. Therefore, this study was aimed at investigating the correlation
Accepted 13 December
between MUAC and BP among the community of Walter Sisulu University (WSU). A total of 230 2023
participants from WSU (students and staff members), 113 females and 117 males aged ≥ 18 years
participated in this cross-sectional study. MUAC, systolic BP (SBP) and diastolic BP (DBP) were KEYWORDS
measured using standard procedures. In a Pearson’s correlation analysis, MUAC was positively mid upper arm
correlated with SBP and DBP in both women (SBP; r = 0.53, P< 0.001; DBP; r = 0.45 P < 0.001) and circumference; blood
pressure; obesity; Walter
men (SBP; r = 0.29 P = 0.001; DBP; r = 0.25 P = 0.007). Furthermore, in the multivariable-adjusted Sisulu university
regression analysis, MUAC was positively associated with SBP in women only (adjusted R2 = 0.489, community; subcutaneous
β = 0.29 (95% CI = 0.16; 2.08)), P =0.023) after adjusted for age, body fat percentage, waist-to- fat
height ratio, smoking and alcohol. MUAC is positively correlated with BP in women, not in men of
WSU community. MUAC, as a simple and low-cost quantifiable parameter, could be employed as
a risk indicator in the early detection and prevention of cardiovascular diseases (CVDs) in women.

PLAIN LANGUAGE SUMMARY

This study investigated the use of an anthropometric measurement as an indicator for
hypertension. Anthropometric measurements are non-invasive quantitative measurements of the
human body. Within this study, we evaluated the productiveness of mid upper arm circumference
(MUAC) as an indicator for hypertension in the WSU community. Studies have shown that MUAC,
being a simple and cost-effective method, can be employed in resource-limited settings.
Furthermore, the findings of this study have revealed a positive correlation between MUAC and
blood pressure in women from the WSU community, indicating that the greater their MUAC, the
higher their blood pressure, further emphasizing their increased risk of developing hypertension.
Consequently, these findings will contribute in the prevention of hypertension and obesity, even
in areas where accessibility to expensive resources is limited. Furthermore, this investigation has
raised awareness about hypertension and obesity within the WSU community, encompassing
individuals from diverse geographical regions and racial backgrounds. Thus, we firmly believe that
this study has had a substantial impact. Additionally, it will serve as a motivation for the
community to transition from unhealthy lifestyles to healthier ones, which include dietary
improvements, increased physical activity, and decreased alcohol consumption. Ultimately, these
changes will significantly reduce the risk of developing cardiovascular diseases.
List of Abbreviations: BP: Blood Pressure; BMI: body mass index; CVDs: cardiovascular diseases;
DBP: diastolic blood pressure; MUAC: mid upper arm circumference; PP: pulse pressure; SBP:
systolic blood pressure; WHO: World Health Organization; WSU: Walter Sisulu University

Introduction low-income countries (Jagannathan et al., 2019). High

Cardiovascular diseases (CVDs) pose a serious public blood pressure (BP) is a major risk factor for CVDs
health threat, which contributes significantly to the and can cause a variety of complications including
global illness burden in both high-, middle- and death if left untreated (World Health Organization

