US Measure of FAT BODY

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Ultrasound as an approach to assessing bodycorn position 14

Marie T Faneii, PhD, RD and Robert J Kuczmarski, MPH, RD

ABSTRACT Body composition is an important indicator of nutritional status. The mostcommonly used indirect method for estimating body fat is based on measurements of subcuta-neous fat tissue. It has been suggested that ultrasonic measurements may be more precise than

those of the caliper and therefore may yield more accurate measures of subcutaneous fat tissue.This study was designed to correlate ultrasonic and caliper measurements of subcutaneous fatwith body density determined by hydrostatic weighing. Subcutaneous fat thickness was measured

at seven body sites (triceps, biceps, subscapula, waist, suprailiac, thigh, and calf) with a Langeskinfold caliper and an ADR ultrasonic scanner, equipped with a display-screen, 7MHz trans-

ducer, and electronic calipers. Regression equations to predict body density, and hence body fat,were derived for each technique using a minimal number of body sites. The sample consisted of

124 white men, aged 18 to 30 yr. Mean body density determined by hydrostatic weighing was

1.07 g/ml (SD ± 0.01) and mean body fat was 12.7% (SD ± 5.8). Both ultrasonic and calipermeasurements of waist, thigh, and triceps had the highest correlation with body density.Regression equations using these three sites in all possible two-site combinations were derived

for each technique. The predictions of body density from these equations did not differsignificantly. These results suggest that in free-living, nonobese, white men, body fat can beestimated with nearly the same degree of accuracy using either the caliper or ultrasonic tech-nique. Am J Clin Nuir l984;39:703-709.

KEY WORDS Body composition, densiotometry, ultrasonics

Introduction

Accurate measurements of body compo-sition are essential for evaluating nutritionalstatus and for planning the dietetic aspectsof health care programs. Among the meth-ods to estimate body fat, hydrostatic weigh-ing is perhaps the most accurate, but alsothe most cumbersome, noninvasive tech-nique currently available. A more practicalmethod for both field surveys and routineclinical assessment is the measurement ofsubcutaneous fat thickness. This measure-ment is most commonly taken with a caliperas a double fold of skin and subcutaneousfat tissue, ie, skinfold. For lean subjects,caliper measurements of skinfolds correlatehighly with direct measures of skin and sub-cutaneous fat thickness obtained by inci-sions (r = 0.83) (1) and by electrical conduc-tivity (r = 0.81) (2).

As with most techniques, there are limi-tations associated with the caliper method

which may result in inaccurate estimates ofsubcutaneous fat thickness and, conse-quently, of total body fat. These limitationsinclude the inability to control inter- andintrasubject variation in skinfold compress-ibility, the inability to palpate the fat-muscleinterface, and the impossibility of obtaininginterpretable measurements on very obesesubjects (2-6). Variation in skinfoldcompression has been attributed to such fac-tors as subcutaneous fat thickness, state of

‘From the Department of Nutrition, School of Pub-lic Health, University of North Carolina, Chapel Hill,NC.

� in part by University Research CouncilGrant Funds and School of Public Health BiomedicalResearch Support Funds, University of North Carolina,Chapel Hill, NC.

Presented in part at the Western Hemisphere Nu-trition Congress VII, Miami, FL, August 10, 1983.

4Address reprint requests to: Marie T Fanelli, De-partment of Nutrition, 315 Pittsboro Street 325H, Uni-versity of North Carolina, Chapel Hill, NC 27514.

Received October 7, 1983.Accepted for publication November 29, 1983.

The American Journal of Clinical Nutrition 39: MAY 1984, pp 703-709. Printed in USA© 1984 American Society for Clinical Nutrition

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704 FANELLI AND KUCZMARSKI

In response to advertisements placed in municipaland university newspapers, 124 white men, aged 18 to

hydration, and distribution of fibrous tissueand blood vessels (3, 7).

