LEADING ARTICLE

Use of anthropometric techniques in dietetic practicendi_

1420 62..6462..64

INTRODUCTION

Anthropometry from the Greek anthropos (human or man)and metre (measure), originally developed from the arts asearly painters and sculptors required information about therelative proportions of the body to create realistic lifeimages.1 The earliest record of anthropometry for scientificpurposes dates back to the German physician JohannSigismund Elsholtz (1623–1688) who studied the relation-ship between body proportions and the incidence of dis-ease.1 Anthropometry has been used extensively in a varietyof different fields including the arts, history, anthropology,archaeology, criminology, architecture, industrial design andergonomics. It has also been used widely by the military,fashion and clothing design, psychology, exercise science,medicine and nutrition. Although, there are similarities inthe anthropometric techniques conducted across these dis-cipline areas, there are also many differences.2

Skill in anthropometry is considered an entry-levelcompetency for dietitians by the Dietitians Association ofAustralia (DAA)3 and is included in all current DAAendorsed practice guidelines.4–11 Many nutritional assess-ment and disease-specific guidelines relevant to the practiceof dietitians (e.g. obesity, diabetes and malnutrition) alsoinclude anthropometric measures to assess and monitordisease risk or progression.12–14 Clearly, competency inanthropometry is necessary for assessment of healthy indi-viduals throughout each life stage and those with a widerange of medical conditions that require dietetic interven-tion. Despite its relevance and importance in dietetic assess-ment and monitoring, few studies have evaluated its use bydietitians in clinical practice.

USE OF ANTHROPOMETRICTECHNIQUES IN DIETETIC PRACTICE

The paper by Lai et al. (this issue pp. 65–70) provides valu-able insight into the frequency of use and self-perceivedcompetence of Australian practicing dietitians (n = 151) inanthropometric techniques. Although the sample worked ina range of specialist dietetic areas and considered anthro-pometry to be an important clinical tool (93%), measuresother than height and weight were routinely used by lessthan 30% of participants. Circumference measures such aswaist girth that feature in obesity4 and diabetes8,14 practiceguidelines and mid-upper arm circumference recommendedin a number of nutritional assessment guidelines formalnutrition7,11–13 were infrequently used. Assessment ofsubcutaneous body fat stores via the skinfold technique, also

recommended in guidelines for assessing malnutrition7,11–13

was rarely measured (<5% of participants). The barrierscited by dietitians for not using anthropometry included alack of prior experience, inadequate training or unavailabil-ity of protocols or procedures for measurement. Inadequateconfidence, equipment, space, time and support to takeanthropometric measures was also raised. Patients who weremore difficult to ambulate were often not measured. Only afew study participants accessed other body compositionassessment methods such as bioelectrical impedance (BIA)or dual x-ray absorptiometry (DXA).

VALUE AND PRACTICALITY OFANTHROPOMETRY IN CLINICALDIETETIC PRACTICE

Unlike commonly used measures of heaviness such as bodymass and body mass index, surface anthropometry offersinsight into body composition, allowing a practitioner tointerpret changes in both fat and lean mass.15 Within nutri-tion and dietetics, the collection of surface anthropometrydata (skinfolds, girths) offers insight into nutritional statusand changes in body composition in response to activedisease and/or dietary or other lifestyle interventions.15

Although an array of other techniques have become increas-ingly available to monitor these characteristics, such as BIAor DXA, anthropometry is more portable and cost effective.Typically, anthropometry is not influenced by hydrationstatus, gastrointestinal tract contents or other abnormalitiesof fluid balance in healthy individuals16 and even in diseasestates that result in fluid retention (e.g. kidney disease),anthropometry has been favourably compared with othermeasures such as BIA or DXA.5,17,18 Anthropometry is safeand does not involve a radiation dose. A basic anthropom-etry kit to measure circumferences, skinfolds, mass andstature retails for approximately AUD$500–1000 and withcare and regular (six monthly to annual depending on use)calibration can last five to ten years.

