6.

Anthropometric measurements
Obesity, is one of the know risk factors for cardiovascular and other chronic diseases. It can
be measured using weight and height and is usually assessed by body mass index (BMI), i.e.
weight in kilograms divided by square of height in meters. Waist-to-hip ratio as well as waist
circumference alone can be used as an indicator for abdominal obesity. Several other methods,
like skinfold thickness, are used to measure body fat, but there are no uniform methods
available for them and they will be not further discussed in this report.
The main focus of this chapter will be on weight and height measurement. Issues relating to
waist and hip circumference measurement will also be considered.
6.1 Methods
Most people are aware of their height and weight. Therefore, data on weight and height can be
obtained through a questionnaire. However, there are problems with self-reported data that are
usually based on not very accurate bathroom scales. Also, systematic biases have been found
between measured and self-reported weight and height. (1, 2). Self-reported weight tends to
be lower than measured weight. The reverse is true for self-reported height. As a result, BMI
tends to be under-estimated if it is based on self-reported data , and does not necessarily
facilitate the comparison between populations or within populations over time. The magnitude
of these biases varies from population to population, is age and sex dependent, and also may
vary in time. Therefore, for cardiovascular risk factor surveys, actual weight and height
measurements should be made. It is easy to make accurate measurements, provided that the
proper equipment, well standardized methods, and trained personnel are used.
6.1.1 Type of scale
A traditional balanced beam scale has been considered a reliable instrument for population
measurement. In the past years, they have often been replaced by electronic digital scales,
which are easier to operate. The problem with digital scales is that they are usually impossible
to calibrate. The accuracy of bathroom scales is not sufficient for population measurement.
WHO MONICA Project
In the WHO MONICA Project, the use of balanced beam scales was recommended. If digital
scales were used, testing with standard weights was of particular importance. The floor
surface on which the scale rests must be hard and should not be carpeted or covered with
other soft material. The scale should be balanced at zero weights (3). Both digital and

balanced beam scales were used. A few centres used a bathroom scale during home visits,
when the subject was unable to attend the examination site (4).
Risk factor monitoring in the Netherlands
In the Monitoring Project on Cardiovascular Disease Risk Factor and the MORGEN-project
the balanced beam scales were used (5). In the REGENBOOG project each Municipal Health
Centre used their own scales, which were either balanced beam scales or digital ones (6).
Risk factor monitoring in Germany
The German Federal Health Survey 1998 used balanced beam scales (7).
UK National Health Surveys
In the National Health Surveys in the UK electronic bathroom scales with digital display were
used (8).
NHANES III
In NHANES III an electronic digital scale with the kilogram mode was used (9).
6.1.2 Type of height measurement instrument
WHO MONICA Project
The MONICA Manual instructs: Height is measured in conjunction with the weight
measurement. It may precede or follow this procedure. The height ruler must be taped
vertically to a hard flat surface, with no molding (skirting board), with the base at floor level.
A carpenter's level should be used to ensure vertical placement of the rule. The floor surface
must be hard (tile, cement, etc.) and must not be carpeted or be covered with other soft
materials. If only a carpeted surface is available, a wooden platform should be placed on the
carpet to serve as a reference for the height measurement (3).
Risk factor monitoring in the Netherlands
In the Monitoring Project on Cardiovascular Disease Risk Factors in the Netherlands a wallmounted stadiometer was used (10). In the REGENBOOG project each Municipal Health
Centre used their own height measuring device, which in most cases was wall-mounted
measuring tape (6).