Ultrasound has been proposed as an alter-native noninvasive technique to measuresubcutaneous fat thickness because it mayovercome some of the limitations of thecaliper (6, 8, 9). Ultrasonic scanners arecapable of measuring subcutaneous fat atdepths of 100 mm or more without tissuecompression and can reliably detect densityinterfaces with an accuracy of 1 mm. In the1960’s and early 1970’s, ultrasonic measure-ments were demonstrated to be strongly cor-related with direct measures of subcutaneousfat by electrical conductivity (r = 0.98) (2),needle puncture (r = 0.98) (10), and soft-tissue radiographs (r = 0.88) (6). These datasuggested that ultrasonic measurements ofsubcutaneous fat may be more accurate thancaliper measurements.

Over the years, research defining the prac-tical applications of ultrasound in anthro-pometry has not kept pace with advances inthe electronics of ultrasonic technology. Apossible explanation is that traditionally thisequipment was limited to use in hospitalswhere tissue resolution at near fields was notessential. It is only recently that high reso-lution transducers required for characteriz-ing subcutaneous tissues have become avail-able.

The purpose of this investigation was todescribe the relative merits and validity ofultrasound with respect to two other nonin-vasive techniques for estimating body den-sity. Measures of subcutaneous fat obtainedwith a skinfold caliper and ultrasonic scan-ner were compared to body density deter-mined by hydrostatic weighing. The follow-ing report presents 1) the correlations be-tween caliper and ultrasonic measurementsof subcutaneous fat at specified anatomicalsites; 2) the correlations of both the caliperand the ultrasonic measurements of subcu-taneous fat with densitometrically deter-mined body density; and 3) regression equa-tions developed to predict body density andsubsequently, total body fat from caliper andfrom ultrasonic measurements of subcuta-neous fat.

Methods

Subjects

30 yr. volunteered to participate in this study. Informedconsent forms were signed by each subject before par-ticipation. All of the procedures used were in accord-ance with the ethical standards of the InstitutionalBoard for Experimentation with Human Subjects ofthe School of Public Health at the University of NorthCarolina at Chapel Hill.

Procedures

Anthropometric measurements were taken for eachsubject dressed only in a swim suit in the followingsequence: measurements of subcutaneous fat by caliperand then by ultrasound, stature measurement, weightmeasurement, and finally hydrostatic weighing.

Subcutaneous fat thickness was measured by caliperand ultrasonic techniques at seven sites on the right sideof the body. The sites and their anatomical descriptionsare as follows: triceps, midpoint between the acromionand olecranon processes on the posterior aspect of thearm; biceps, midpoint of muscle belly; subscapula, in-ferior angle of the scapula; waist, midpoint between lastrib and iliac crest at the midaxillary line; suprailiac,oblique fold on the iliac crest at the midaxillary line;thigh, anterior aspect of the thigh midway between theinguinal fold and midpoint of the patella; and calf,posterior aspect of the lower leg at the maximal girth.Each site was marked with a wax-based cosmetic pencil.

To eliminate interobserver error, one investigatorread all the caliper measurements and another read allthe ultrasonic measurements. For both techniques, twoindependent measurements were taken at each site, andvalues were recorded to the nearest 0.5 mm. If thevalues were not within 1 mm of each other, a thirdmeasurement was taken. The two values that agreedwithin 1 mm were averaged and the mean was acceptedas the representative value.

All skinfolds were measured with a Lange skinfoldcaliper (Cambridge Scientific Instruments, Cambridge,MD) which was checked against a calibration gaugebefore each use. Skinfolds were taken in accordancewith a standard anthropometric procedure (11).

