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4 Health-Related Fitness Measures for Youth: Body Composition KEY MESSAGES Body composition is a physiologic characteristic that affects an indi- vidual's ability to carry out daily tasks with vigor. Although body com- position is not a demonstrative action like other health-related fitness components, the committee has operationally defined it as a component of fitness, a health marker, and a modifier of fitness for the purposes of this report. Both body weight (mass) and body fat (absolute fatness and relative fat distribution) are elements of body composition that have implications for health and fitness. It is important to measure weight and height in national youth fitness surveys to derive body mass index (BMI), an indicator of weight-for-height; waist circumference, an indicator of abdominal adiposity; and skinfolds, an indicator of subcutaneous adipose tissue. These three recommended field indicators of body composition for a national youth fitness survey uniquely measure different elements, and each can be linked to health markers and outcomes in both youth and adults. For example, A high BMI is related to the risk of type 2 diabetes and hypertension. Waist circumference is linked to risk factors for cardiovascular dis- ease, type 2 diabetes, and all-cause mortality. Elevated skinfold thicknesses and proportionally more subcutaneous fat on the trunk are associated with an elevated risk for cardiovascu- lar disease and metabolic syndrome. 79

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80 FITNESS MEASURES AND HEALTH OUTCOMES IN YOUTH Only standing height and weight should be measured in school and other educational settings to calculate BMI given such concerns as measurement errors and privacy. Two approaches to interpreting the results of the above three mea- sures are recommended to determine whether individuals or popula- tions are at risk of poor health outcomes. For BMI, the cut-points (cutoff scores) based on the 2000 Centers for Disease Control and Prevention (CDC) growth charts and percentiles should be applied for underweight, overweight, and obesity evaluations. Interim cut-points for waist circum- ference and skinfold measures should be set at levels analogous to those currently being applied by the CDC for BMI. This approach should be used until evidence becomes available to support establishing waist circumference and skinfold cut-points by associating those measures with cardiometabolic risk factors. B ody weight (mass) and body fat distribution are elements of body composition that have implications for health and fitness. No element on its own adequately and comprehensively describes an individual's body composition, and each element has been linked with various health markers and outcomes in youth. Measures of body composition have been used in the past as a compo- nent of fitness test batteries (see Table 2-6 in Chapter 2). The background paper for the Second International Consensus Symposium on Physical Activity, Fitness and Health in 1992 offered an outline of "components and factors of health-related fitness" (Bouchard and Shephard, 1994; Bouchard et al., 2007) in which body composition was included as a morphological component of health-related fitness. In a review of existing fitness tests, 10 of 15 physical fitness test batteries for children and adolescents included body composition as a component of health-related fitness (Artero et al., 2011; Castro-Piero et al., 2010), but the supporting evidence for their inclusion was quite variable. Body composition differs from the other fitness components reviewed in this report at various levels. First, there are different perspectives on whether body composition should be considered a component of fitness. The committee considered body composition to be a physiologic character- istic that affects an individual's ability to carry out daily tasks with vigor and to be influenced by physical activity behavior. Second, body composi- tion influences performance on many fitness tests and itself is also an indica- tor of health. The committee thus defined body composition operationally as a component of fitness, a marker of health, and a modifier of fitness,

