Frisancho

Triceps norms A. Roberto

skin fold and for assessment Frisancho,

Ph.D.3

ABSTRACT

derived

upper arm muscle size of nutritional status1’2

Basect

on a cross-sectional

from the United arm circumference

sample

of 12,396

States Ten-State Nutrition Survey and triceps skin fold are reported.

white

subjects

0 to 44 years, for right measurements for each

of 1968-1970,

aged

percentiles

defmed

by

the

age

of

amount of subcutaneous and protein reserve. characterized

13

years,

and

fat and degree However,

by

adulthood,

males

of muscularity

measurements

exceed

in children of

females

by

reflects

subcutaneous

about

56%.

the individual

fat

among

The

calorie

populations

by a low

degree of fatness may not be a sensitive indicator of nutritional status and growth. On the other hsnd, measurements of muscularity in children do serve as an adequate general index of nutritional status and growth in size. Am. J. Clin. Nutr. 27: 1052-1058, 1974.

the size of the muscle mass is an indicator of protein reserve, measurement of limb muscle size has been used currently to assess the nutritional status of children (1-3). These evaluations are usually made through comparison of the estimated upper arm muscle circumference of a given population against the “standard” (1). It must be noted, however, that this standard for muscle circumference for the ages of 1 to 60 months was calculated using the arm circumference of Polish children (reported in 1964) and the triceps skin folds of British children (reported in 1955 (4) and 1962 (5)). In the same manner, the muscle circumference for children 6 to 15 years was estimated from the arm circumference of British children (reported in 1955 (4, 5)) and the triceps skin folds of children in the United States obtained prior to World War II and reported in 1941 (6). It is quite evident that normative data derived through this procedure are not applicable in terms of time or population. Clearly, there is a crucial need for the development of more appropriate estimates of muscle size. Therefore, the purpose of this article is to provide estimates of upper arm muscle size derived Because

indirect

1052

TheAmerican

Journal

of Clinical Nutrition

from folds States.

the arm circumference of the white population

Materials

and triceps skin in the United

methods

and

Sample This study is based on a cross-sectional sample

of

5,637 males and 6,759 females aged 0 to 44 years, derived from the Ten-State Nutrition Survey of 1968-1970. This survey was probability sample of families viduals residing in the states Kentucky, ington,

Michigan, California,

New

based on a stratified and unrelated indiof Texas, Louisiana,

York,

Massachusetts,

West Virginia,

and

Wash-

South

Carolina.

The sampling families living

procedure included a large proportion of who, according to the 1960 census, were in low-income areas and a small proportion of

families

living

Although

the

‘From

ment,

in middleprimary

the

The

Center

for

and upper-income

areas (7).

interest

state

Human

University

of

Michigan 48104. 2Supported in part by with the Center for Disease

and

with

the

use

Survey

Human

Growth

Professor

of Anthropology.

each

Growth

and

Michigan, Contract Control,

of raw data

Nutrition

Ann

was

Develop-

Arbor,

HSM 21 72-522 Atlanta, Georgia,

from

the Ten-State

of 1968-1970.

Associate

27: OCTOBER

in

Scientist

and

1974,

pp.

Development

1052-1058.

of

the

and

Center for Associate

Printed in U.S.A.

Downloaded from www.ajcn.org by on May 19, 2009

upper From these individual, the arm muscle diameter, arm muscle circumference, and arm muscle area were calculated. Thereafter, age- and sex-specific percentiles for all three estimates of muscle size were obtained. The development of subcutaneous fat, as indicated by the triceps skin fold, in males is characterized by slow apposition, while in females, is continuous throughout childhood, adolescence, and adulthood. Sexual dimorphism in triceps skin fold is defined by the age of 3 years, and by adulthood, females exceed males by 83%. The muscle area in the upper arm during childhood exhibits considerable changes with age. Sexual dimorphism is

UPPER malnutrition

ARM

CIRCUMFERENCE

AND

among

Ten-State

the poor, the universe of the Survey does not include all of the groups within a state, nor is it restricted poor. Rather, the target population also