An ADR Real Time Scanner, model 2130, equippedwith a 7.0 MHz transducer, display-screen, freeze-framecapacity, and electronic calipers (ADR Ultrasound,Tempe, AZ) was used to measure subcutaneous fatthickness (excluding skin thickness) at the same markedsites as skinfolds. A water-soluble transmission gel wasapplied to the array of the transducer. The transducerwas then held manually about 0.5 mm above themarked site with the gel providing acoustic contactwithout depression of the dermal surface. To assureaccurate depth readings the transducer was positioneduntil the ultrasonic beam was perpendicular to the tissueinterfaces at each site. An angle of incidence other than900 may result in a transmission parallax error (12). Asnoted, the ADR scanner is equipped with a HewlettPackard display-screen for visual presentation of ultra-sonic images. Using the near and far field gain controls,the image was focused and then frozen. Subcutaneousfat thickness was measured directly from the screenwith the use of electronic calipers positioned at the skin-fat and fat-muscle interfaces (Fig 1). Fat thicknessdepths less than 3 mm were measured directly from the


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ESTIMATES OF BODY FAT FROM ULTRASONIC MEASURES 705

FIG 1. Thigh site as measured by ultrasound. Ar-rows indicate position of electronic calipers. Arrow Iindicates skin-fat interface; arrow 2, fat-muscle inter-face; and arrow 3, muscle-bone interface. The left high-lights the fat layer between skin and muscle (11 mm)while the right points out the muscle between subcuta-neous fat and the femur (31 mm).

screen with a draftsman’s caliper (HB, Germany), be-cause the electronic calipers could not be positioned tomeasure to these depths. Vertical and horizontal cali-bration of the equipment was routinely checked accord-ing to the manufacturer’s instructions (13).

The percentage compression associated with the cal-iper technique was determined for each body site. Per-centage compression was calculated by the followingequation which was developed for this study:

U-0.5C% compression = x 100

where: U = mean fat thickness (mm) measured byultrasound; C = mean skinfold thickness (mm) meas-ured by caliper.

Stature was measured against a vertical height boardto the nearest 0.1 cm. Each subject stood with feet flatand eyes looking straight forward, keeping his heels,buttocks, and shoulders in contact with the board whilethe headboard was lowered and stature recorded.

All men were weighed to the nearest 0.1 kg on adouble beam balance. The accuracy of this balance waschecked and verified with standard test weights.

Hydrostatic weighing was conducted according tothe procedures described by Pollock et al (14). Eachman entered the hydrostatic weighing tank and wascompletely submerged. Precautions were taken to as-sure that no air was trapped by the subject’s body hair

or swim suit. Underwater weighings were continueduntil the heaviest weight reading was repeated twice.This value was used in the calculation of body density.Water temperature was recorded immediately after eachsubject was weighed. Residual lung volumes were meas-ured independently in a plethysmograph (iaeger BodyTest, Germany) at the Pulmonary Function Laboratoryof North Carolina Memorial Hospital, Chapel Hill.Body density (Db) was calculated from the formula ofGoodman and Buskirk (15):

WaDb - Wa-Ww - V.

Dw

Where: Wa = weight of subject in air, kg; Ww = weightof subject in water minus weight of equipment, kg; Dw= density of water at X#{176}C,g/ml; V = residual lungvolume, I.

Percentage of body fat was calculated from bodydensity according to the formula of Sin (16): % bodyfat = (4.95/Db - 4.50) x 100.

Statistical analysis

Mean values, SDs, and ranges for age, height, weight,body density, residual lung volume, percentage bodyfat, percentage compression, and caliper and ultrasonicmeasurements of subcutaneous fat at each body sitewere calculated. Using the Statistical Analysis Systempackage for zero-order Pearson correlation analysis forthe null hypothesis, Ho = 0, coefficients of correlationbetween body density, as determined by hydrostaticweighing, and subcutaneous fat thickness measured ateach body site with caliper and ultrasound were alsocalculated(17). Multiple regression analyses, using bodydensity as the dependent variable, and subcutaneous fatthickness as the independent variables, were performedseparately for caliper and ultrasonic measurements (17).Regression analysis was used to identify the body sites

that provided the best estimation of body density fromcaliper and from ultrasonic measurements of subcuta-neous fat and to develop equations for predicting bodydensity from these selected sites.

Results

The physical characteristics of the menare presented in Table 1. Mean body densitywas 1.07 g/ml which by Siri’s formula, cor-responds to a mean body fat of 12.7%. Thefrequency distribution of the body densityvalues is reported in Table 2. Approximately53% (n = 23) had more than 17% body fat.Thus, this sample was comprised mainly ofrelatively lean men.