CONTACT Nthai E Ramoshaba nramoshaba@wsu.ac.za

© 2024 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted
use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the posting of the
Accepted Manuscript in a repository by the author(s) or with their consent.
2 W. S. MTHETHWA ET AL.
(WHO), 2014). Obesity is a major risk factor for a
variety of conditions, including high BP (Poirier et al.,
2006; Abraham et al., 2015).
Several anthropometric indicators for obesity are
well established (Yang et al., 2010, Shifraw et al.,
2021., Mazıcıoğlu et al., 2010). Body mass index
(BMI) is the most widely employed anthropometric
measurement and is often utilized for determining
the prevalence of obesity (Hales et al., 2017, Sartorius
et al., 2015, Pienaar et al., 2015). BMI can be deceiv-
ing, especially when considering someone with a
high proportion of lean muscle (Rothman, 2008).
Furthermore, a centrally obese person may have a
normal BMI, hence the majority of circumference
measurements for obesity such as waist circumfer-
ence, neck circumference and mid-upper arm cir-
cumference (MUAC) are widely employed as
indications of central obesity (Ben-Noun and Laor
2003, Fatchurohm et al., 2021, Zhu et al., 2020). The
MUAC assessment is one of the simplest, inexpen-
sive, rapid, and practical (takes minimal effort from
both the examiner and the examinee) and can be
used as a screening tool in epidemiological surveys
or in low-resource settings (Ramoshaba et al., 2015).
BMI on the other hand is quite difficult to establish
in low-resource settings as it requires height and
weight measurements and the standard equipment
for the aforementioned is expensive and necessitates
calculations (Himes, 2009; Sultana et al., 2015).
There have been studies that reported that BP is
closely related to MUAC in children both boys and
girls from South African rural and urban areas
(Ledwaba et al., 2014, Ramoshaba et al., 2015). In con-
trary, it has been observed that MUAC predominantly
associate with BP in women than men from Indonesia
and China (Fatchurohmah et al., 2021, Hou et al.,
2019). However, the relationship between MUAC and
BP is scant in South African communities such as his-
torically disadvantaged universities. Therefore, it is cru-
cial to establish the association between MUAC and BP
among the Walter Sisulu University (WSU) community,
in order to predict the development of hypertension,
which will aid in its early prevention. This current
study investigated the relationship between MUAC and
BP among WSU community.
Methods
Study design and data collection
WSU is one of South Africa’s historically disadvan-
taged universities, located in the Eastern Cape
Province. This study employed a cross-sectional study
design, with a sample size of 230 participants from
WSU, 185 (18-37 years) students, 45 staff members
(18-63 years), both males (n = 117) and females
(n = 113). Participants were recruited by word of
mouth from their residences and offices to the phys-
iology laboratory where the data were collected. A
general demographic and lifestyle questionnaire was
completed by each participant and the data with
regard to age, gender, ethnicity, self-reported smoking,
and self-reported alcohol consumption.
Measurements
Anthropometric measurements
Anthropometric measurements were carried out by
researchers and well-trained assistants in accordance
with the guidelines of the International Society for the
Advancement of Kinanthropometry (Marfell-Jones
et al., 2012). A tape measure (Lufkin Steel Tape;
W606PM; Lufkin, TX, USA; Apex, NC, USA) was used
to measure mid-upper arm and waist circumference to
the nearest 0.1 cm, the participants settled into a com-
fortable position with their arms at their sides. The
mid-acromiale-radiale was marked. The tape measure
was then positioned perpendicular to the long axis of
the humerus, where the mid acromiale-radiale was
marked, while the muscles of the arm were relaxed,
and MUAC measurements were taken. According to
Shifraw et al. (2021), MUAC of 24.5 cm is the optimal
cutoff in both women and men to identify underweight
and the cut-offs to identify overweight and obese are
>28.0 cm and >30.0 cm, respectively.
The waist circumference measurements were taken
at the level of the narrowest point between the iliac
crest and the bottom part of the thoracic cage, with
the participants standing in an upright position after
mild expiration. The participants assumed a relaxed
standing position with their arms folded across
the thorax.
A SECA 213 Portable Stadiometer was used to mea-
sure the body height to the nearest 0.1 cm (SECA,
Hamburg, Germany). The participants had to stand with
their feet together and their heels, buttocks, and upper
back touching the scale for body height measurements.
The participants were instructed to take a deep breath
and hold it while keeping their heads in the Frankfort
plane. A gentle upward lift was applied through the
mastoid processes. The stadiometer’s base was then low-
ered to the vertex of the head, and if there was a lot of
hair on the head, a small amount of pressure was applied
to touch the top of the head. Using an electronic scale,
the body weight was measured to the nearest 0.1 kg
 Blood Pressure 3