Nutrition

lower-income to only the

included middle- and upper-income individuals who, because of changes in residential patterns since 1960, were living in the selected areas when the survey was conducted (7). The mean sample included in this study

average income was $13,122.

for

the

TRICEPS

is more prevalent in males than in females may result in an overestimation of male muscle an

increasing

anthropometric of body

meaand

size

degree

as the

cross-sectional

(14),

it

area

to

configura-

tion approaches rectangularity. Third, the equations do not take into account variations in skin fold compressibility. Clegg and Kent (15) indicate that female triceps skin-fold compressibility is 4.8% greater than that of the male. In this study the average skin-fold was 7 mm and the maximum value was 21 According

skin-fold

The survey included standard surements for the assessment

1053

FOLDS

arm

mm. Measurements

SKIN

mation of

of female

3.1

to these data,

compressibility mm.

muscle

However,

the

could

result

circumference

the

estimates

of muscle

size

can

status. In this article, we report information for the upper arm circumference and triceps skin folds for the whole sample of whites who participated

be affected percentile)

in the Ten-State Nutrition Survey. 1) Upper arm circumference measured to the nearest millimeter

the skin-fold thickness is over 21 mm. Fourth, as the measurements of skin folds and upper arm circumference were taken by several technicians, the magnitude of the measurement error cannot be quantified.

nutritional

(millimeters) was with a steel tape

with the right arm hanging

relaxed.

was taken midway between and olecranon process.

the

Triceps

skin

fold

of the

(millimeters)

was

acromion

measured

of muscle

size

The following three estimates of muscle size were derived: 1) Arm muscle diameter (millimeters) was estimated

by

computation

Arm

muscle

(8-10)

as follows:

diameter (mm) arm circumference

=

(mm)

-

triceps

2) Arm

muscle

computation Arm

muscle

3) Arm as follows: Arm

size

(1,

circumference 2, 11)

(mm)

=

-ir

muscle area (mm2)

It must be noted in the upper arm

reasons.

First,

the

(mm)

was derived by

(mm)

arm circumference

area

fold

as follows:

circumference

muscle

skin

(mm2)

that

(triceps

the

are only circumference

skin fold)

was calculated (12, 13)

(arm

diameter2)

calculations approximations of muscle

because

skin-fold

compressibil-

to

the nearest tenth of a millimeter with a Lange Skin-fold Caliper having a pressure of 10 g/mm2 of contact surface area. The measurement was taken on the back of the arm and midway between the point of the acromion and olecranon process while the arm was hanging relaxed. Estimates

adequate comparisons ity increases when

upper levels (95th and may prevent

of muscle for does

four not

include an estimate of bone diameter, and any variation in humeral diameter is therefore not accountable. The deletion of humeral diameter in the calculation may result in an overestimation of male in relation to female values, as male humeri are on the average greater in diameter than those of the female, regardless of the nutritional status of the population. Second, the equations assume that the upper arm is cylindrical in form, an assumption subject to some inaccuracy. For example, because flattening of the

Results

and

Table

Arm

1 gives arm

upper

discussion

the

circumference

percentiles and

for triceps

the

mid-

skin

fold.

circumference

As shown by the 50th percentile values, the circumference between the age of 1 and 5 years increases approximately 11% in girls and 15% in boys. Between 6 and 13 years, the increase in boys is almost 32% and 34% in girls; between 14 and 30 years, males show an increase of 27%, whereas in females this equals only 13%. These data suggest that the arm circumference either during childhood (1 to 5 years) or adolescence is not independent of age as is currently assumed. Nevertheless, it must be noted that, for example, compared with height or weight during childhood, the arm circumference shows a small change. Therefore, as indicated by other investigators (1-3, 13, 16) evaluations of nutritional status based on arm circumference during childhood may not require an exact knowledge of age. arm

