Clin Physiol Funct Imaging (2007) 27, pp135137

doi: 10.1111/j.1475-097X.2006.00718.x

Review Article

The origin of the 173-m2 body surface area normalization:

problems and implications
James G. Heaf
Department of Nephrology B, Copenhagen University Hospital, Herlev, Denmark

Summary
Correspondence
James G. Heaf, Graevlingestien 9,
2880 Bagsvaerd, Denmark.
E-mail: heaf@dadlnet.dk

Accepted for publication

Received 23 July 2006;
accepted 3 November 2006

Key words
body surface area; glomerular filtration rate

A historical review of the origins of body surface area (BSA) determination reveals a
number of theoretical and methodological errors, as does the choice of 173 m2 as
the normal BSA for humans. BSA normalization is justifiable for some physiological
variables, e.g. glomerular filtration rate and cardiac output, but not all. However,
other normalization indices, in particular extracellular volume, offer theoretical and
practical advantages compared with BSA. While the choice of the figure 173 m2 is
essentially arbitrary, and inapplicable to modern Western populations, its retention
as a permanent physiological constant is recommended, in order to permit
international and historical comparisons.

Introduction
173 is probably the most famous number in medical physiology, expressing (in square meters) the standardized body surface
area (BSA) used to normalize a number of physiological
variables, in particular glomerular filtration rate (GFR) and
cardiac output. The arguments for and against using body surface
area to normalize physiological data have recently been reviewed
(Delanaye et al., 2005). There are several problems:
(1) Surface area is a fractal variable (Mandelbrot, 1982), i.e.
the more it is magnified, the more details become apparent, and
the greater the total surface area becomes, virtually ad infinitum.
Thus, BSA is essentially just as indefinable as the length of the
British coastline (Slone, 1993), and the figure of 173 represents
an arbitrary choice of magnification.
(2) Attempts to measure surface area in severely obese
individuals have proved to be both difficult and inaccurate
(Tucker & Alexander, 1960).
(3) The use of any index to normalize physiological
parameter requires first, that the parameter is a statistically
significant linear function of the index, and secondly, that the
intercept is not significantly different from zero. These
requirements seem to be fulfilled for BSA when applied to
GFR in adults, but not for cardiac output or renal plasma flow
(Turner & Reilly, 1995). The authors, however, add that
indexing only partially reduced dependency on body surface
area, since estimated slopes of the regressions of the indexed
measures of GFR on BSA were not actually zero. Furthermore,

the correlation coefficient between GFR and BSA can be as low

as 024 (Dooley & Poole, 2000): the poorer the correlation, the
more difficult it is to prove deviation from the zero intercept
and deviation from linearity.
(4) A normalized physiological value should in principle be
constant for all young, healthy population groups, e.g. males,
females, children and adults. Problematically, the use of BSA for
GFR normalization results in low values for children aged 15
years (Kurtin, 1988), a finding which has no obvious
physiological explanation. While some studies have shown a
lower GFR in females (Gross et al., 1992; Peters, 1992), other
studies have shown no difference (Granerus & Aurell, 1981;
Grewal & Blake, 2005). Thus, BSA correction is probably valid
for intersexual comparisons.
(5) The theory for the choice of BSA as index is that it is an
expression of a universal physiological law, viz. that body
metabolism is proportional to BSA. Thus, metabolism should be
proportional to weight2/3, even when different species are
compared. Toxicological studies, however, suggest that the ratio
is nearer weight3/4 (Slone, 1993).
Body weight is not a useful normalization index, but possible
alternatives include extracellular volume fluid, total body water
and lean body mass (Kurtin, 1988; Peters, 1992; Delanaye et al.,
2005). In particular, ECV seems to solve the problem of low
normalized GFR in children (Peters et al., 1994). These are
relatively difficult to measure; however, ECV can be measured
directly from the distribution volume of chrome-EDTA during
GFR estimation (White & Strydom, 1991).

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Journal compilation  2007 Blackwell Publishing Ltd Clinical Physiology and Functional Imaging 27, 3, 135137

135

136 Origin of body surface area normalization, J. G. Heaf

Measurement of BSA
The most commonly used formula for determining BSA is the
Du Bois formula from 1916 (Du Bois & Du Bois, 1916). BSA
was determined by tightly covering the patients with manila
paper moulds. The moulds were then removed, opened and
placed flat on photographic film. The film was subsequently
exposed to light. Finally, the unexposed film was cut out and
weighed. The BSA was derived from the weight by dividing by
the average density of the photographic area. While the
methodology was impeccable, only eight adults and one child
were studied. The child was a cachexic girl weighing 627 kg at
21 months of age, and the adults included the notorious Mrs
McK, a 15-m tall lady weighing 100 kg, who is an outlier in
many subsequent equations. Other patients included an 18-yearold with cachexia because of type 1 diabetes and a 36-year-old
man with the physical development of an 8-year old. The
derivation of the equation was based on the arguable philosophical premise that, as BSA is two dimensional, the sum of the
power for weight multiplied by 3 added to the power for height
had to be exactly 2. Surprisingly, the derived formula works
well for normal adults, but breaks down when applied to
children. Tucker & Alexander (1960) attempted to assess its
relevance for extremely obese patients (>100 kg), but experienced considerable difficulty: it was difficult for the four obese
people to stand up for the time required for the entire taping
process; it was decided to use the measurement in which the