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BODY COMPOSITION 81 for the purposes of this report. Finally, the relationships between body composition, in particular percent body fat, and health outcomes are well established in both youth and adults. Thus, the committee did not collect evidence on the relationship between any body composition field measures and health outcomes. The committee identified appropriate measures of body composition by selecting field-based items that were valid, reliable, and feasible for implementation in either a national survey or a school or other educational setting. This chapter provides an overview of the existing measures of body composition and presents the committee's conclusions about the best mea- sures of body composition based on their relationship to health in youth, as well as their integrity and feasibility. The committee's full recommenda- tions for measuring body composition in a national fitness survey and in schools and other educational settings can be found in Chapters 8 and 9, respectively. MEASUREMENT OF BODY COMPOSITION Body weight is a gross measure of the mass of the body. The partition- ing and quantification of mass into its basic elements has been a major focus of study historically and has accelerated with the refinement of models (Wang et al., 1992, 2005) and the development of technology (Ackland et al., 2012; Heymsfield et al., 2005; Roche et al., 1996). A variety of models and methods--developed largely in adults--have been used to partition body mass into several elements: fat-free mass, fat mass, total body water, fat-free dry mass, and bone mineral. As assessment techniques have become refined, models have evolved from those including the traditional two ele- ments (body mass = fat-free mass + fat mass) to those including three, four, or five elements (Wang et al., 1992, 2005), with fat mass--or adipose tissue as it is labeled in anatomical models--being basic to all models. Body composition can be approached at several levels: atomic, molecu- lar, cellular, tissue, and whole body (Wang et al., 1992, 1995). The technol- ogy for measuring specific elements of body mass at each level and factors influencing body composition have been summarized (Heymsfield et al., 2005; Roche et al., 1996). While no single criterion measure of body com- position is universally accepted as the gold standard (Ackland et al., 2012), laboratory measures (e.g., underwater weight, body potassium, total body water, and dual-energy X-ray absorptiometry [DXA]) are considered the most accurate techniques. DXA provides measures of bone mineral and of fat and lean tissues. The other three laboratory measures have major limitations. Underwater weighing is used to estimate body density, which is then converted to percentage body fat; total body potassium and total body water provide measures of fat-free mass. Quite often, the laboratory

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82 FITNESS MEASURES AND HEALTH OUTCOMES IN YOUTH measures are used together (especially underwater weighing, total body water, and a measure of bone mineral) to provide an estimate of body composition, depending on the model selected (see, e.g., Gutin et al., 1996). Several additional laboratory techniques, as well as field measurements available for estimating body composition in youth in various settings (e.g., research, education/practice, clinical), have been reviewed extensively by others (Heymsfield et al., 2005; Roche et al., 1996). Critical evaluation of body composition methodology at each level of analysis (Wang et al., 1992, 1995) is beyond the scope of this report. Further, while laboratory methods--such as DXA, hydrostatic weighing, ultrasound, densitometry, and air displacement plethysmography (e.g., Bod Pod)--have many advantages (such as more specific measurements and reduced measurement variation, measurement of the whole body, minimal subject burden, and relative ease of administration), they typically require highly specific training and special and expensive equipment. Some of the equipment also lacks the mobility that may be necessary to access large samples of youth. Overall, the measurement of body composition is dependent on the question being addressed, the information necessary, and the applica- tion of the assessment protocols (Ackland et al., 2012). For example, techniques used for collecting data to track the health status of a given population epidemiologically will likely differ from those used to collect data to achieve advances in sports performance. Also, many laboratory methods are not feasible for use in the field because of limitations cited earlier. Direct evaluation of body composition (i.e., DXA measure of adiposity) is not the same as indirect and associated proximity measures of body composition. Body mass index (BMI) is used for classification of weight status (underweight, normal, overweight, obese), although it does not accurately predict percent body fat (Moreno et al., 2006). Accordingly, the selection of body composition measures depends on what element is of interest, which in turn depends on the question(s) being asked. Given the desirability of a comprehensive understanding of an individual's body composition, as well as considerations of feasibility in practice settings such as schools, the committee focused its review on low-cost field-based measures of body composition. Laboratory measures, such as DXA, may be appropriate for some national surveys, like the National Health and Nutrition Examination Survey (NHANES), for which the equipment is transported in a trailer and only a small sample of youth is studied. For large national surveys in which youth are tested nationwide in a school setting, however, field-based measures are more suitable than laboratory measures. Field-based measures include anthropometry (skinfolds, weight, height [weight-for-height in the form of BMI], waist circumference) and bioelectric impedance analysis