Triceps Boys triceps

skin fold at the age of 2 years skin fold of 10 mm

have (for

a median the 50th

percentile), which thereafter declines gradually, and at approximately the age of 8 years, reaches its lowest value (8 mm). After this age, they exhibit a slow increase, and by the age of 12 years, reach a peak of 11 mm. This is the

Downloaded from www.ajcn.org by on May 19, 2009

2)

The measurement tip

significantly at the of the distribution

greater female in an underestiby an average

1054

FRISANCHO

TABLE

1

Percentiles

whites

for

upper

arm

of the Ten-State

circumference

Nutrition

and

Survey

triceps

skin

folds

for

of 1968-1970 Triceps

Age group

0.0-0.4

17.5-24.4 24.5-34.4 34.5-44.4

0.3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 21 30 40

circumference

No.

5th

15th

41

113

120

140 177 210 208 262 264 309 301 287 315 294 294 266 207 179 166 142 545 679 616

128 141 144 143 146 151 154 161 165 170 177 184 186 198 202 217 230 250 260 259

137 147 150 150 155 159 162 168 174 180 186 194 198 211 220 232 238 264 280 280

152 157 161 165 169 172 176 185 190 200 208 216 230 243 253 262 275 292 310 312 Females

46

skin fold

percentiles,

percentiles,

mm

50th

85th

95th

5th

15th

Males 134

147

153

4

5

168 170 175 180 185 188 194 205 217 228 240 253 270 279 302 300 306 330 344 345

175 180 182 190 199 198 212 233 262 255 276 291 297 321 320 335 326 354 366 371

5 5 6 5 5 5 4 5 5 5 6 5 5 5 4 4 4 4 4 4

7 7 7 6 6 6 6 6 6 6 7 7 6 6 6 5 5 5 6 6

mm

50th

85th

95th

8

12

15

9 10 9 9 8 8 8 8 9 10 10 11 10 10 9 9 8 10 11 12

13

15

13

14

12 12 12 11 11 12 14 16 17 19 18 17 19 20 14 18 21 22

14 14 16 15 14 17 19 22 25 26 25 22 26 27 20 25 28 28

0.0-0.4

0.3

107

118

127

145

150

4

5

0.5-1.4

1

172

125

134

146

162

170

6

7

8 9

12 12

13 15

1.5-2.4 2.5-3.4

2 3

143 145 150 155 158 162 166 175 181 186 196 204 214 216 224 224 233 243 250

155 157 162 i69 170 178 183 192 203 210 220 230 240 245 249 250 260 275 286

171 169 176 185 187 199 207 222 236 251 256 270 284 281 286 291 297 324 340

6 6

7 7

10 10

13 12

15 14

4

136 137 145 149 148 153 158 166 170 173 185 186 201 205 211 207 215 230 232

180 176

3.5-4.4

172 163 215 233 259 273 270 284 276 268 267 229 184 197 187 142 836 1153 933

184

5

7

10

12

14

195 202 216 231 255 263 280 275 294 306 310 322 328 329 361 374

6 6 6 6 6 6 7 6 7 8 8 8

7 7 7 7 7 8 8 9 9 10 11 10 12 12 12 14

10 10 10 10 11 12 12 13 14 15 16 15 16 17 19 22

13 12 13 15 17 19 20 20 23 22 24 23 26 25 29 32

16 15 17 19 24 24 29 25 30 28 30 27 31 31 36 39

4.5-5.4 5.5-6.4 6.5-7.4 7.5-8.4 8.5-9.4 9.5-10.4 10.5-11.4 11.5-12.4 12.5-13.4 13.5-14.4 14.5-15.4 15.5-16.4 16.5-17.4 17.5-24.4 24.5-34.4 34.5-44.4

5 6 7 8 9 10 11 12 13 14 15 16 17 21 30 40

so-called preadolescent fat wave (1 7). After boys reach this age, the triceps skin fold declines until they are 17 years old, when they attain a low value of 8 mm. The median value for adults is only between 10 and 12 mm. In

.