tape followed all the folds of the skin as opposed to a straightline measurement between two points; the exact location of
the superior border of the greater trochanter was difficult to
determine, etc. (Fig. 1). They concluded that the Du Bois
formula was reasonably accurate ()11% to +2%), while the
derived linear formulae were unsatisfactory ()8% to +20%).
Readers will prefer to use the formulae developed by Gehan &
George (1970) or Haycock et al. (1978), both of which are
based on a considerably larger number of patients (401 and 81,
respectively), although the superiority of these formulae to the
Du Bois formula remains to be clearly proved (van der Sluys &
Guchelaar, 2002).

The origin of 173 m2

In these evidence-based times, it is perhaps surprising to read
how little documentation was required for the derivation of this
figure, which first appeared in a study by McIntosh et al. (1928)
(Fig. 2). On the basis of clearance studies of eight children and
seven adults, the paper states: Our experience confirms that of
Addis and his colleagues. More constant normal values
are obtained if one substitutes A ( surface area) in place of
W ( weight) in the clearance formulae. We have found it
convenient to use as a unit the surface area 173 square meters
which is the mean of the areas of men and women of 25,
estimated from the adjusted medico-actuarial tables of Baldwin
and Wood published by Fiske and Crawford. The Du Bois
formula was used. The tables described young US citizens
applying for life insurance. They were not referenced directly,
but an adjusted version was published by Fisk & Crawford
(1927). While these individuals had been examined fully
clothed, every effort was made to reach as accurate an estimate
as possible: the figures for men were adjusted from the MedicoActuarial Tables by subtracting 1 inch from height in shoes, and
5 pounds from weight in clothes, and for women by
subtracting 15 inches and 4 pounds, respectively, thereby
giving us an insight into American clothing standards in the
1920s. There seems to be a minor error in the calculation: the
correct figure is 172 m2.

Quo vadis?

Figure 1 Determining BSA in the obese (Du Bois & Du Bois, 1916).

The figure 173 m2 has served the physiological community

well for nearly 80 years, but is clearly no longer applicable to
Western populations, as can be seen from Table 1. As early as

Figure 2 The birth of a number. Reproduction of the first publication of the figure 1.73 m2. (McIntosh et al. 1928).
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Journal compilation  2007 Blackwell Publishing Ltd Clinical Physiology and Functional Imaging 27, 3, 135137

Origin of body surface area normalization, J. G. Heaf 137

References

Table 1 Evolution of body dimensions 19272002.

25-year
olds
Male
Weight (kg)
Height (cm)
BSA (m2)
Female
Weight (kg)
Height (cm)
BSA (m2)
All
BSA (m2)
BMI (kg m)2)

US 1927
(Fisk &
Crawford,
1927)

US 2002
(Ogden
et al.,
2004)

EU 2002
(Health
Statistics,
2002)

689
1727
180

832
1768
204

786
1772
198

585
1626
162

710
1631
181

648
1654
174

172
223

192
267

186
243

BMI, body mass index; BSA, body surface area.

1951, Homer Smith (Smith, 1951) noted that there was a

problem with the value 173 m2. The figure of 173 sq. m. is of
course arbitrary. The writer has averaged the surface areas
reported by 11 groups of investigators and obtains 185 sq.
m. for 263 men and 181 m2 for 164 women. If we accept the
basic premise that the index of normalization should be the
average BSA of US 25-year-old males and females, then a new
index of normalization 192 m2 should be adopted. This would
have the added advantage of resulting in an immediate, but
unfortunately one-off, 9% increase in world GFR. The approach
is, however, problematic. Periodic adjustments, e.g. once every
decade, would be required for the foreseeable future. Some
physicians might be horrified by the implication that an average
body mass index (BMI) of 267 kg m)2 would now be defined
as normal. One possible solution could be to choose a less
overtly obese population, such as the European Union. This
would improve, but not remove, the normative problem, but
might just provide a short respite. Another possible approach
follows from the observation that 173 m2 corresponds to a BMI
of 223, a figure which both then (Fisk & Crawford, 1927) and
now is associated with the lowest mortality. Thus, serendipity
has given us an optimal value for BSA, which should be
preserved for posterity regardless of present and future
developments of the reference interval. While accepting that
the choice of 173 m2 is arbitrary, the political decision to
permanently retain the value will permit comparisons of
different populations, separated by both geography and time.
Again, to quote Homer Smith (Smith, 1951): It is immaterial
which figure is used so long as all investigators use the same
figure, and since innumerable data are now reported in terms of
173 m2, we may accept this usage as established. A suitable
symbol of the decision to create this new fundamental
physiological constant could be the deposition of a square
platinumiridium plate of exactly 173 m2 at the Bureau
International des Poids et Mesures, Se`vres, Paris.

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 2007 The Author

Journal compilation  2007 Blackwell Publishing Ltd Clinical Physiology and Functional Imaging 27, 3, 135137