Risk factor monitoring in Germany

The German Federal Health Survey 1998 used a height rod that was attached to the balanced
beam scales (7).
UK National Health Surveys
The National Health Surveys in the UK used a portable stadiometer with a collapsible device
with a sliding head plate, a base plate and three contacting rods marked with a measuring
scale (8). The Health Survey of England 1999 introduced the demi-span measure (11) as an
alternative size measure for persons who had difficulty standing straight (12).
NHANES III
In NHANES III a stadiometer was used (9).
6.1.3 Type of measurement tape for waist and hip circumference measurement
WHO MONICA Project
In the WHO MONICA Project it is recommended that a plastic metric tape is used. The tape
should be held firmly and its horizontal position should be ensured. The two sides of the tape
should be differently colored or have a scale only on one side. If the tape is uniformly colored,
with readings on both sides, one side should be blanked out. (3)
Risk factor monitoring in the Netherlands
In the Monitoring Project on Cardiovascular Disease Risk Factors, the MORGEN-project and
the REGENBOOG project the household measuring tape was used (5, 6).
UK National Health Surveys
In the National Health Surveys in the UK an insertion tape calibrated in mm, with a metal
buckle at one end was used (8).
NHANES III
In NHANES III a insertion tape calibrated in mm, with a metal buckle at one end was used
(9).
Other surveys
No information on tape measure was found for Risk factor monitoring in Germany.

6.1.4 Removal of clothes

WHO MONICA Project
According to the WHO MONICA Project protocol the participant had to remove his/her shoes
and heavy outer garments (jacket, coat, etc.) before weight and height measurements were
made (3). It was recommended that the circumference of waist and hip be measured while
subjects were semi-clothed, i.e. waist uncovered with the subjects wearing underwear only. If
it was not possible to follow this procedure in a centre, the alternative was to measure the
circumference on subjects without heavy outer garments with all tight clothing, including the
belt, loosened and with the pockets emptied. (3) All MONICA centres asked the subject to
remove heavy outer garments before measurement of waist and hip circumference. About half
of the centres asked also to remove other garments before measurement. (4)
Risk factor monitoring in the Netherlands
In the Monitoring Project on Cardiovascular Disease Risk Factors and the MORGEN-project
in the Netherlands, subjects were asked to remove their outdoor clothes and shoes before
anthropometric measurements were taken (5, 10). In the REGENBOOG, subjects were asked
to remove their shoes and trousers/skirts before the anthropometrical measurements (13).
Risk factor monitoring in Germany
The German Federal Health Survey 1998 measured height, weight, and waist and hip
circumference after the subject removed shoes and heavy clothing (7).
UK National Health Surveys
In the National Health Surveys in UK the subjects were asked to remove their outdoor clothes
and shoes before anthropometric measurements were made (8).
NHANES III
In NHANES III subjects were asked to remove their outdoor clothes and shoes before
anthropometric measurements were made (9).
6.1.5 Technique and resolution of weight measurement
Measurement of weight to the nearest full kilogram should be sufficient for the precise
estimation of the population mean value of weight. However, a biased rounding to the nearest
kilogram may be subjective and cause systematic error. Therefore, the resolution of

measurement should be chosen such that it corresponds to the natural resolution of the type of
scale used. For a balanced beam scale it is usually 200g/100g, and less for a digital scale.
WHO MONICA Project
The MONICA Manual (3) gives the following instructions for the technique of weight
measurement:
The participant should stand in the centre of the platform as standing off-centre may affect
measurement.
The weights are moved until the beam balances (the arrows are aligned).
The weight is read and recorded on the form. Record weights to the nearest 200 g.
Self-reported weights are not acceptable in mobile persons. Refusals to be weighed should be
recorded as refusals. Only participants who are immobile (e.g. amputees) may self-report their
weights. Be sure to note this on the form. Participants must not read the scales themselves.
About half of the centres measured weight to the nearest 200 g and the other half to the
nearest 100 g, but other resolutions were also used (4).
Risk factor monitoring in the Netherlands
In the Monitoring Project on Cardiovascular Disease Risk Factors and the MORGEN-project
in the Netherlands the weight was measured to the nearest 100 g. (5, 10). In the
REGENBOOG project the weight was measured to the nearest 500 g. The subject was asked
to stand in the middle of the scale, feet apart from each other during the weighing. (13)
Risk factor monitoring in Germany
The German Federal Health Survey 1998 protocol required the weight to be measured to the
nearest 100 g. If a persons was heavier than 150 kg, a comment was to be entered in the data
sheet to prevent such an extreme measurement to be flagged as "suspicious" (7).
UK National Health Surveys
In the National Health Surveys in UK weight was measured to the nearest 100 g (8).
NHANES III
In NHANES III the weight was measured to the nearest 10 g (9).