9 9 9 10

contrast, females between 2 and 8 years remain stable. Thereafter, they show a rapid increase, reaching a median value of 16 mm by the age of 1 5 years, and during adulthood the median values are between 17 and 22 mm.

Downloaded from www.ajcn.org by on May 19, 2009

0.5-1.4 1.5-2.4 2.5-3.4 3.5-4.4 4.5-5.4 5.5-6.4 6.5-7.4 7.5-8.4 8.5-9.4 9.5-10.4 10.5-11.4 11.5-12.4 12.5-13.4 13.5-14.4 14.5-15.4 15.5-16.4 16.5-17.4

Age Midpoint, years

Arm

UPPER Muscle

ARM

CIRCUMFERENCE

AND

size

SKIN

FOLDS

1055

muscle area from age 1 to 12 years increases steadily. This trend, however, is not noticeable when the size of the muscle is expressed in terms of diameter and circumference. For example, between 1 and 5 years in boys and

Tables 2 and 3 give the percentiles for the diameter, circumference, and area of muscle, These data show that in both boys and girls, the TABLE 2 Percentiles for upper arm diameter whites of the Ten-State Nutrition

TRICEPS

and upper arm circumference for Survey of 1968-1970 Arm

muscle

circumfer

diameter

percentiles,

mm

5th

15th

50th

85th

0.3

26

30

34

40

42

81

1

32

34

39

44

46

100

2 3 4 5 6 7

35 36 38 39 40 41

37 38 39 41 43 43

40 42 43 45 47 48

44 46 48 50 51 52

46 48 50 53 53

8 9

44 44

46 46

50 51

55 58

10 11 12 13 14 15 16

45 48 49 51 53 55 59

48 50 52 54 58 59 65

53 55 58 62 67 70 73

17

66

69

21 30 40

69 70 71

74 77 76

0.3 1 2 3

27 31 34 34

29 32 36 37

33 37 40 41

37

4

36

38

5

38

40

6

38

41

7 8

39 41

9

ence perce ntiles,

mm

Age

midpoint, years”

95th

5th

15th

50th

85th

95th

Males

106 123

125 137

133 146

111 114 118 121

117 121 124

127 132 135

138 145 151

146 152 157

130

141

156

166

127

134

146

159

55 59 64

130 138 138

137

151

164

144

158

174

167 173 185

143

161

182

200

59 62 66 71 74 80 83

64

142

152

168

186

202

67 70 77 84

150 153 159 167

158 163 169 182

174 181 195 211

194 207 224

211 221 242

234

265

86 89

173 186

185 205

220 229

252 260

271 281

78

86

92

206

217

245

271

290

82 86 86

91

97

217

232

258

286

305

94

100

220

241

270

295

315

96

101

222

239

270

300

318

92 102

104

115

126

117

128

135

Females 40

86 97

42

41 44 44 46

43 46 46 48

105 108 114

112 116 120

125 128 132

140 138 146

146 143 152

44

48

51

119

124

138

151

160

45

49

53

121

129

140

155

165

42 44

47 48

52 53

56

123

132

146

162

175

138

151

168

186

45

50

56

59 62

129

43

136

143

157

176

193

10

44

47

52

58

11 12 13 14 15

44 48 49 53 52

48 51 53 56 55

55 57 59 61 62

62 64 66 70 70

62 67

139 140

147 152

163 171

182 195

196 209

68 71 74 74

150

161

179

200

212

155

165

185

206

225

166 163

175

193

221

234

173

195

220

232

16

54

57

64

72

83

171

178

200

227

260

17 21 30 40

54 54 56 57

56 58 60 61

62 65 68 69

71 73 78 80

77 80 87 89

171 170 177 180

177 183 189 192

196 205 213 216

223 229 245 250

241 253 272 279

The age group

#{176}

and n are the same

as in Table

1.