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BODY COMPOSITION 83 (BIA). These measures were selected based on their relationship to health markers, their integrity and reliability, and their previous use. Skinfolds provide an indication of subcutaneous fat at specifically defined measurement sites. Skinfolds can also be used to predict percent body fat. They can be expressed as a sum of skinfolds (overall subcutaneous fat) and as a ratio of trunk to extremity skinfolds (relative subcutaneous fat distribution). BMI (kg/m2) is an indicator of weight-for-height. It is used inter- nationally in public health and nutrition surveys to monitor weight status, specifically overweight and obesity. At the extremes of heaviness, BMI is probably a reasonable indicator of fatness in the general population. Waist circumference increasingly is used as an indicator of central or abdominal adiposity rather than percent body fat, which can vary greatly among individuals with a similar BMI. Located in the abdominal region, abdominal fat is composed of three elements: visceral, retroperitoneal, and subcutaneous. BIA provides a measure of resistance or impedance; some BIA systems are calibrated directly to fat-free mass (or fat). Some other systems provide a measure of total body water that is then trans- formed to an estimate of fat-free mass. The equation for converting resistance to total body weight usually includes height. Algorithms used in estimating body composition with BIA with commercially available units are considered proprietary information, which is a major shortcoming. Moreover, it has been suggested that equa- tions provided by manufacturers may not be suitable for estimating body composition in youth of different racial/ethnic backgrounds (Haroun et al., 2010). Given its shortcomings and the abundant evidence on the effectiveness of other field-based measures, the committee did not explore BIA further. However, if shortcomings due to proprietary equations were resolved and the algorithms accounted for changes in the composition of fat-free mass dur- ing childhood and adolescence, for sex differences, and for racial/ ethnic variations in body composition, BIA might be considered a useful measure of body composition in youth, particularly given its ease of administration. LITERATURE REVIEW PROCESS As noted earlier, the fact that body composition is a measure of health is well established. Also well established is that percent body fat is related to health outcomes and that there are various tests with which to measure

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84 FITNESS MEASURES AND HEALTH OUTCOMES IN YOUTH percent body fat, subcutaneous fat, or abdominal adiposity. Therefore, the Centers for Disease Control and Prevention's (CDC's) literature review, described in Chapter 3, did not include body composition as a fitness com- ponent; the CDC review, however, included articles in which body compo- sition appeared as a modifier of fitness or as a health marker or both. For this reason, the committee considered each such article for inclusion in its review, and this chapter includes findings from selected studies from the CDC review, as well as others, in which body composition was considered as a fitness component, a health marker, or a modifier of physical fitness. A body of literature from obesogenic intervention research was also reviewed. In addition, the committee reviewed validity and reliability data specific to field tests that measure various aspects of body composition. Further, articles on specific topics related to body composition (e.g., growth and maturation, race/ethnicity, and body composition and health) were identi- fied and chosen for inclusion in this chapter. BODY COMPOSITION IN YOUTH In addition to age, energy intake, and other factors, individual differ- ences in biological maturation, gender, and race/ethnicity affect elements of body composition such as fat mass and fat-free mass, subcutaneous fat, and fat distribution. The following discussion is based on trends described in Malina (1996, 2005) and Malina et al. (2004). Variation in Body Composition with Age, Gender, and Maturation Status Fat-free mass, fatness, and relative fat distribution in late childhood and adolescence (approximate school ages) vary with age, between genders, and among individuals of contrasting maturation status. Age- and gender- related changes are discussed in the subsections that follow. Variation associated with maturation status is then briefly considered. Fat-Free Mass The principles underlying several methods for estimating body compo- sition warrant special consideration when applied to growing and matur- ing youth. It is important to determine when mature (adult) levels of the primary elements of fat-free mass are reached. This relates to the concept of chemical maturity, defined by Moulton (1923, p. 80): "The point at which the concentration of water, proteins, and salts [minerals] becomes comparatively constant in the fat-free cell is named the point of chemical maturity of the cell." Chemical maturity of fat-free mass is not attained until after the adolescent growth spurt, probably about ages 16-18 in girls

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BODY COMPOSITION 85 and 18-20 in boys (Lohman, 1981, 1986; Malina, 2005; Wells et al., 2010). When adult values of its primary components are reached, fat-free mass is chemically mature. On average, fat-free mass has a growth pattern like that of stature and body mass. Differences over time until chemical maturity is reached reflect a larger fat-free mass, specifically bone mineral content and skeletal muscle mass in males. That is, the relative contribution of water to body mass decreases while the relative contributions of solids--protein, mineral, and fat--increase during approximately the first two decades of life, which are dominated by the biological activities of growth and maturation. Sex differences are apparent during the adolescent growth spurt. On average, fat-free mass in males contains relatively less water and more protein and mineral compared with that in females from childhood into young adult- hood (Malina et al., 2004). Density of fat-free mass is also greater in males, which reflects primarily sex differences in skeletal muscle mass and bone mineral. These are only average trends, and it should be noted that there are variations among individuals and with biological maturation (status and timing). Although efforts continue to derive more accurate estimates of the chemical composition of fat-free mass, three points should be noted: (1) the composition of fat-free mass changes during growth and maturation, (2) variation among individuals is considerable, and (3) chemical maturity is not attained until late adolescence or young adulthood. Ideally, equa- tions and constants used to estimate body composition should be adjusted for the chemical immaturity of the fat-free mass in growing and maturing individuals. Fat Mass Fat mass increases more rapidly in girls than in boys during childhood and continues to increase through adolescence in girls (Malina, 2000). Fat mass appears to reach a plateau, or to change only slightly, near the time of the adolescent spurt in boys (around age 13-15) (Malina, 2000). Fat mass as a percentage of body mass (percent body fat) increases gradually during childhood, and sex differences are small. Percent body fat increases through adolescence in girls; it increases into early adolescence in boys and then declines. The decline during male adolescence is a function of the ado- lescent spurt in fat-free mass, more specifically muscle mass. Sex differences in body composition are negligible in childhood, and are established dur- ing the adolescent spurt and sexual maturation (Malina, 2000). Although estimated fat mass is similar in male and female adolescents, females have greater percent body fat.