6.1.6 Technique and resolution of height measurement

WHO MONICA Project
The WHO MONICA Manual instructs: The participant is asked to remove his/her shoes and
heavy outer garments. To measure height, the participant should stand with his/her back to the
height rule. The back of the head, back, buttocks, calves and heels should be touching the
upright, feet together. The top of the external auditory meatus (ear canal) should be level with
the inferior margin of the bony orbit (cheek bone). The position is aided by asking participant
to hold the head in a position where he/she can look straight at a spot, head high, on the
opposite wall. Place the triangle on the height rule and slide down to the head so that the hair
(if present) is pressed flat (3).
The MONICA Manual recommended to record information about the height measurement on
the survey form to the nearest centimetre (3). Nevertheless, many centres recorded it to the
nearest half a centimetre (4)
Risk factor monitoring in the Netherlands
In the Monitoring Project on Cardiovascular Disease Risk Factors and the MORGEN-project
in the Netherlands the subject should be standing in upright position against the wall with the
feet at a 45o angle. The height was measured to the nearest 0.5 cm. (5, 10) In the
REGENBOOG project the height was measured to the nearest 0.5 cm. The subject was asked
to stand straight, heels together and feet in 45o angle. (13)
Risk factor monitoring in Germany
In the German Federal Health Survey 1998 subjects were positioned with the back to the
measuring rod. Back of the head, back, and buttocks had to touch the measuring rod. Feet had
to be close together. Subjects were asked to stand upright and avoid forced breathing. The
measurement was made to the closest 0.5 cm. (7) (A paper by Bergmann KE et al. (14) claims
a precision of 0.1 cm for height measurements).
UK National Health Surveys
In the National Health Surveys in the UK the subject was instructed to stretch to the
maximum height and to position the head in the Frankfort plane (eye-ear plane). The reading
was recorded to the nearest 0.1 cm. (8)

NHANES III
In NHANES III the subject was asked to stand straight on the floor board of the stadiometer
with his/her back to the vertical backboard of the stadiometer. The weight should be evenly
distributed on both feet and feet should point slightly outwards at a 60o angle. The horizontal
bar is lowered to the crown of the head with sufficient pressure to compress the hair. The
height was measured to the nearest 0.1 cm. (9)
6.1.7 Technique and resolution of waist and hip measurement
To be able to compare the waist measurements between studies the method of the
measurement needs to be the same. If the waist circumference is measured at the narrowest
portion of the torso, the circumference can, on average, be 10 cm less than when measured
directly above the iliac crest (15).
WHO MONICA Project
In the WHO MONICA Project it is recommended to record the measurement of the waist
circumference at a level midway between the lower rib margin and iliac crest in cm to the
nearest 0.0 or 0.5 cm. Example: If the exact measurement is 87.7 cm, code the item 0875. The
maximum hip circumference over the buttocks should be recorded in cm to the nearest 0.0 or
0.5 cm. Example: if the exact measurement is 93.2 cm, code the item 0930. (3)
In the final survey all populations followed the MONICA protocol. In general, measurements
of waist and hip circumference were made to the nearest 0.5 cm. There were eight centres
which made the measurements to the nearest 1 cm. (16)
Risk factor monitoring in the Netherlands
In the Monitoring Project on Cardiovascular Disease Risk Factors, the MORGEN-project and
the REGENBOOG project the waist and hip circumferences were recorded to the nearest 0.5
cm. The waist circumference was measured from the position between lower rib and upper
side of the pelvis. The hip circumference was measured from the widest position. [(5, 13)
Risk factor monitoring in Germany
In the German Federal Health Survey 1998 waist circumference was measured at the
narrowest portion between the lower rib margin and the upper margin of the iliac crest. Hip
circumference was to be measured as the maximal circumference between the upper margin
of the iliac crest and the crotch (7).