Mean values of subcutaneous fat meas-ured by the caliper and ultrasonic techniquesand correlation coefficients between themeasurements are presented in Table 3.Measurements by the two techniques corre-


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TABLE 1

Physical characteristics of subjects (n = 124)

Variable

Age (yr)Ht(cm)Wt(kg)Body density (g/ml)*Residual lung volume (1)Body fat(%)t

Mean

24.3178.4

74.51.071.63

12.7

SD Range

3.56.29.00.010.425.8

18.0-30.0162.8-194.0

56.2-105.71.03-1.090.70-2.60

3.5-32.7

TABLE 2Frequency distribution of body density

* Derived from hydrostatic weighing.

t Calculated from Siri’s formula, using the body density value derived from hydrostatic weighing.

* Caliper measurement is the doublefold of skin and

subcutaneous fat, while ultrasonic measurement is thesingle thickness of subcutaneous fat.

t p < 0.0001.


and percentage body fat

Bodydensities

Body fattn

Frequency

04

g/m!

1.030-1.0391.040-1.0491.050-1.0591.060-1.0691.070-1.0791.080-1.0891.090-1.099

Total sample

%

30.6-26.426.3-21.921.8-17.417.3-13.012.9-8.8

8.7-4.54.5-0.4

21011333333

2124

1.68.18.9

26.626.626.6

1.6100

* Derived from hydrostatic weighing.t Calculated from Sin’s formula.

TABLE 3Mean subcutaneous fat thickness (mm) as determinedby caliper and ultrasonic techniques and correlationsof measurements by technique and site

Site Caliper0 Ultrasound

x±SD

Triceps 10.1 ± 4.1 6.1 ± 2.5 0.807tBiceps 3.6 ± 1.4 2.4 ± 1.2 O.703tSubscapula 10.5 ± 2.8 5.6 ± 1.8 0.677tWaist 16.0 ± 7.0 10.6 ± 3.8 0.855tSuprailiac 15.1 ± 6.7 8.1 ± 3.8 O.734tThigh 11.4± 5.1 6.0± 2.1 0.871tCalf 8.9 ±3.8 5.1 ± 1.8 0.763t

lated significantly (p < 0.0001) at all sites.The measurements from the caliper and ul-trasonic techniques taken over the triceps,waist, and thigh sites correlated more highlythan those taken over the other sites.

Compression generally ranged between 10and 40% for fat thickness values recordedwith the caliper for each body site. Of theseven sites measured, the thigh, waist, andtriceps sites demonstrated the least amountof variance in percentage compression. The

data were examined to determine whetherthere was greater compressibility with in-creasing skinfold thickness. No consistenttrends were detected.

To determine which body sites, by tech-nique, were the most accurate in predictingtotal body fat, the subcutaneous fat thick-nesses obtained by caliper and ultrasound ateach site were individually compared withbody density derived from hydrostaticweighing (Table 4). All correlations werenegative and highly significant (p <0.0001).The caliper measurements of subcutaneousfat for most sites had slightly higher corre-lations with body density than with ultra-sound. Of the sites measured, the triceps,waist, and thigh sites demonstrated thestrongest correlations with body density, re-gardless of the measurement technique. Forthe caliper technique, the triceps site ap-peared to be the best single predictor of bodydensity (r = 0.749); for the ultrasonic tech-nique, the waist was the best single predictor(r = 0.736).

Two different procedures were used todevelop regression equations to predict bodydensity. First, forward stepwise multipleregression analysis was used with body den-sity as the dependent variable and subcuta-

TABLE 4Correlation coefficient (r) between body density andsubcutaneous fat thickness measured at seven bodysites with caliper and ultrasound

Site Caliper Ultrasound

Triceps -0.704Biceps -0.594Subscapula -0.543 �0.479*Waist -0.736SuprailiacThighCalf -0.59l -0.579

* p <0.0001.