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86 FITNESS MEASURES AND HEALTH OUTCOMES IN YOUTH Weight-for-Height BMI, as a measure of weight-for-height, declines from infancy through early childhood and reaches its lowest point at about age 5-6. It then increases linearly with age through childhood and adolescence and into adulthood. Sex differences in BMI are small during childhood, rise dur- ing adolescence, and persist into adulthood (Malina et al., 2004). The rise in BMI after it reaches a nadir at age 5-6 has been labeled the "adiposity rebound" (Rolland-Cachera et al., 1984). It has been suggested that indi- viduals who have an early adiposity rebound have an increased probability of being overweight in late adolescence and young adulthood (Rolland- Cachera et al., 1984). The concept of adiposity rebound needs further study. In the context of body composition, there is a need to document specific changes in body composition during the rebound. Does it reflect an increase in fat mass or an increase in fat-free mass? Some evidence suggests the latter (Katzmarzyk et al., 2012). Subcutaneous Fat A skinfold thickness is a double fold of skin and underlying soft tis- sues, primarily adipose tissue. Two commonly used skinfolds are the triceps and subscapular. The former increases with age from childhood through adolescence in females, whereas it decreases during the adolescent spurt in males (Malina, 2000). On the other hand, the latter increases from child- hood through adolescence in both sexes. As a result, the adolescent sex difference in the triceps skinfold is marked compared with the relatively small difference in the subscapular skinfold. Any number of skinfolds can be and have been measured. Changes in individual skinfolds are variable during growth and specifically relative to the timing of peak height velocity, more so in boys than in girls (Malina et al., 1999). Such variation may influence age-associated trends. Relative Fat Distribution Fat distribution refers to regional variation in the accumulation of adipose tissue in the body. With advances in technology (computed tomog- raphy [CT] scans, magnetic resonance imaging [MRI]), attention shifted to abdominal fatness, specifically visceral versus subcutaneous. With wide- spread availability of DXA, trunk and extremity distribution of adipose tissue also has received more attention (Malina, 1996, 2005). Ratios of skinfolds measured on the trunk to those measured on the extremities are commonly used to estimate relative subcutaneous fat distribution. Ratios of trunk to extremity skinfold thicknesses increase gradually through child-