Collection of reliable anthropometry data demands tech-nicians who are highly skilled, enabling them to identify andinterpret small but potentially important clinical changes.2

Anthropometric data enrich dietetic assessment and whencollected longitudinally provide useful bio-feedback thatinforms clinical intervention and enhances patient/clientmotivation.19 For the private practitioner, the use of surfaceanthropometry not only provides invaluable insight intointerventions applied but also creates the potential foran additional revenue stream. Despite concern about

Nutrition & Dietetics 2010; 67: 62–64 DOI: 10.1111/j.1747-0080.2010.01420.x

© 2010 The AuthorsJournal compilation © 2010 Dietitians Association of Australia

62

equipment or technician error,20 which is an issue with anybody composition assessment method, in trained hands,surface anthropometry delivers efficient, safe, cost effective,reliable and clinically meaningful information.2 For thesereasons, it is recommended in DAA and other disease-specific practice guidelines.

TRAINING IN ANTHROPOMETRY

Training in anthropometry is not overly challenging orlengthy, especially for those with existing scientific expertiseand knowledge of basic anatomy. Technicians however,need to be meticulous particularly with accurate site loca-tion, body positioning of the client and measurement tech-nique. Measurements just 1–2 cm away from a defined sitecan produce significant differences in results.21 Further-more, if repeat measurements are taken over time, it isimportant that the same technician collect the data.22 Dupli-cate or triplicate measures over all sites for the same subjectare also important to reduce technician error and equip-ment must be well maintained and calibrated. Measurementin a private location with the client presenting in appropri-ate attire is also important for both the client and dietitianto conduct the measurements in a comfortable and profes-sional manner.

Anthropometric training programs such as the one devel-oped by the International Society for the Advancement ofKinanthropometry (ISAK) certify basic competency (level 1)covering measurement of mass, stature, skinfolds (eightsites), girths (five girths including mid-arm, waist and hip)and bone breadths (humerus and femur). The courseincludes three days of intensive, primarily hands on mea-surement training and a practical examination to assess accu-racy and precision of participant measures against a criterionanthropometrist. Within six months post course, skill is con-solidated with participants completing 20 anthropometricprofiles in their own time to a set level of intra-tester preci-sion. In a dietetic career, this time investment (approxi-mately 35 hours) produces a satisfactory level of skill andconfidence to undertake the anthropometric measurementsrequired for clinical dietetic practice. The ISAK trainingexperience indicates that almost all students who fullyparticipate in the course develop an acceptable or betterlevel of competence according to set intra- and inter-anthropometrist measurement criteria.23 Reaccreditation(practical re-examination and a further 20 profiles) everyfour years is recommended to maintain currency of skill,confidence and the quantification of measurement error,the later providing insight into the interpretation of results.

The ISAK training system is endorsed by elite sports insti-tutes within Australia and all staff involved in anthropomet-ric measurement must have completed a level 1 ISAKcertification (at a minimum). In a similar way, adoption of astandardised protocol and training pathway consistent withDAA and disease-specific practice guidelines would supportthe level of confidence and competence of Australian dieti-tians in anthropometry. The paper by Lai et al. indicates thatfurther consideration should be given to the provision of

anthropometric training support to practising dietitians andto the level of training required for entry-level competency.

LEADERSHIP OPPORTUNITIES INANTHROPOMETRY FOR DIETITIANS

Given dietitians have the skill set to best interpret nutritionalstatus, body composition and physique traits of their clients,it’s only logical that they should be proficient anthropome-trists and provide leadership in this specialised area. Asresearch using anthropometry in clinical populations islimited, dietitians have a unique opportunity to demonstratehow anthropometric skills can be used to assist in the effec-tive assessment of clients and also to evaluate and supportthe efficacy of dietetic therapy.

Helen O’Connor, PhD, APD1 and Gary Slater, PhD, APD2

1Senior Lecturer in Nutrition,Discipline of Exercise & Sport Science,

Faculty of Health Science,University of Sydney, Sydney, New South Wales, and

2Senior Lecturer in Nutrition and Dietetics,School of Health and Sport Sciences,

Faculty of Science, Health and Education,University of the Sunshine Coast, Queensland, Australia

REFERENCES

1 Harris B. Health, height and history: an overview of recentdevelopments in anthropometry history. Soc Hist Med 1994; 7:297–320.

2 Norton K, Olds T. Anthropometrica. Sydney: University of NSWPress, 1996.

3 Dietitians Association of Australia. National Competency Stan-dards for Entry-Level Dietitians. Canberra: Dietitians Associationof Australia, 2009.