(SECA, Hamburg, Germany). The scale reading was calculation revealed that a minimum sample size of n
checked before the participants climbed onto it, then = 89 would be required to perform our multivariate
they stood on the center of the scale without support regression analysis with an effect size of 0.15, alpha
and with their weight evenly distributed on both feet. set to 0.05, and power to 0.95.
The head was tilted upwards, and the eyes were fixed
forward. The waist-to-height ratio (waist circumference
(cm)/height (cm)) was calculated. Results
Body fat percentage was determined using a body Table 1 (available on the last section of the manu-
composition scale (Omron BF511 Body Composition script) shows the characteristics of WSU community
monitor, China) where the participants stood bare by gender, women featured a higher MUAC (29.54 vs.
footed on the scale making sure their feet were on 28.26 cm, P = 0.030) and body fat percentage (40.31
the foot electrodes with their head tilted upwards and vs. 25.29%, P= <0.001) mean than men. There was no
eyes looking in a forward direction. They then pressed difference in BP by gender. Pearson correlation anal-
their hands firmly on the grip electrodes and raised yses for women and men MUAC of women revealed
their arms vertically. Elbows and arms were extended a positive correlation with SBP (r = 0.56; P = <0.001
straight at a 90° angle to the body. vs. r = 0.29; P = 0.002), DBP (r = 0.46; P vs r = 0.21
P = 0.020) and PP (r = 0.42; P = <0.001 vs. r = 0.22;
P = 0.016) than MUAC of men. Table 2 shows the
BP measurements multivariable-adjusted regression analysis in woman
Omron M3 BP monitor was used to assess clinic BP results, the MUAC remained positively associated
(Omron, Kyoto, Japan). After the participants have with SBP in women (adjusted R2 = 0.489, β = 0.29
been seated for at least five minutes or more, three (95% CI = 0.16; 2.08)), P =0.023) adjusted for age,
readings of SBP, DBP, and heart rate were taken at body fat percentage, waist-to-height ratio, smoking,
five minutes intervals from the dominant arm (Weber and alcohol. DBP and PP showed no significant asso-
et al., 2014). The average of the last two readings ciation with MUAC in women. Table 3 shows the
were used. The pulse pressure (PP) was determined multivariable-adjusted regression analysis in men
by subtracting the SBP from the DBP. The BP was results, whereby the MUAC showed no significant
categorized into elevated BP (SBP = 120-129 mmHg, association with SBP, DBP but PP (adjusted R2 = 0.031
DBP < 80 mmHg); prehypertension (SBP = 130-139, β = 0.29 (95% CI = 0.1;1.3), P =0.027), adjusted for
DBP = 80-89 mmHg); hypertension (SBP ≥ 140 mmHg
or DBP ≥ 90 mmHg) (Carey et al., 2018).
Table 1. Characteristics of Walter Sisulu University
community.
Statistical Analysis Women Men
Characteristics (N = 113) (N = 117) P-value
The formal test (Kolmogorov-Smirnov test) and Age (Years) 23.90 ± 7.78 24.52 ± 9.06 0.580
graphical approaches were used to analyze normal Height (cm) 159.59 ± 6.26 166.89 ± 7.95 <0.001
Weight (kg) 69.24 ± 17.04 65.30 ± 12.42 0.046
data distribution. Continuous data was presented as MUAC (cm) 29.54 ± 4.78 28.26 ± 4.07 0.030
mean ± standard deviation. The student t-test was WHtR 0.50 ± 0.08 0.46 ± 0.07 <0.001
Body fat (%) 40.31 ± 10.38 25.29 ± 12.34 <0.001
used to compare the continuous data by gender. SBP (mmHg) 123.09 ± 18.69 125.54 ± 14.86 <0.001
Categorical data was presented as frequencies and DBP (mmHg) 80.78 ± 12.28 79.77 ± 10.59 0.505
HR (bpm) 80.09 ± 12.19 73.09 ± 13.41 <0.001
proportions. Chi-square tests were used for categorical PP (mmHg) 41.68 ± 11.32 45.87 ± 9.79 0.003
variables to test differences between men and women. BP categories
A Pearson correlation analysis was performed to  Elevated BP, n (%) 19(16.8) 29(24.8)
Prehypertension, n (%) 14(12.4) 23(19.7) 0.047
determine the relationship between the MUAC and Hypertension, n (%) 16(14.2) 20(17.1)
BP in women and men. A multivariate regression Weight categories by MUAC
 Underweight, n (%) 11(9.7) 23(19.7) 0.023
analyses in women and men were performed to inves-  Overweight, n (%) 12(10.6) 21(17.9)
tigate associations between the MUAC and BP,  Obese, n (%) 47(41.6) 32(27.4)
Lifestyle
adjusted for age, body fat percentage, waist-to-height  Smoking, n (%) 19 (16.8) 37 (31.6) 0.009
ratio, smoking and alcohol. All the statistical analyses Alcohol, n (%) 55(48.7) 70(59.8) 0.089
were performed using the Statistical Package for the Abbreviations: MUAC, mid upper arm circumference; BMI, body mass
index; WHtR, waist to height ratio; SBP, systolic blood pressure; DBP, dia-
Social Sciences (SPSS Inc., Chicago, IL, USA, 26.0). stolic blood pressure; HR, heart rate; PP, pulse pressure; BP, blood
The statistical significance was set at P < 0.05. A power pressure.
4 W. S. MTHETHWA ET AL.