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BODY COMPOSITION 87 hood in both sexes, and there is no sex difference in the ratios. Subse- quently, ratios tend to be rather stable in females but to increase in males through adolescence. Males accumulate proportionally more subcutaneous fat on the trunk than the extremities, while females accumulate relatively similar amounts on both the trunk and extremities (Malina, 1996; Malina and Bouchard, 1988). Ratios of trunk to extremity adiposity based on DXA show similar trends (He et al., 2004; Taylor et al., 2010). Ratios of abdominal visceral and subcutaneous adiposity show small differences with age and sex from childhood into early adolescence in normal-weight youth, but males have proportionally more visceral adiposity in later adolescence. A similar trend associated with age and sex is not clearly apparent in over- weight/obese youth (Katzmarzyk et al., 2012). Maturity-Associated Variation Children and adolescents advanced in maturity status compared with their chronological-age peers tend to be fatter and to have proportionally more subcutaneous fat on the trunk (Malina and Bouchard, 1988; Malina et al., 2004). The maturity-associated trend also continues into young adulthood (Beunen et al., 1994a; Kindblom et al., 2006; Labayen et al., 2009; Sandhu et al., 2006). Samples in studies using DXA, CT scans, and MRI generally involve several age groups, so that it is difficult to clearly specify maturity differences in each gender. Stage of puberty (clinically and/or self-assessed) is often described, but not systematically analyzed. When it is described, youth typically are grouped by pubertal stage or stages so that several ages are represented within a group (Katzmarzyk et al., 2012). Variation in Body Composition with Race/Ethnicity The pattern of gender- and maturity-related differences is similar in all racial/ethnic groups. African Americans have greater total bone mineral content during childhood, adolescence, and adulthood than whites. Com- parisons between Mexican Americans and whites show small differences in fat-free mass and bone mineral content, although Mexican Americans tend to have greater adiposity. Data for skinfolds indicate proportionally more subcutaneous adipose tissue on the trunk in African Americans, Mexican Americans, and Asian Americans compared with whites. In contrast, data on the distribution of visceral and subcutaneous adiposity overlap among ethnic groups. Unfortunately, the available data often combine multiple age groups and in some instances combine males and females and/or youth of different ethnic groups (Katzmarzyk et al., 2012; Malina, 2005).

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88 FITNESS MEASURES AND HEALTH OUTCOMES IN YOUTH BODY COMPOSITION, FITNESS, AND HEALTH IN YOUTH This section considers body composition as both a modifier of physical fitness and a health marker. Body Composition as a Modifier of Physical Fitness Body composition is one of many factors that influence performance on laboratory- and field-based tests of physical fitness. Fat-free mass and its major tissue component, skeletal muscle mass (force-generating tissue of the body), obviously are important to performance on many tests. Absolute fat-free mass is significant in tests requiring the projection of objects (e.g., overhead medicine ball throw) and a variety of strength tests. Fat-free mass also is highly correlated with height in children and adolescents. Fat mass and percent body fat are more variable, but excess fatness (absolute and relative) tends to exert a negative influence on performances on fitness tests that require movement or projection of the body through space (i.e., runs and jumps) as opposed to projection of objects, as well as on endurance tests on cycle ergometers (Boileau and Lohman, 1977; Houtkooper and Going, 1994; Malina, 1975, 1992). Two studies of national samples of Belgian youth considered relation- ships between the sum of skinfolds (four in boys, five in girls) and a variety of fitness tests (Beunen et al., 1983; Malina et al., 1995). Among males aged 12-20, partial correlations (controlling for height and body mass) and sev- eral relevant fitness test items (static arm pull strength, sit-and-reach, vertical jump, left lifts, flexed arm hang, agility) were negative and low to moderate, 0.13 to 0.40. Corresponding partial correlations in girls aged 7-17 ranged from 0.08 to 0.42 (Physical Working Capacity-170 [PWC-170], step test recovery, arm pull strength, sit-and-reach, sit-ups, leg lifts, flexed arm hang, standing long jump, vertical jump agility). Comparison of the fattest and leanest 5 percent of participants highlighted the negative influence of exces- sive subcutaneous fatness for all fitness test items except sit-and-reach, arm pull strength, and PWC-170. Differences in flexibility were negligible. The fattest were absolutely stronger (boys and girls) and generated more watts (girls only), reflecting their larger body size. The fattest youth of both sexes also were advanced in skeletal maturation compared with their leanest peers of the same age groups (Beunen et al., 1982, 1994b). Trends were generally similar in more recent samples of normal-weight and obese youth. For example, sum of skinfolds was inversely related to schoolchildren's performance on the progressive aerobic cardiovascular endurance run (PACER), push-up, and curl-up tests (r = 0.30 to 0.49) (Lloyd et al., 2003). Low levels of cardiorespiratory endurance were asso- ciated with percent body fat in African American and white adolescents

