1052 TheAmerican Journal of Clinical Nutrition 27: OCTOBER 1974, pp. 1052-1058. Printed in U.S.A. Triceps skin fold and upper arm muscle size norms for assessment of nutritional status1’2 A. Roberto Frisancho, Ph.D.3 ABSTRACT Basect on a cross-sectional sample of 12,396 white subjects aged 0 to 44 years, derived from the United States Ten-State Nutrition Survey of 1968-1970, percentiles for right upper arm circumference and triceps skin fold are reported. From these measurements for each 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 defmed by the age of 13 years, and by adulthood, males exceed females by about 56%. The amount of subcutaneous fat and degree of muscularity in children reflects the individual calorie and protein reserve. However, measurements of subcutaneous fat among populations characterized 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. Because the size of the muscle mass is an indirect indicator of protein reserve, measure- ment 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 circum- ference 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 from the arm circumference and triceps skin folds of the white population in the United States. Materials and methods 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 based on a stratified probability sample of families and unrelated indi- viduals residing in the states of Texas, Louisiana, Kentucky, Michigan, New York, Massachusetts, Wash- ington, California, West Virginia, and South Carolina. The sampling procedure included a large proportion of families who, according to the 1960 census, were living in low-income areas and a small proportion of families living in middle- and upper-income areas (7). Although the primary interest in each state was ‘From the Center for Human Growth and Develop- ment, The University of Michigan, Ann Arbor, Michigan 48104. 2Supported in part by Contract HSM 21 72-522 with the Center for Disease Control, Atlanta, Georgia, and with the use of raw data from the Ten-State Nutrition Survey of 1968-1970. Associate Scientist of the Center for Human Growth and Development and Associate Professor of Anthropology. by guest on September 26, 2014 ajcn.nutrition.org Downloaded from
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1052 TheAmerican Journal of Clinical Nutrition 27: OCTOBER 1974, pp. 1052-1058. Printed in U.S.A.
Triceps skin fold and upper arm muscle sizenorms for assessment of nutritional status1’2
A. Roberto Frisancho, Ph.D.3
ABSTRACT Basect on a cross-sectional sample of 12,396 white subjects aged 0 to 44 years,
derived from the United States Ten-State Nutrition Survey of 1968-1970, percentiles for rightupper arm circumference and triceps skin fold are reported. From these measurements for each
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 sizewere 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 throughoutchildhood, 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 theupper arm during childhood exhibits considerable changes with age. Sexual dimorphism is
defmed by the age of 13 years, and by adulthood, males exceed females by about 56%. The
amount of subcutaneous fat and degree of muscularity in children reflects the individual calorie
and protein reserve. However, measurements of subcutaneous fat among populations
characterized by a low degree of fatness may not be a sensitive indicator of nutritional status
and growth. On the other h�snd, 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.
Because the size of the muscle mass is anindirect indicator of protein reserve, measure-ment of limb muscle size has been usedcurrently to assess the nutritional status ofchildren (1-3). These evaluations are usuallymade through comparison of the estimated
upper arm muscle circumference of a givenpopulation against the “standard” (1). It mustbe noted, however, that this standard formuscle circumference for the ages of 1 to 60months was calculated using the arm circum-ference of Polish children (reported in 1964)
and the triceps skin folds of British children(reported in 1955 (4) and 1962 (5)). In thesame manner, the muscle circumference forchildren 6 to 15 years was estimated from thearm circumference of British children (reportedin 1955 (4, 5)) and the triceps skin folds ofchildren in the United States obtained prior toWorld War II and reported in 1941 (6). It isquite evident that normative data derived
through this procedure are not applicable interms of time or population. Clearly, there is acrucial need for the development of moreappropriate estimates of muscle size. Therefore,the purpose of this article is to provideestimates of upper arm muscle size derived
from the arm circumference and triceps skinfolds of the white population in the UnitedStates.
Materials and methods
Sample
This study is based on a cross-sectional sample of5,637 males and 6,759 females aged 0 to 44 years,derived from the Ten-State Nutrition Survey of1968-1970. This survey was based on a stratifiedprobability sample of families and unrelated indi-viduals residing in the states of Texas, Louisiana,Kentucky, Michigan, New York, Massachusetts, Wash-
ington, California, West Virginia, and South Carolina.The sampling procedure included a large proportion offamilies who, according to the 1960 census, wereliving in low-income areas and a small proportion offamilies living in middle- and upper-income areas (7).Although the primary interest in each state was
‘From the Center for Human Growth and Develop-
ment, The University of Michigan, Ann Arbor,Michigan 48104.