Downloaded from www.ajcn.org by on May 19, 2009

94 108

FRISANCHO

1056 TABLE 3 Percentiles for arm muscle

area of whites

derived

from

the Ten-State

Nutrition

Survey

Male arm muscle

Age midpoint, years”

5th

a re

percent

15th

50th

Female muscle

iles, mm 85th

95th

1,244 1,500

1,414

1,201

5th

arm

a rea percentil

15th

es, mm

50th

85th

95th

670 821

866 1,084

1,058

1,272

1,304

1,460

1,241

1,693 1,628

522

703

1 2

791 978

928 1,082

1,284

1,525

1,686

885

991

3

1,027

1,163

1,384

1,670

1,842

928

1,068

1,298

1,551 1,516

4

1,106

1,224

1,451

1,805

1,973

1,040

1,143

1,390

1,693

1,828

5

1,171

1,342

1,579

1,930

2,193

1,119

1,227

1,516

1,825

2,045

6

1,275

1,435

1,700

2,019

2,220

1,163

1,333

1,563

1,902

2,174

7

1,342

1,485

1,815

2,152

2,386

1,213

1,384

1,700

2,096

2,433

8 9 10

1,506

1,647 1,637 1,832

1,987 2,074 2,239

2,398 2,645 2,753

2,729 3,188 3,239

1,322 1,473 1,528

1,513 1,625 1,727

1,818 1,955 2,115

2,239 2,477 2,637

2,758 2,978 3,066

11

1,801

1,987

2,406

3,000

3,544

1,551

1,842

12 13

1,874 2,012

2,126 2,273

1,781 1,905 2,186

2,052 2,178 2,430

3,486 3,582

2,645

3,902 4,661 5,601

3,018 3,183

2,231 2,375 2,741 3,373

3,401 3,998 4,358

2,335 2,558

14 15 16 17

2,603 3,013 3,544

2,711 2,952

3,382 3,883

4,014 4,358

2,729 3,331 3,743

3,867 4,184 4,771

5,060 5,363 5,826

5,826 6,266 6,713

2,126 2,316 2,316

2,387 2,510 2,502

3,031 3,198 3,058

3,838 4,096 3,968

4,279 5,386 4,612

21 30

3,748 3,837

4,273 4,634

5,315 5,802

6,529 6,912

7,411 7,918

2,289 2,486

2,679 2,856

3,341 3,606

4,164 4,772

5,089 5,889

40

3,938

4,563

5,820

7,183

8,041

2,566

2,926

3,724

4,991

6,195

a The

1,608

age group

and

n are the

same

as in Table

591 756

1,690

1.

girls, there is an increase of nearly 35% in muscle area, whereas in diameter or circumference, the comparable value amounts to only approximately 16%. In other words, estimates of muscle diameter and circumference underestimate the magnitude of the tissue changes. In boys, the greatest 2-year increase in muscle area occurs between the ages of 15 and 17 years, at which time there is an increase of 904 mm2 or nearly 23%. In girls, the greatest increment occurs between the ages of 12 and 14 years, increasing almost 15% in muscle area (L = 394 mm2). Until the age of 12 years, sexual dimorphism in terms of muscle area is not well defined. At the age of 13 years, males exceed females by 11% and, during adolescence, this difference increases sharply. By the age of 40 years, the sexual dimorphism in the muscle area is over 56%. These sex differences are less marked when the muscle size is expressed either in diameter or circumference. Because the muscle area shows greater changes with age than the diameter or circumference, it would be advisable that evaluations

of nutritional status of children be based on estimates of muscle areas as well. With the nomogram given recently by Gurney and Jelliffe (18), the difficulties of calculating muscle areas are simplified. The use of skin-fold thickness in the assessment

of nutritional

status

of children

is based

the assumption resulting from

that increased subcutaneous either high calorie intake

Consequently,

evaluations

on

fat, or low energy expenditure, reflects a greater calorie reserve. From which it follows that fatter children for their age are both taller and developmentally more advanced than average children (17, 19-27). This generalization is supported by animal experimental studies mdicating that overnutrition speeds maturation and dimensional growth (28). However, we must point out that in some parts of the world it seems likely that, as we indicated by our studies of Central American samples (10, 29, 30), the levels of fatness that are considered average in the United States populations cannot be found except in the upper ranges of the distribution. based

on

skin-fold

thickness

of nutritional

of children

status

from

Downloaded from www.ajcn.org by on May 19, 2009

0.3

1,522

892

of 1968-1970

UPPER

populations fatness may

characterized not be that

Experimental that

the

either

CIRCUMFERENCE

by a low degree of sensitive (10, 29, 30).

and clinical studies have

shown

in muscle mass, determined creatinine output or limb mea-

decrease

through

surements,

ARM

during

malnutrition

exhibit

have

been

met.