UK National Health Surveys

In the National Health Surveys in the UK the waist circumference was measured from the
midpoint between the lower rib and the upper margin of the iliac crest and hip circumference
from the widest circumference around the buttocks below the iliac crest. Both circumferences
were measured to the nearest 0.1 cm. (8)
NHANES III
In NHANES III the waist circumference was measured from the high point of the iliac crest
and the hip circumference from the maximum extension of the buttocks. Both circumferences
were measured to the nearest 0.1 cm. (9)
6.1.8 Use of self-reported data
The self-reported data of the height is more likely to overestimate the real height. For the
weight, lean persons tend to overestimate their weight and obese persons underestimate. (1, 2)
WHO MONICA Project
In the WHO MONICA Project, self-reported weights and heights were not acceptable in
mobile persons. Those who refused to be measured were to be recorded as refusals. Only for
participants who were immobile (e.g. amputees) could self-report weights be used (3).
Risk factor monitoring in the Netherlands
In the Monitoring Project on Cardiovascular Disease Risk Factors, the MORGEN-project and
the REGENBOOG project no self-reported data were accepted (5).
Other surveys
No information on the use of self-reported data was found for: Risk factor monitoring in
Germany, UK National Health Surveys, and NHANES III.
6.2 Quality assurance
6.2.1 Selection of measurers
WHO MONICA Project
MONICA did not have any instructions for the selection of measurers.

Other surveys
There was also no information on selection of personnel for anthropometric measurements
available for Risk factor monitoring in The Netherlands, Risk factor monitoring in Germany,
UK National Health Surveys, and NHANES III.
6.2.2 Training of the measurers
WHO MONICA Project
In the WHO MONICA Project, seminars were organized to train the persons who were
responsible for the surveys in each population. These then conducted the training of the local
measurers for anthropometric measurements in each population.
There is no general instruction in the WHO MONICA Project about the monitoring of
terminal digit preference in the waist and hip circumference measurements. In populations
where the accuracy of the measurement was 0.5 cm, the zero preference was seen in half of
the populations in waist and hip circumference measurements. (16)
Risk factor monitoring in Germany
The survey personnel of the German Federal Health Survey 1998 was trained by a
commercial company in all aspects of data collection. The performance of the personnel,
especially the adherence to the protocol, was assessed during surprise site visits (17).
EPIC-Germany Study
Each person of the field staff in the Epic-Germany Study was trained in all aspects of data
collection, so that one person could obtain all data from a study participant. The training was
conducted by external experts in interview techniques and anthropometric measurements. It
consisted of one week of lectures and practical experience, followed by certification. (18)
Other surveys
There was no information available in the literature on the type of training of personnel for
anthropometric measurements for Risk factor monitoring in the Netherlands, UK National
Health Surveys, and NHANES III.
6.2.3 Testing the scales
The inaccuracy of the scale can cause bias for the population mean weight.

WHO MONICA Project

In the WHO MONICA Project, it was recommended to check the scales using standard
weights at least monthly and whenever the scales are installed at a new location. If the error
was more than 1 kg the measurements taken since the scales were last checked should not
have been used or reported to the MONICA Data Centre (MDC). Scales were to be checked
for the zero level every day before starting measurement and immediately afterwards. If there
was an error of more than 1 kg, the measurements taken since the scales were last checked
should not have been be used or reported to the MDC. (3)
In the MONICA surveys different centres tested scales at very different frequency during the
surveys. In a few populations the scales were not checked at all and in a few centres scales
were tested daily. In most centres scales were tested on a weekly or monthly basis (4).
Risk factor monitoring in the Netherlands
In the REGENBOOG project the scales were calibrated by manufacture of the scales (6).
Risk factor monitoring in Germany
The description of the German Federal Health Survey 1998 states that equipment for
anthropometric measurements was checked and calibrated daily, but it does not go into
details.
EPIC-Germany Study
The electronic scales used in the EPIC-Germany Study were controlled for measurement
accuracy and technical correctness several times per year, as required by the German Bureau
of Standardization (18)
NHANES III
In NHANES III it was prescribed that the scales should be calibrated at the beginning and end
of each stand (of the mobile examination centre) by using calibration weights (9).
Other surveys
No information on calibration of scales was found for UK National Health Surveys.
6.2.4 Testing height measuring device
WHO MONICA Project