2Supported in part by Contract HSM 21 72-522with the Center for Disease Control, Atlanta, Georgia,and with the use of raw data from the Ten-StateNutrition Survey of 1968-1970.
� Associate Scientist of the Center forHuman Growth and Development and Associate
UPPER ARM CIRCUMFERENCE AND TRICEPS SKIN FOLDS 1053
malnutrition among the poor, the universe of theTen-State Nutrition Survey does not include all of thelower-income groups within a state, nor is it restrictedto only the poor. Rather, the target population alsoincluded middle- and upper-income individuals who,because of changes in residential patterns since 1960,were living in the selected areas when the survey wasconducted (7). The mean average income for thesample included in this study was $13,122.
Measurements
The survey included standard anthropometric mea-surements for the assessment of body size andnutritional status. In this article, we report informa-tion for the upper arm circumference and triceps skinfolds for the whole sample of whites who participatedin the Ten-State Nutrition Survey.
1) Upper arm circumference (millimeters) wasmeasured to the nearest millimeter with a steel tapewith the right arm hanging relaxed. The measurementwas taken midway between the tip of the acromionand olecranon process.
2) Triceps skin fold (millimeters) was measured to
the nearest tenth of a millimeter with a LangeSkin-fold Caliper having a pressure of 10 g/mm2 ofcontact surface area. The measurement was taken onthe back of the arm and midway between the point ofthe acromion and olecranon process while the arm washanging relaxed.
Estimates of muscle size
The following three estimates of muscle size were
derived:1) Arm muscle diameter (millimeters) was esti-
mated by computation (8-10) as follows:
Arm muscle diameter (mm) =
arm circumference (mm) -
triceps skin fold (mm)
2) Arm muscle circumference (mm) was derived bycomputation (1, 2, 11) as follows:
Arm muscle circumference (mm) =
arm circumference -ir (triceps skin fold)
3) Arm muscle area (mm2) was calculated (12, 13)as follows:
Arm muscle area (mm2) (arm diameter2)
It must be noted that the calculations of musclesize in the upper arm are only approximations for four
reasons. First, the circumference of muscle does not
include an estimate of bone diameter, and anyvariation in humeral diameter is therefore not account-able. The deletion of humeral diameter in thecalculation may result in an overestimation of male inrelation to female values, as male humeri are on theaverage greater in diameter than those of the female,regardless of the nutritional status of the population.Second, the equations assume that the upper arm iscylindrical in form, an assumption subject to someinaccuracy. For example, because flattening of the
arm is more prevalent in males than in females (14), it
may result in an overestimation of male muscle area toan increasing degree as the cross-sectional configura-
tion approaches rectangularity. Third, the equationsdo not take into account variations in skin fold
compressibility. Clegg and Kent (15) indicate thatfemale triceps skin-fold compressibility is 4.8% greaterthan that of the male. In this study the averageskin-fold was 7 mm and the maximum value was 21mm. According to these data, the greater femaleskin-fold compressibility could result in an underesti-mation of female muscle circumference by an averageof 3.1 mm. However, the estimates of muscle size can
be affected significantly at the upper levels (95thpercentile) of the distribution and may preventadequate comparisons because skin-fold compressibil-ity increases when the skin-fold thickness is over 21mm. Fourth, as the measurements of skin folds andupper arm circumference were taken by severaltechnicians, the magnitude of the measurement errorcannot be quantified.
Results and discussion
Table 1 gives the percentiles for the mid-
upper arm circumference and triceps skin fold.
Arm circumference
As shown by the 50th percentile values, thearm circumference between the age of 1 and 5
years increases approximately 11% in girls and
15% in boys. Between 6 and 13 years, theincrease in boys is almost 32% and 34% in girls;between 14 and 30 years, males show anincrease of 27%, whereas in females this equals
only 13%.These data suggest that the arm circum-
ference either during childhood (1 to 5 years)or adolescence is not independent of age as is
currently assumed. Nevertheless, it must benoted that, for example, compared with heightor weight during childhood, the arm circum-ference shows a small change. Therefore, asindicated by other investigators (1-3, 13, 16)evaluations of nutritional status based on armcircumference during childhood may not re-quire an exact knowledge of age.