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TABLE 5

Multiple regression equations#{176} r SEE Body fart (04)

x ± SD

0.779 0.0083 12.3 ±4.80.768 0.0085 12.2 ± 4.70.745 0.0088 12.1 ± 4.6

0.809 0.0078 12.4 ± 4.90.769 0.0085 12.3 ± 4.70.762 0.0086 12.3 ± 4.7

* Key to variables in equations: I = triceps; 2 = waist; 3 = thigh.

t Calculated from Siri’s formula using predicted body density value. Mean body fat calculated from Siri’sformula using body density derived from hydrostatic weighing equals 12.7% (SD ± 5.8%).


neous fat thickness at each of the seven sitesas the independent variable. For both thecaliper and ultrasonic techniques, there wasa small improvement in the correlation coef-ficient values with the inclusion of a secondbody site in the equation. Using three ormore body sites did not significantly increasethe accuracy of the prediction of body den-sity over the use of two sites. Therefore, itappears that values of subcutaneous fat attwo body sites are adequate for the predic-tion of body density.

In this study of relatively lean, healthymen, the two skinfolds among the sevenmeasured that provided the best predictionof body density were the triceps and waist.The multiple correlation using these twosites together was r = 0.779 and the unbiasedstandard error of estimate (SEE) was 0.0083(Table 5). Ultrasonic measurements of sub-cutaneous fat at the waist and thigh sitesgave the best prediction of body density. Themultiple correlation using two sites simul-taneously was r = 0.809 and the SEE =

0.0078 (Table 5). Thus, the best predictionfor the ultrasonic technique was slightly bet-ter than that of the best prediction for thecaliper technique, as indicated by the slightlyhigher r value and slightly lower SEE value.

The data were subsequently analyzedusing the SAS General Linear Models Pro-cedure, with body density serving as thedependent variable and subcutaneous fatthickness at two designated sites as the in-dependent variables. The sites selected forthis model were the triceps, waist, and thigh

because they individually demonstratedstrong correlations with body density. Theformulas for prediction of body density fromthe various two-site combinations alongwith their r and SEE values are presented inTable 5.

The mean values for percentage body fatgenerated from the formulas using calipermeasurements are not significantly differentfrom those derived from ultrasound meas-urements. Correlation coefficients were cal-culated to evaluate the relationship betweenthe predicted density values by measure-ment technique for each two-site combina-tion. The correlations were r = 0.869 fortriceps-waist sites, r = 0.800 for thigh-waistsites, and r = 0.864 for thigh-triceps sites.These findings suggest that the predictiveaccuracy of the six formulas is very similar.

Discussion

The mean percentage body fat calculatedfrom Siri’s formula using densitometricallyderived body density was compared to pre-viously reported mean values for men ofsimilar ages. The mean of 12.7% body fat inthe present study was less than the meanvalues of 15.0, 14.6, and 13.4% reported byDurnin and Womersley (18), Wilmore andBehnke (19), and Pollock et al (14), respec-tively, but exceeded the mean value of10.3% reported by Sloan (20). These incon-sistencies may be associated with the overallstate of physical fitness of the subjects rep-resented in the various study samples.

Multiple regression equations for prediction of body density (Db)using caliper or ultrasonic measurementsof subcutaneous fat

A. Caliper measurements (mm) = X

Db = 1.09651 - 0.00165(X,) - 0.00061 (X2)Db = 1.09656 - 0.00091 (X2) - 0.00102 (X3)Db = 1.09492 -0.00200(X1) - 0.00041 (X3)

B. Ultrasonic Measurements (mm) = Y

Db = 1.10377 - 0.00163(Y2) - 0.00273(Y3)Db = 1.09832 - 0.00179(Y) - 0.00164(Y2)Db = 1.09897 - 0.00 199 (Y1) - 0.00278 (Y3)


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Subcutaneous fat thickness measured bythe caliper technique had slightly higher cor-relations with body density when comparedwith the ultrasonic technique for five of theseven sites. Sloan (20) also found body den-sity to be more highly correlated with thecaliper technique than with ultrasound. Thecorrelation coefficient values reported bySloan for both techniques were somewhathigher than those reported here. Neverthe-less, in the present study, ultrasonic meas-urements showed good agreement with cal-iper measurements. For the triceps site, thecorrelation between these two techniques (r= 0.807) was higher than that observed byHaymes et al (r = 0.64) (6) but similar tothat reported by Bullen et al (r = 0.80) (10).