In other

words, reflect

a child a greater

The

author

Kathleen Font of this study.

acknowledges

and Mrs. Diane

the

Clark

assistance

of

Mrs.

in the preparation

tion

of

FOLDS

1057

W. H. Measurement

subcutaneous

fat,

with

and young adult males. Med. 9: 201, 1955. 5. TANNER, J. M., AND Standards for subcutaneous Brit.

and

Brit. R.

interpreta-

norms

for

children

J. Prevent

Social

H. WHITEHOUSE. fat in British children.

1: 446, 1962. R., M. A. GIRSHIK AND E. P. HUNT, measurements of American boys and girls

Med.

J.

6. O’BRIEN,

Body for garment ton, D. C.:

No. 454), 1941.

PubI. 7.

and pattern construction. WashingU.S. Dept. Agriculture (Miscellaneous

Ten-State Nutrition ical Development,

U.S.

Dept.

Center 72-813

of

Survey 1968-1970, II. Demographic Data.

Health,

Education

for Disease 1, 1972.

Control

I. HistorAtlanta:

and

Publ.

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(HSM)

8. BRO2EK, J. Body measurements including skinfold thickness, as indicator of body composition. In: Techniques for Measuring Body Composition, edited by J. Brolek and A. Henschel. Washington, D. C.: Natl. Aced. Sci.-Nat. Res. Council, 1961. 9.

10.

McFIE, J., malnutrition bone, muscle

AND

H. F. WELBOURN. Effect the development 76: 97, 1962.

of

in infancy on and fat. J. Nutr.

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A. R., AND S. M. GARN. and muscle size: implications

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of

Skinfor of 24:

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STINI,

W.

upper

A.

arm

muscle

circumference

protein-deficient

diet

population. 1972.

12.

Am.

BAKER,

and tissues 1958.

13. GURNEY,

14.

15.

J.

in Phys.

interrelations in man.

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XVI.

in

associated

P. T., E. E. HUNT

growth brachial 16: 39,

The

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basis Harvard

CLEGG, sibility

E. J., AND C. KENT. Skin-fold in young adults. Human Biol.

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of morphological Univ. Press, 181,

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AND

E.

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Am.

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17. GARN, S. M., AND J. A. HASKELL. Fat thickness and developmental status in childhood and adolescence. Am. J. Diseases Children 99:

References 1. JELLIFFE, D. B. The assessment of the nutritional status of the community. World Health Organ. Monograph Ser. No. 53. Geneva. 1966.

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E.

R. P., AND

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D. B. JELLIFFE

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J. M., AND

anthropometry gram

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ference Am.

19. GARN, growth 1959. 20.

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with greater muscle size would protein reserve than a less muscular one. Indeed, previous investigations have pointed out that differences in the development of muscle are associated with differences in nutritional background (9, 35). Our investigations on samples from Central America indicate that during growth, greater muscularity is related to greater stature, showing that measurements of muscularity in children of underdeveloped countries do serve as a general index of nutritional status and growth in size. In view of these reasons, the applicability of the present data will certainly depend on the population to which it is applied. Furthermore, any evaluation of nutritional status must take into account that there are variations in the amount of subcutaneous fat and muscle and in the pattern of fat deposition (36-39). For this reason, and as recently pointed out by Jelliffe and Jelliffe (16), there is a critical need for locally applicable standards. It is hoped that the present article is a contribution toward this end. El

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