If a height ruler taped to the wall was used for height measurement, the WHO MONICA
manual recommended that the correct vertical position of the ruler was to be checked daily
and corrected as necessary. If the position of the ruler was found to be inaccurate by more
than 1 cm, the measurements taken since the ruler was last checked should not have been used
or reported to the MDC (3).
EPIC-Germany Study
The anthropometers used in the EPIC-Germany Study were controlled for measurement
accuracy and technical correctness several times per year with standard references. (18)
Risk factor monitoring in the Netherlands
In the REGENBOOG project the height measuring device was tested with wooden centimeter
(6).
NHANES III
In NHANES III it was recommended that the stadiometer be calibrated with calibration rods
at the beginning of each stand, once every two weeks, and at the end of each stand after all
examinations (9).
Other surveys
UK National Health Surveys, and Risk factor monitoring in Germany used stadiometers or
height rod respectively, but no information was found whether and how these devices were to
be calibrated.
6.2.5 Testing of measuring tape for waist/hip measurements
WHO MONICA Project
The MONICA Manual requires that the length of the tape used for waist and hip
circumference measurement be checked before starting the survey and the length should be
rechecked against a standard measure at least once a month and replaced as appropriate. (3)
There are no data available about the checking of the tape during the surveys.
Risk factor monitoring in Germany
The description of the German Federal Health Survey 1998 makes a general statement about
daily checking and calibration of equipment used for anthropometric measurements, but it is
not clear whether this includes the tapes (7).

Other surveys
No information on the checking of measuring tape was available for Risk factor monitoring in
the Netherlands, UK National Health Surveys, and NHANES III.
6.2.6 Data quality control during the survey
WHO MONICA Project
In the WHO MONICA Project, there were no special instructions about quality control of
weight and height measurements during the surveys. Only few populations tested or recertified weight and height measurers during the surveys (4).
Risk factor monitoring in the Netherlands
In the REGENBOOG project some visits were done to the examination sited during the
surveys (6).
Risk factor monitoring in Germany
For the German Federal Health Survey 1998 the leader of the local survey team reviewed the
daily data entry forms for plausibility and consistency. Records on the error rate of the
measurers were kept that were then used to determine need for re-training (7). In addition,
there were occasional surprise site visits to observe and evaluate the performance of the
survey personnel according to an agreed checklist (17). The checklist for height measurement
gives the flavour of these evaluations.
Checklist for Height Measurements
Was floor clean, covered?
Did subject remove shoes?
Was heavy clothing removed?
Were feet positioned in parallel?
Was subject standing straight?
Was subject breathing normally?
Correct head position?
Was head bracket properly lowered?

Was head bracket position maintained after subject stepped off the scale?
Was measurement made to closest 0.1 cm?
Were any special circumstances recorded?
Was height measurement > 2 m made properly
Quarterly, the data collected by each measurer were investigated for terminal digit preference,
stability of distribution parameters (mean, median, range, standard deviation), and preference
of terminal digit "0" for extreme values (17).
NHANES III
In NHANES III the online data entry was designed to function as a quality control measure by
minimizing possible measuring and recording errors. Tolerance levels or ranges had been set
for each measurement. If a measurement did not fall within these ranges, the system displayed
an "out of range" message and the examiner could recheck the measurement and enter the
"correct" value. It was possible that some persons values (i.e., very small or very large)
would not be within the "normal" ranges. Therefore, the examiner and recorder would verify
the original measurement value. Again, tolerance levels allowed for some inter-observer
differences, but discrepant measures which exceeded the levels had to be resolved. The
system also edited the data for placement of decimal points and number of digits. For
instance, if the number of positions entered for a measurement exceeded the number of
positions allowed for a measurement, a message was displayed and the cursor would not
advance until the problem was resolved. (9)
EPIC-Germany Study
Each measurer was observed at least four times per year during the 4-year study period.
Quality control criteria were location of measurement points, measurement procedure, and
handling of measurement device. Deviations from the required measurement procure were
discussed with the measurer and the monitoring was repeated until the measurements were
performed satisfactorily. (18)
Other surveys
No information was found about data quality control during the survey for UK National
Health Surveys.
6.2.7 Retrospective quality assessment reports