The mean subcutaneous fat thicknessesmeasured by ultrasound were greater thanone-half of the mean caliper values, indicat-ing a compression effect. The appropriate-ness of skinfold measurements in the assess-ment of nutritional status needs further in-vestigation if the caliper technique is shownto significantly underestimate actual fatthickness. For this sample of white men, thevariation in compression over the triceps,waist, and thigh sites did not appear to be asource of error in the prediction of bodydensity. However, this may not be true forother populations. Therefore, more researchis needed to determine the extent to whichskinfold compression makes an appreciabledifference in estimating body fat in samplesof nonlean individuals.

The multiple correlation coefficients forcaliper measurements from two body siteswith body density compared favorably withthose from other studies. Similar body den-sity predictions were obtained by using anyone of the three possible skinfold combina-tions presented in Table 5. Previous studieshave reported the following combinations toyield the highest multiple correlation coef-ficients: thigh and abdomen (18), thigh andchest (14), and thigh and subscapula (20). Itshould be noted that all of these combina-tions include an extremity and trunk site. Ithas been suggested that such combinationsare good predictors of anatomical fat distri-bution which may be an important diagnos-tic determinant of one’s susceptibility tochronic diseases (21). Even more interesting

is the absence of the triceps site from thesecombinations, recalling that the triceps siteis continually reported to be the best singlepredictor of body density and overall adi-posity (16, 22).

The regression equation derived in thisstudy using the ultrasonic measurements ofsubcutaneous fat at the thigh and waist sitespredicted body density as accurately asSloan’s equation using ultrasonic measure-ments at the suprailiac and thigh sites (20).This is evidenced by the almost identicalmultiple correlation coefficients, that is r =

0.809 in this report and r = 0.805 reportedby Sloan. The equation derived in the pres-ent study was cross-validated on the datafrom men examined by Sloan. This equationyielded the same value for body density thatSloan had obtained by hydrostatic weighing.This was expected since the ages and physi-cal characteristics of Sloan’s population weresimilar to that of the present sample. There-fore, it appears that the formula developedfrom this research may be used interchange-ably with Sloan’s equation for other samplesof white men, aged 18 to 30 yr, with bodydensity values ranging between 1.03 and1.10 g/ml. Other studies involving differentsamples of subjects are encouraged andneeded to test the formula’s general applic-ability.

The results of this study differ from thoseof Borkan et a! (23) who found the Langeskinfold caliper to be more effective thanultrasound in assessing subcutaneous fat. Apartial explanation may be that the BodyComposition Meter used by Borkan et alwas relatively less sensitive than the ADRReal Time Ultrasonic Scanner used in thisstudy. The readout from the Body Compo-sition Meter uses a series of light-emittingdiodes spaced at 1-mm increments. In the-ory, a single diode should appear at eachinterface. However, it has been found thatin practice many diodes may be lit at oncewhich introduces measurement errors anduncertainties (Fanelli M, unpublished obser-vations). Future development of ultrasonicdevices should include a design that helpsthe user to more easily identify the wavereflected from a tissue interface. A display-screen such as that found on the ADR scan-ner helps minimize measurement error be-


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cause it enables the investigator to identifyvisually these tissue interfaces. With regardto near field chatter with ultrasound, a re-cent communication suggests that much ofthese near field effects has been eliminatedthrough advances in electronic design (24).