4 Dietitians Association of Australia. Best Practice Guidelines forthe Treatment of Overweight and Obesity in Adults. Canberra:Dietitians Association of Australia, 2005.

5 Dietitians Association of Australia. Evidence based guidelinesfor the nutritional management of chronic kidney disease. NutrDiet 2006; 63 (Suppl. 2): S35–45.

6 Dietitians Association of Australia. Evidence based guidelinesfor the nutritional management of cancer cachexia. Nutr Diet2006; 63 (Suppl. 2): S5–32.

7 Dietitians Association of Australia. Australasian Clinical PracticeGuidelines for the Nutrition in Cystic Fibrosis. Canberra: DietitiansAssociation of Australia, 2006.

8 Dietitians Association of Australia. Evidence Based Practice Guide-lines for the Nutritional Management of Type 2 Diabetes Mellitus inAdults. Canberra: Dietitians Association of Australia, 2006.

9 Dietitians Association of Australia. Evidence based practiceguidelines for the nutritional management of patients receivingradiation therapy. Nutr Diet 2008; 65 (Suppl. 1): S1–20.

10 Dietitians Association of Australia. Evidence Based PracticeGuidelines for the Nutritional Management of Adult Kidney Trans-plant Recipients. Canberra: Dietitians Association of Australia,2009.

11 Dietitians Association of Australia. Evidence based practiceguidelines for the nutritional management of malnutrition in

Leading article

© 2010 The AuthorsJournal compilation © 2010 Dietitians Association of Australia

63

adult patients across the continuum of care. Nutr Diet 2009; 66(Suppl. 3): S1–34.

12 World Health Organization. Physical Status: The Use and Inter-pretation of Anthropometry. Report of A WHO Expert Committee.(WHO Technical Report Series, No. 845). Geneva: World HealthOrganization, 1995.

13 Vellas B, Guigoz Y, Garry PJ et al. The Mini Nutritional Assess-ment (MNA) and its use in grading the nutritional state ofelderly patients. Nutrition 1999; 15: 116–22.

14 American Diabetes Association. Nutrition recommendationsand interventions for diabetes. A position statement of theAmerican Diabetes Association. Diabetes Care 2008; 31 (Suppl.1): S61–78.

15 Roche AF. Anthropometry and ultrasound. In: Roche AF,Heymsfield SB, Lohman TG, eds. Human Body Composition.Chicago, IL: Human Kinetics, 1996; 167–89.

16 Norton K, Hayward S, Charles S, Rees M. The effects of hypo-hydration and hyperhydration on skinfold measurements. In:Norton K, Olds T, Dollman J, eds. Sixth Scientific Conference ofthe International Society for the Advancement of Kinanthropometry.Adelaide: International Society for the Advancement ofKinanthropometry, 1998; 253–66.

17 Oe B, de Fijter CW, Oe PL, Stevens P, de Vries PM. Four-siteskinfold anthropometry (FSA) versus impedance analysis (BIA)in assessing nutritional status of patients on maintenance hae-modialysis. Which method is preferred in routine patient care?Clin Nephrol 1998; 49: 180–5.

18 van den Ham EC, Kooman JP, Christiaans MH et al. Bodycomposition in renal transplant patients: bioimpedance analysiscompared to isotope dilution, dual x-ray absorptiometry andanthropometry. J Am Soc Nephrol 1999; 10: 1067–79.

19 Melin I, Karlstrom B, Lappalainen R, Berglund L Monsen R,Vessby B. A program of behaviour modification and nutritioncounselling in the treatment of obesity: a randomised 2 y clini-cal trial. Int J Obes 2003; 27: 1127–35.

20 Ulijazek SJ, Kerr DA. Anthropometric measurement error andthe assessment of nutritional status. Br J Nutr 1999; 82: 167–77.

21 Hume P, Marfell-Jones M. The importance of accurate site loca-tion for skinfold measurement. J Sports Sci 2008; 26: 1333–40.

22 Ruiz L, Colley JR, Hamilton PJ. Measurement of triceps skinfoldthickness: an investigation of sources of variation. Br J Prev SocMed 1971; 25: 165–7.

23 Marfell-Jones M, Olds T, Stewart A, Carter L. ISAK AccreditationHandbook. Potchefstroom, South Africa: ISAK, 2006.

Leading article

© 2010 The AuthorsJournal compilation © 2010 Dietitians Association of Australia

64