Table 2. Independent association between BP as dependent variable and MUAC as main independent variable in women.
SBP (mmHg) DBP (mmHg) PP (mmHg)
Adj.R = 0.460
2
Adj.R = 0.363
2
Adj.R2 = 0.234
IV β (95% CI) P-value β (95% CI) P-value β (95% CI) P-value
MUAC (cm) 0.29(0.16; 2.08) 0.023 0.25(−0.06; 1.32) 0.072 0.18(−0.33; 1.31) 0.241
Age (years) 0.36(0.47; 1.27) <0.001 0.34(0.24; 0.82) <0.001 0.21(−0.01; 0.68) 0.055
Body fat (%) −0.23(−0.82; −0.03) 0.037 −0.24(−0.57; −0.01) 0.045 −0.11(−0.47; 0.21) 0.443
WHtR (kg/m2) 0.32(13.09; 131.64) 0.017 0.29(0.95; 85.57) 0.045 0.19(−21.67; 79.87) 0.258
Smoking, n (%) −0.01(−7.79; 6.47) 0.855 −0.10(−8.35; 1.83) 0.207 0.08(−3.50; 8.70) 0.400
Alcohol, n (%) −0.06(−7.60; 3.17) 0.419 −0.02(−4.36; 3.34) 0.795 −0.07(−6.32; 2.92) 0.467
Abbreviations: MUAC, mid-upper arm circumference; WHtR, waist-to-height ratio; SBP, systolic blood pressure; DBP, diastolic blood pressure; PP, pulse
pressure; IV, independent variables.

Table 3. Independent association between BP as dependent variable and MUAC as main independent variable in men.
SBP (mmHg) DBP (mmHg) PP (mmHg)
Adj.R2 = 0. 115 Adj.R2 = 0.205 Adjusted R2 = 0.031
IV β (95% CI) P-value β (95% CI) P-value β (95% CI) P-value
MUAC (cm) 0.23(0.02;1.69) 0.046 0.10(−0.33; 0.83) 0.391 0.25(0.01; 1.19) 0.046
Age (years) 0.09(−0.21; 0.51) 0.416 0.24(0.03; 0.53) 0.028 −0.12(−0.39; 0.12) 0.306
Body fat (%) −0.30(−0.65; −0.06) 0.018 −0.27(−0.44; −0.03) 0.026 −0.16(−0.33; 0.08) 0.241
WHtR (kg/m ) 2
0.22(−20.29; 113.47) 0.170 0.25(−8.19; 84.31) 0.106 0.06(−38.65; 55.71) 0.721
Smoking, n (%) 0.11(−2.90; 9.66) 0.288 0.16(−0.70; 7.99) 0.099 −0.01(−4.69; 4.17) 0.906
Alcohol n (%) 0.08(−3.67; 8.52) 0.432 0.06(−2.85; 5.58) 0.523 0.05(−3.24; 5.36) 0.625
Abbreviations: MUAC, mid-upper arm circumference; WHtR, waist-to-height ratio; SBP, systolic blood pressure; DBP, diastolic blood pressure; PP, pulse
pressure; IV, independent variables.

age, body fat percentage, waist-to-height ratio, smok-
ing, and alcohol in men.
Discussion
This cross-sectional study investigated the relationship
between MUAC and BP among the community of
WSU, one of the historically disadvantaged universi-
ties. We found a significant positive correlation
between the MUAC and BP in women not in men.
This means that arm circumferences increase with BP
in women more than in men.
The global burden of obesity has been substan-
tially underestimated by the reliance on BMI in pre-
vious studies (Yusuf et al., 2004, Romero-Corral
et al 2008). Furthermore, an INTERHEART study
provides more insight into the reliability of different
anthropometric obesity measurements such as waist
to hip ratio, waist and hip circumferences, where
waist to hip ratio revealed a highly significant asso-
ciation with myocardial infarction risk attributable to
obesity as compared to BMI (Yusuf et al., 2005). In
this study, we used a different approach, that has
been recently proposed to assess obesity which is
MUAC (Shifraw et al., 2021). We found that women
had bigger MUAC as compared to men in this study.
Previous studies have revealed mixed results on the
relationship between MUAC and BP based on gender
and age. In children and adolescence, it was reported
that MUAC positively correlate with BP in both boys
and girls (Bassareo et al 2018; Ramoshaba et al 2015).
In young adults, Fatchuromah et al (2021) reported no
significant relationship between MUAC and BP in men
while Hastuti et al (2018) observed that MUAC is the
strongest indicator for BP in women than men. Moreover,
in older people, MUAC was associated more with high
BP in women than in men (Hou et al., 2019). These
previous findings are precisely in agreement with the
results of this study that MUAC relates positively with
BP more predominantly in women than men. Therefore,
is critical in paying more attention to women with big-
ger MUAC in the early identification and that will help
in prevention of high BP or hypertension.
The probable explanation for the gender differ-
ence in the relationship between MUAC and BP in
adults could be biological variations between men
and women, such as immune system response, phys-
ical performance, muscular capacity, and hormone
effects. For instance, men often have more muscle
mass and capacity than women due to a greater pro-
portion of testosterone, whereas women usually dis-
play more upper body adiposity than men (Wells
et al 2007, Hazlip et al 2015). The gender difference
in body fat or adiposity distribution may contribute
to more predominant relationship between MUAC
and BP among women as compared to men observed
in this study.
Generally, precise mechanism that links MUAC
and BP is not yet clear, however there is evidence