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BODY COMPOSITION 89 (Gutin et al., 2005); with visceral and subcutaneous abdominal fat and waist circumference in African American and white youth aged 8-17, con- trolling for age, sex, pubertal status, and BMI (Lee and Arslanian, 2007); with percent body fat, percent abdominal fat, and waist circumference in 8-year-old boys and girls (Stigman et al., 2009); and with BMI, skinfolds, and predicted percent body fat in obese children of both sexes aged 6-13 (Nassis et al., 2005). Studies evaluating the relationship between BMI and fitness tests gener- ally have focused on the negative influence of obesity (Chatrath et al., 2002; Deforche et al., 2003; Kim et al., 2005; Mota et al., 2006; Stratton et al., 2007) or BMI as a covariate of aerobic fitness (Beets and Pitetti, 2004; Beets et al., 2005). Youth aged 5-14 classified as "underfit" (based on pass-fail scores on five fitness tests) were at greater risk of obesity (Kim et al., 2005). Correlations between BMI and indicators of fitness tended to be linear in well- and undernourished children aged 6-14 (Malina et al., 1998), but were curvilinear in youth aged 12-15 (Bovet et al., 2007) and young adults (Sekulic et al., 2005; Welon et al., 1988). A recent study with a representa- tive sample of Brazilian youth showed that, after adjusting for potential confounding factors, weight and BMI were negatively correlated with per- formance on the long jump, curl-up, pull-up, 9-minute run, 20-meter run, and 4-meter shuttle run (Dumith et al., 2012). Data on variations in fitness across the broad spectrum of BMI within relatively narrow age groups are limited. Relationships between BMI and fitness varied among fitness test items in four age groups--9-10, 11-12, 13-15, and 16-18--in a national sample of Taiwanese youth (Huang and Malina, 2010). Correlations were low to moderate and did not vary among age groups or between sexes. They were highest for a distance run/walk (800/1,600 meters, 0.17 to 0.34) and lowest for the sit-and-reach (0.04 to 0.12). For sit-ups and the standing long jump, however, correlations were higher for boys than for girls (r = 0.15 to 0.23 versus 0.10 to 0.14 and 0.22 to 0.27 versus 0.12 to 0.17, respectively). In a national sample of Taiwanese youth (Huang and Malina, 2010), sex-specific regressions of fitness items on BMI, using a nonlinear quadratic model, indicated differential effects for individual tests, which varied with age and sex. Relationships for the sit-and-reach were similar and slightly curvilinear in girls aged 9-10 and boys aged 9-12, but were parabolic among girls aged 11-18 and boys aged 13-18. Peaks of the parabola were sharper in adolescent boys than in adolescent girls. Youth of both sexes aged 1318 with either higher or especially lower BMIs had the poorest flexibility. Relationships for sit-ups were similar in girls and boys aged 9-12. Above ~20 kg/m2 in girls and ~18 kg/m2 in boys, sit-ups declined with increasing BMI. The decline was initially slight but accelerated with increasing BMI, more so in girls. The relationship between BMI and performance on sit-ups was parabolic in

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100 FITNESS MEASURES AND HEALTH OUTCOMES IN YOUTH weight for the derivation of BMI, (2) waist circumference, and (3) triceps and subscapular skinfold thicknesses. Height also serves as an indicator of linear growth status. (See Annex 4-1 for common examples of measurement techniques.) The committee concluded that the above three measures of body com- position are important to collect in a national youth fitness survey for sev- eral reasons. First, each measure is a proximal estimation of body fat and has increased standard of error of over laboratory measures. Also, there is consensus that the measurement of body composition is multidimensional (Bouchard et al., 1994). Second, no single measure is considered the gold standard and representative of all body composition tenets for children of all morphologies: BMI is a marker of obesity, waist circumference is a marker of abdominal adiposity, and skinfold thicknesses are a measure of subcutaneous fat. The measures recommended have acceptable validity and reliability. To interpret the findings of body composition testing and determine whether individuals or populations are at risk of negative health out- comes, the committee recommends employing two approaches. For BMI, the CDC's current established cut-points for underweight, overweight, and obesity should be applied. Interim cut-points for the waist circumference and skinfold measures should be set at levels that are analogous to those currently being applied by the CDC for BMI. This approach should be used until the necessary evidence becomes available to support establishing waist circumference and skinfold cut-points by associating those measures with cardiometabolic risk factors. The committee's full recommendation for including body composition in a national youth fitness survey is presented in Chapter 8. When body composition is measured in schools and other educational settings, important concerns arise related to the measurement of waist cir- cumference and skinfolds. Therefore, the committee recommends that only BMI be used in these settings. A full description of considerations and the committee's recommendation for schools and other educational settings is included in Chapter 9.