Triceps skin fold
Boys at the age of 2 years have a mediantriceps skin fold of 10 mm (for 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 of12 years, reach a peak of 11 mm. This is the
so-called preadolescent fat wave (1 7). After contrast, females between 2 and 8 years remainboys reach this age, the triceps skin fold stable. Thereafter, they show a rapid increase,declines until they are 17 years old, when they reaching a median value of 16 mm by the age ofattain a low value of 8 mm. The median value 1 5 years, and during adulthood the medianfor adults is only between 10 and 12 mm. In values are between 17 and 22 mm.
UPPER ARM CIRCUMFERENCE AND TRICEPS SKIN FOLDS 1055
#{176}The age group and n are the same as in Table 1.
Muscle size muscle area from age 1 to 12 years increases
steadily. This trend, however, is not noticeableTables 2 and 3 give the percentiles for the when the size of the muscle is expressed in
diameter, circumference, and area of muscle, terms of diameter and circumference. ForThese data show that in both boys and girls, the example, between 1 and 5 years in boys and
TABLE 2Percentiles for upper arm diameter and upper arm circumference forwhites of the Ten-State Nutrition Survey of 1968-1970
Arm muscle
Agemidpoint,
diameter percentiles, mm circumfer ence perce ntiles, mm
girls, there is an increase of nearly 35% inmuscle area, whereas in diameter or circum-
ference, the comparable value amounts to onlyapproximately 16%. In other words, estimatesof muscle diameter and circumference under-estimate the magnitude of the tissue changes.
In boys, the greatest 2-year increase inmuscle 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 greatestincrement 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 dimorphismin terms of muscle area is not well defined. Atthe age of 13 years, males exceed females by11% and, during adolescence, this differenceincreases sharply. By the age of 40 years, thesexual dimorphism in the muscle area is over56%. These sex differences are less markedwhen the muscle size is expressed either indiameter or circumference.
Because the muscle area shows greaterchanges with age than the diameter or circum-ference, it would be advisable that evaluations
of nutritional statusestimates of musclenomogram given recently by Gurney andJelliffe (18), the difficulties of calculatingmuscle areas are simplified.
The use of skin-fold thickness in the assess-ment of nutritional status of children is based on
the assumption that increased subcutaneous fat,
resulting from either high calorie intake or lowenergy expenditure, reflects a greater caloriereserve. From which it follows that fatter
children for their age are both taller anddevelopmentally more advanced than averagechildren (17, 19-27). This generalization issupported by animal experimental studies mdi-cating that overnutrition speeds maturation anddimensional growth (28). However, we must
point out that in some parts of the world itseems likely that, as we indicated by our studies
of Central American samples (10, 29, 30), thelevels of fatness that are considered average inthe United States populations cannot be found
except in the upper ranges of the distribution.Consequently, evaluations of nutritional status
UPPER ARM CIRCUMFERENCE AND TRICEPS SKIN FOLDS 1057
populations characterized by a low degree of
fatness may not be that sensitive (10, 29, 30).Experimental and clinical studies have shown
that the decrease in muscle mass, determinedeither through creatinine output or limb mea-
surements, during malnutrition exhibit a greater
reduction than body weight (31-33). Thisreduction in muscle size occurs as a compensa-tory mechanism to provide amino acids forgluconeogenesis and protein synthesis in theliver (34). These indications would suggest thatif the skeletal musculature is well maintained,the protein requirements for growth and body
tissues have been met. In other words, a child
with greater muscle size would reflect a greater
protein reserve than a less muscular one.Indeed, previous investigations have pointedout that differences in the development of
muscle are associated with differences in nutri-tional background (9, 35). Our investigations
on samples from Central America indicate that
during growth, greater muscularity is related togreater stature, showing that measurements of
muscularity in children of underdeveloped
countries do serve as a general index ofnutritional status and growth in size.
In view of these reasons, the applicability of
the present data will certainly depend on thepopulation to which it is applied. Furthermore,
any evaluation of nutritional status must takeinto account that there are variations in the
amount of subcutaneous fat and muscle and inthe pattern of fat deposition (36-39). For thisreason, and as recently pointed out by Jelliffe
and Jelliffe (16), there is a critical need forlocally applicable standards. It is hoped that thepresent article is a contribution toward this
end. ElThe author acknowledges the assistance of Mrs.
Kathleen Font and Mrs. Diane Clark in the preparationof this study.
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