WHO MONICA Project

In the WHO MONICA Project, retrospective quality assessment reports were prepared (4, 16).
They give detailed description of the instruments and procedures used, and the achieved
quality of weight and height measurements and waist and hip circumference measurements in
each population.
Other surveys
No information on retrospective quality assessment of anthropometric measurement was
located for Risk factor monitoring in the Netherlands, Risk factor monitoring in Germany, UK
National Health Surveys, and NHANES III.
6.3 Indicators used for reporting the results
WHO MONICA Project
In the WHO MONICA Project the results from weight and height measurements were
reported using population means of body mass index (BMI), weight and height (19). For
overweight, two cutoff points were used, BMI > 25 kg/m2 and BMI > 30 kg/m2 (20).
In the WHO MONICA Project the waist and hip circumference measurements are reported
using waist-to-hip ratio (WHR), and means of waist and hip circumference measurements
(21). For obesity, two cutpoints for the percentage of waist-hip ratio were used: WHR > 0.94
and WHR > 1.02 for men and WHR > 0.80 and WHR > 0.88 for the women (20). Also limits
WHR > 0.80 and WHR > 1.00 have been used (19).
Risk factor monitoring in the Netherlands
In the Monitoring Project on Cardiovascular Disease Risk Factors in the Netherlands
categorised BMI as: < 25 kg/m2, 25 - 29.9 kg/m2, > 30 kg/m2. (10)
German National Health Survey
In the German National Health Survey 1984-91 the following categories of BMI were used: <
25 kg/m2 and > 30 kg/m2. (22) In a report of the German Federal Health Survey 1998 (14),
cutoff points for BMI were < 20, 20 to < 25, 25 to < 30, and 30 kg/m2. Cutoff points for
waist-hip ratio were for men > 1 and for women > 0.85. The German Federal Health Survey
1998 used the identical cut points for BMI and waist/hip ratio (14)

UK National Health Surveys

In the Health Survey for England the BMI and waist-to-hip ratio were used in reporting.
Obesity was defined as a BMI greater than 30 kg/m2 , and overweight as > 25 kg/m2 but 30
kg/m2. (8)
NHANES III
In NHANES III the following categories of BMI were used: overweight (BMI > 25.0 kg/m2),
pre-obese (BMI 25.0 - 29.9 kg/m2), class I obese (BMI 30.0 - 34.9 kg/m2), class II obese
(BMI 35.0 - 39.9 kg/m2) and class III obese (BMI > 40 kg/m2). (23) Waist circumference was
used when reporting obesity and cut-points, > 102 cm for men and > 88 cm for women were
used. (24)
6.4 Discussion and conclusion
In surveys where field examinations are made, weight and height should be measured. The
measurements are cheap and easy to perform and accurate if proper equipment, procedures
and quality assurance are used. Bias can result either from incorrect measurement procedure
or false calibration of the measurement devices.
The measurement of waist and hip circumferences is also recommended, although their
measurement is not as easy as the measurement of weight and height. The level at which the
measurement is to be made, as well as the pressure of the tape measure will need to be
carefully standardized. There were differences between surveys in the level at which
measurements were made.
At the moment, a balanced beam scale is still the most reliable device for weight
measurement. Digital scales, which are already employed by some studies, are easy to use and
to move from one examination site to another, but they are usually difficult or impossible to
calibrate.
All surveys considered in this report asked the subjects to remove their outdoor clothes and
shoes before height, weight, waist and hip circumference measurements. In some surveys, the
participants were allowed to wear trousers, in others, trousers were removed. Trousers can
easily weigh up to one kilogram, and are often made of thick material. Therefore, they can
introduce a noticeable bias in the population estimates of BMI and waist and hip
circumference.

There were differences between the surveys in the resolution at which the measurements were
recorded. Even a low resolution, such as measuring weight to the nearest kilogram, is not a
problem for population monitoring, provided that the rounding is done properly.

BMI was used as the indicator of overweight and obesity in all surveys. Different ways of
categorizing BMI were used in the reporting, but all surveys used 30 kg/m2 as the lower limit
for obesity.

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From : http://www.thl.fi/publications/ehrm/product1/section6.htm