The findings from this study suggest thatthe caliper and ultrasonic techniques areequally effective in predicting body densityand, hence, total body fat of lean men. Bothtechniques can be performed with minimalinconvenience to the subjects. In addition toits ability to assess subcutaneous fat tissue,the ultrasonic method permits direct meas-urements of muscle tissue. Furthermore,permanent records of underlying fat andmuscle thicknesses can be obtained withultrasonic scanners equipped with cameraattachments. The ability to monitor anddocument changes in fat and muscle tissueswould enable clinicians to assess, and thenif necessary, modify diet and nutritional sup-port of patients. Reviewing these pictorialrecords with patients may well improve theircompliance with prescribed therapy. fl

The authors thank Joy Wood for her assistance withthe computer programming of statistical analyses, Dr.Robert McMurray of the UNC Exercise PhysiologyDepartment for use of his laboratory facilities, and theADR Ultrasound Company for the loan of its equip-ment.

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2. Booth RAD, Goddard BA, Patton A. Measurementof fat thickness in man: a comparison of ultra-sound, Harpenden calipers and electrical conduc-tivity. Br J Nutr I 966;20:7 19-25.

3. Himes JH, Roche AF, Siervogel RM. Compressi-bility of skinfolds and the measurement of subcu-taneous fatness. Am J Clin Nutr 1979;32:l734-40.

4. Garrow is. New approaches to body composition.Am J Clin Nutr l982;35:1 152-8.

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6. Haymes EM, Lundergren HM, LoomisiL, BuskirkER. Validity of the ultrasonic technique as a

method of measuring subcutaneous adipose tissue.Ann Hum Biol l976;3:245-5l.

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8. Sanchez CL, Jacobson HN. Anthropometry meas-urements, a new type. Am J Clin Nutr1978;3l:1 116-17.

9. Whittingham PDGV. Measurement of tissue thick-ness by ultrasound. Aerospace Med I 962;33: 1121-7.

10. Bullen BA, Quaade F, Olesen F, Lund SA. Ultra-sonic reflections used for measuring subcutaneousfat in humans. Hum Biol l965;37:375-84.

11. National Center for Health Statistics. HANES II.Examination staff procedures manual for the healthand examination survey, 1976-1979. Rockville,MD: National Center for Health Statistics, 1976.

12. Donald I, Brown TG. Demonstration of tissueinterfaces within the body by ultrasonic echosounding. Br i Radiol 1961 ;34:539-50.

13. ADR Real Time Ultrasound Scanner, model 2130,operator’s manual. Tempe, AZ: ADR Ultrasound,1978.

14. Pollock ML, Hickman T, Kendrick Z, Jackson A,Linnerud AC, Dawson G. Prediction of body den-sity in young and middle-aged men. J AppI Physioll976;40:300-4.

15. Goldman RF, Buskirk ER. Body volume measure-ment by underwater weighing: description of amethod. In: Brozek I, Henschel A, eds. Techniquesfor measuring body composition. Washington, DC:National Academy of Science, 196 1:78-89.

16. Lohman TF. Skinfold and body density and theirrelation to body fatness: a review. Huth Biol198 l;53: 18 1-225.

17. Ray AA, ed. SAS’s user’s guide: Statistics. 1982 ed.Cary, NC: SAS Institute Inc. 1982.

18. Durnin JVGA, Womersley J. Body fat assessedfrom total body density and its estimation fromskinfold thickness: measurements on 481 men andwomen aged 16 to 72 years. Br J Nutr l974;32:77-97.

19. Wilmore JH, Behnke AR. An anthropometric es-timation of body density and lean body weight inyoung men. J AppI Physiol l969;27:25-3 1.

20. Sloan AW. Estimation of body fat in young men.i AppI Physiol l967;23:3l 1-15.

21. Mueller WH, Stallones L. Anatomical distributionof subcutaneous fat: skinfold site choice and con-struction of indices. Hum Biol 198l;53:32l-35.

22. Seltzer CC, Mayer J. Greater reliability of the tri-ceps skinfold over the subscapular skinfold as anindex of obesity. Am J Clin Nutr 1967;20:950-3.

23. Borkan GA, Hults DE, Cardarelli i, Burrows BA.Comparison of ultrasound and skinfold measure-ments in assessment of subcutaneous and totalfatness. Am J Phys Anthropol l982;58:307-l3.

24. Toyokawa H, Kimura N, Marui E. Validity inidentification of the target wave at thigh. Jap JPublic Health (in press).


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