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BODY COMPOSITION 101 ANNEX 4-1 MEASUREMENT OF BODY COMPOSITION QUALITY CONTROL AND TECHNIQUES Body composition measurements should be taken by trained individuals using established techniques. Error--the discrepancy between a measured value and its true quantity--is inherent in anthropometry. It can be ran- dom3 or systematic.4 Replicate measurements of the same subject are used to estimate vari- ability or error. Replicates on the same individual are taken independently by the same technician after a period of time has elapsed (intraobserver) or are taken on the same individual by two different technicians (interob- server). Replicate measurements provide an estimate of imprecision. The technical error of measurement is a widely used measure of replicability (Malina et al., 1973; Mueller and Martorell, 1988). Technical errors are reported in the units of the specific measurement. Intra- and interobserver technical errors for a variety of dimensions in national surveys and several more local studies are summarized by Malina (1995). Accuracy is another aspect of the measurement process. It refers to how closely measurements taken by one or several technicians approximate the "true" measurement. Accuracy ordinarily is assessed by comparing measurements taken by technicians with those obtained by a well-trained or "criterion" anthropometrist (the reference). Note, however, that well- trained, expert anthropometrists do make errors. The height, weight, waist circumference, and triceps and subscapular skinfold measurement techniques described below are provided as examples from the commonly used NHANES Anthropometry Procedures Manual.5 Stature and Weight Stature, or standing height, is the linear distance from the floor or standing surface to the top (vertex) of the skull. It is measured to the near- est millimeter with the subject in standard erect posture, without shoes. 3Random error is associated with variation within and among individuals in measure- ment technique, problems with the measuring instruments (e.g., variation in or even lack of calibration or random variation in manufacture), and errors in recording. Random error is nondirectional, i.e., above or below the true dimension. Random errors tend to cancel each other out in large-scale surveys and ordinarily are not a major concern. 4Systematic error results from the tendency of a technician or a measuring instrument to consistently under- or overmeasure a dimension. Such error is directional and introduces bias. Measurement variability also is associated with the individual (e.g., normal variation in physiology, temperament, cooperativeness, and stranger anxiety). 5Available at http://www.cdc.gov/nchs/data/nhanes/nhanes_07_08/manual_an.pdf (accessed May 10, 2012).

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102 FITNESS MEASURES AND HEALTH OUTCOMES IN YOUTH Body weight is a measure of body mass. It is measured to the nearest 100 grams (depending on the type of scale) with the individual attired in ordi- nary, light, indoor clothing without shoes (e.g., gym shorts and a t-shirt). It assumed that the scales would be calibrated regularly for a national survey. Height and weight are used to derive body mass index (BMI) (kg/m2). Waist Circumference The protocol for waist circumference calls for measuring just above the uppermost lateral border of the right illium after normal expiration. The level should be marked on the skin. When the tape is applied, it should make contact with the skin without indenting it. The measurement should not be made over clothing. Two individuals may be needed, especially for some overweight and obese individuals. Skinfolds A skinfold thickness is a double fold of skin and underlying soft tissue at a specific site. Skinfolds are measured to the nearest 0.5 mm (some cali- pers measure to the nearest millimeter, while others measure to the nearest 0.2 mm). Three measurements usually are taken for each skinfold (some protocols recommend two). Triceps skinfold is measured on the back of the arm (over the triceps muscle) at the level midway between the lateral border of the acromial process of the scapula (acromion) and the inferior border of the olecranon process of the ulna. With the arm flexed to 90 degrees at the elbow, the acromion is marked. A measuring tape is placed on the acromion (zero marker) and run down the lateral side of the upper arm. The distance mid- way between the acromion and the olecranon is marked and extended to the back of the arm. The skinfold is measured with the arm hanging relaxed (loosely) at the side by grasping a vertical fold about 1 cm above the mark, with the caliper being placed at the level of the mark. Subscapular skinfold is measured 1 cm below the tip (inferior angle) of the scapula. The measurement site should be marked on the skin. The skinfold should follow the natural anatomical (cleavage) lines of the skin. It is not a vertical fold like that taken over the triceps. REFERENCES Ackland, T. R., T. G. Lohman, J. Sundgot-Borgen, R. J. Maughan, N. L. Meyer, A. D. Stewart, and W. Muller. 2012. Current status of body composition assessment in sport review and position statement on behalf of the ad hoc research working group on body composition health and performance, under the auspices of the I.O.C. Medical Commission. Sports Medicine 42(3):227-249.

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