that an elevation in upper body subcutaneous fat
measured by MUAC is significantly associated with
increased visceral fat and is involved in the develop-
ment of high BP and metabolic diseases independent
of BMI (Liang et al., 2013, Yang et al., 2010). Jensen
et al (2008) and Nielsen et al (2004) briefly noted
that upper subcutaneous fat secretes systematic free
fatty acids, that will cause insulin resistance, inflam-
mation, and increased triglyceride production and
ectopic fat deposition (Kim et al., 2007, Hotamisligil,
2017). Increased levels of free fatty acids may also
cause oxidative stress, by increasing the production
of oxygen free radicals which override the antioxi-
dant system (Masschelin et al 2020). Oxygen free
radicals can elicit the proliferation, hypertrophy, and
collagen deposition of vascular smooth muscle cells,
which thickens the vascular media and narrows the
vascular lumen (Grossman 2008). Additionally, oxi-
dative stress has been linked to endothelial damage,
impaired endothelium-dependent vascular relaxation,
and increased vascular contractile activity, thus lead-
ing to elevated BP (Silver et al 2012). Therefore,
excess free fatty acid release from arm subcutaneous
adipose accumulation could be a plausible mecha-
nism to explain the link between MUAC and BP.
Our findings have some limitations that should be
noted. First, because the current study is a
cross-sectional study, no causal inference can be
drawn. Secondly, although we have adjusted for mul-
tiple confounders, family history, food consumption,
physical activity and bioelectrical impedance analysis
which we did not include might influence these find-
ings. However, we suggest that future studies incor-
porate these variables into linear regression models
in order to confirm our findings among the University
communities. Lastly, this study was limited to the
WSU community, the generalizability of our findings
to other demographic and ethnic communities should
be approached with caution.
Conclusion
This study found a positive association between
MUAC and BP in women not men from the WSU
community. Our findings show that MUAC, as a sim-
ple and low-cost quantifiable parameter, could be
employed as a risk indicator in the early detection
and prevention of CVDs in women.
Acknowledgements
The authors are indebted to all participants (students and
staff members).
Blood Pressure 5
Authors contributions
All authors contributed to design of the study. Conceptualization:
W.S.M., Z.M.M., M.A.M., N.E.R.; Methodology, W.S.M.; anal-
ysis, W.S.M., N.E.R., investigation, W.S.M., data curation,
W.S.M., and Z.M.M., writing—original draft preparation,
W.S.M., writing—review and editing, W.S.M., Z.M.M., M.A.M.,
N.E.R.; supervision, N.E.R. The final approval of the paper
and its revision were accomplished by all writers.
Availability of data and materials
The data that support the findings of this study are acces-
sible from the corresponding author, however access to
these data is restricted, because they were used under
authorization for the current study and hence are not pub-
licly available.
Ethics approval and consent to participate
Ethical clearance was sought-after from the Health Sciences
Ethics Committee of Walter Sisulu University, South Africa
(protocol number: 068/2022). After detailed explanation of
the purpose and aim of the study, as well as a brief demon-
stration of how the measurement techniques were con-
ducted, written informed consent was sought-after from the
participants before enrolment of the study. The study
adhered to the standards of reporting and acted in accor-
dance with the National Data Protection Acts, as the iden-
tities of the participants were kept confidential.
Consent to publication
Not applicable.
Competing interest
Nil
Funding
This study received no external funding. All the equipment
needed to complete the study were available in the Human
Biology Department (Physiology).
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