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ORIGINAL ARTICLE
BMI-related errors in the measurement of obesity
KJ Rothman
Body mass index (BMI) has various deficiencies as a measure of obesity, especially when the BMI measure is based on
self-reported height and weight. BMI is an indirect measure of body fat compared with more direct approaches such as
bioelectrical impedance. Moreover, BMI does not necessarily reflect the changes that occur with age. The proportion of body fat
increases with age, whereas muscle mass decreases, but corresponding changes in height, weight and BMI may not reflect
changes in body fat and muscle mass. Both the sensitivity and specificity of BMI have been shown to be poor. Additionally, the
relation between BMI and percentage of body fat is not linear and differs for men and women. The consequences of the errors in
the measurement of obesity with BMI depend on whether they are differential or nondifferential. Differential misclassification, a
potentially greater problem in case–control and cross-sectional studies than in prospective cohort studies, can produce a bias
toward or away from the null. Nondifferential misclassification produces a bias toward the null for a dichotomous exposure; for
measures of exposure that are not dichotomous, the bias may be away from the null. In short, the use of BMI as a measure of
obesity can introduce misclassification problems that may result in important bias in estimating the effects related to obesity.
International Journal of Obesity (2008) 32, S56–S59; doi:10.1038/ijo.2008.87
Body mass index (BMI) as a measure of obesity is imperfect. BMI is defined as weight divided by height squared (kg/m2). As it
First introduced in the mid-1800s, BMIFan index based on is based on only weight and height, BMI does not measure body
height and weightFhas been used to measure body fat. fat directly. As an indirect measure of obesity, BMI has several
Although it is an indirect measure, research results suggest drawbacks. For example, a person’s percentage of body fat is
that it is correlated with direct measures such as underwater known to increase with age, whereas muscle mass decreases, but
weighing (densitometry) and dual-energy x-ray absorptio- the person’s weight and height do not necessarily reflect such
metry (DEXA). changes in body fat and muscle mass (Figure 1). Some elderly
As a measure of body fat, however, BMI has serious flaws. It persons who are portly but have low muscle mass have normal
does not, for example, take age, sex, bone structure, fat or even low BMI scores, an underestimation of body fat. Also,
distribution or muscle mass into consideration. For these lean persons with high muscle mass, such as athletes, sometimes
reasons and others, BMI can misrepresent the quantity it is have high BMI scores, an overestimation of body fat.
used to measure. There are three main issues to consider Furthermore, the relation between BMI and percentage of
when using BMI, namely (1) errors stemming from the fact body fat is nonlinear, which gives the impression that some
that BMI is an indirect measure of obesity, (2) errors in self- people with considerably different BMIs have identical or nearly
reported data and (3) the poor sensitivity and specificity of identical percentages of body fat. Another problem is that the
BMI. These problems result in misclassification of indivi- correspondence between BMI and body fat differs for men and
duals with respect to body fat, and that misclassification, can women. That is, a man and woman could have the same height
in turn, introduce bias in studies that deal with body fat, and weight and thus have identical BMI scores, but the woman
such as those estimating the effects of obesity on health would most likely have a greater percentage of body fat (Figure 2).
outcomes.
Self-reported data
Correspondence: Dr KJ Rothman, VP Epidemiology Research, RTI Health
Self-reported data are often inaccurate. The use of self-
Solutions, 200 Park Offices Drive, Research Triangle Park, NC 27709-2194,
USA. reported height and weight leads to considerable errors in
E-mail: krothman@rti.org studies relying on BMI,3 in contrast to the use of data
Errors in BMI
KJ Rothman
S57
40 100 60
90
80
30
60
2.0
0.050
1.9
Risk Ratio
1.5 0.025
1.4 0.020
1.3 0.015
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0.50 0.005
0.50 1.0 0.60
0.60 0.000
Sp 0.70
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0.95 ec 0.80
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Sp ific
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eci ity 0.90
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ity 0.90
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1.00
0.60
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0.55
1.00
0.60
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ity itivity
0.55
sitiv Sens
0.50
Sen
Figure 5 Effect of bias from nondifferential misclassification of exposure on
Figure 3 Bias in the risk ratio from nondifferential misclassification of a population-attributable proportion.
dichotomous exposure indicator as a function of its sensitivity and specificity.
16
14
12
10
Mortality rate
0.010
0.009 8
0.008
0.007
6
Risk Difference
0.006
4
0.005
0.004 2
0.003
0.002 0
0.001 18 20 22 24 26 28 30 32
0.50 Actual BMI
0
0.60
1.00
Figure 6 Effect of nondifferential errors in BMI can be a bias away from the
0.95
0.70
0.90
Sp null when BMI is not dichotomized. The green points in the figure indicate the
0.85
ec 0.80
0.80
ific true BMI values, and the red points indicate the incorrect values, which are
0.75
ity 0.90
0.70
ity reported as being closer to the average than the true values. The result of such
0.65
itiv
0.60
1.00 s
0.55
Sen
errors is to exaggerate the slope of the relation between BMI and mortality.
0.50
Figure 4 Bias in the risk difference from nondifferential misclassification of a specificity is much stronger than the dependence on
dichotomous exposure indicator as a function of its sensitivity and specificity. sensitivity. A similar relation holds for the risk difference
(Figure 4).
The situation is different for the population-attributable
who are obese are identified, the relative risk will still be proportion. If sensitivity is perfect, no bias occurs in this
determined to be 2.0 (assuming that 2.0 is the correct value). measure, regardless of imperfect specificity, but with decreas-
If the specificity is imperfect, however, the bias is great even ing sensitivity, the amount of bias becomes increasingly
for small decreases in specificity because the group of people dependent on specificity (Figure 5). As shown in Figures 3–5,
identified as obese will include many who actually are not. reductions in specificity and sensitivity can produce sub-
Thus, errors in specificity dilute the risk ratio dramatically. stantial biases toward the null with nondifferential mis-
Figure 3 illustrates that the dependence of the risk ratio on classification.