Journal Pone 0273824

PLOS ONE
RESEARCH ARTICLE
Design and validation of equations for weight

estimation in adolescents
Daniel Meyer Coracini ID1☯, Cláudia Rucco Penteado Detregiachi ID1,2, Sandra
Maria Barbalho ID1,3,4*, Daniel De Bortoli Teixeira1☯
1 Postgraduate Program in Structural and Functional Interactions in Rehabilitation - University of Marı́lia
(UNIMAR), Marı́lia, São Paulo, Brazil, 2 Department of Nutrition, University of Marı́lia (UNIMAR), Marı́lia, São
Paulo, Brazil, 3 Department of Biochemistry and Pharmacology, School of Medicine, University of Marı́lia
(UNIMAR), Marı́lia, São Paulo, Brazil, 4 School of Food and Technology of Marilia (FATEC), Marilia, São
a1111111111 Paulo, Brazil
a1111111111
☯ These authors contributed equally to this work.
a1111111111 * smbarbalho@gmail.com
a1111111111
a1111111111
Abstract
OPEN ACCESS
Introduction
Citation: Coracini DM, Detregiachi CRP, Barbalho
Measuring weight is difficult to be carried out in bedridden people, with physical deformity or
SM, Teixeira DDB (2023) Design and validation of
equations for weight estimation in adolescents. in emergency units. Under these circumstances, one option is to estimate the weight.
PLoS ONE 18(2): e0273824. https://doi.org/
10.1371/journal.pone.0273824
Objectives
Editor: Eduardo José Cuestas, Hospital Privado
Universitario de Córdoba: Hospital Privado Centro The aim of this study is to propose and validate equations for estimating the weight of Brazil-
Medico de Cordoba, ARGENTINA ian adolescents based on anthropometric variables related to body weight.
Received: July 28, 2021
Accepted: August 16, 2022 Methods

Published: February 2, 2023 The study was developed based on a database created from data collection of a primary
Copyright: © 2023 Coracini et al. This is an open project, which had information from 662 Brazilian adolescents (10 to 19 years old). Based
access article distributed under the terms of the on the variables sex, age (days), weight (kg), height (m) and neck circumference (NC) (cm),
Creative Commons Attribution License, which
equations for estimating weight of adolescents were proposed. The formulas were proposed
permits unrestricted use, distribution, and
reproduction in any medium, provided the original after performing multiple linear regression models and subsequently tested and validated
author and source are credited. using appropriate statistical tests, considering 99% confidence.
Data Availability Statement: Rucco Penteado
Detregiachi, Cláudia (2022), “Anthropometric data
and sexual maturation of adolescents”, Mendeley Results
Data, V1, doi: 10.17632/txfx62y5wp.1 (https://data. Two formulas were generated, the “Rucco Formulas—Adolescents”, one for girls:
mendeley.com/datasets/txfx62y5wp/1).
-131.63091 + (0.00209 × A) + (37.57813 × H) + (3.71482 x NC) and another for boys:
Funding: The authors received no specific funding - 15.2854 + (-0.00414 × A)+ (14.30315 × H2)+ (0.04888 x NC2). Statistical test (R2) indicated
for this work. The funders had no role in study
that the proposed formulas are suitable for estimating weight. Low values of REQM and
design, data collection and analysis, decision to
publish, or preparation of the manuscript. high values of CCI (> 0.8) also reinforce the quality of the proposed formulas.
Competing interests: The authors have declared

that no competing interests exist.
PLOS ONE | https://doi.org/10.1371/journal.pone.0273824 February 2, 2023 1 / 14

PLOS ONE Equations for weight estimation in adolescents
Conclusions
The current weight of adolescents can be estimated with adequate accuracy and precision
using sex-specific “Rucco Formulas—Adolescents”, generated from regression models
using only three predictor variables.
Introduction
Anthropometric measurements represent one of the most used nutritional assessment meth-
ods because it is non-invasive, low-cost, practical and easy to apply [1]. The most used anthro-
pometric measures in the pediatric age group are weight, height, head circumference, and
abdominal circumference [2].
Furthermore, bodyweight is also an important data in the clinical area, being used to
accurately calculate dosages of drugs and fluids, as well as in the correct selection of medical
equipment [3] and ventilation settings [4, 5]. However, weight measurements are difficult to
perform in bedridden people. Another aspect to consider is that in emergency units, where
time is a critical determinant, there is usually no possibility of assessing weight due to logistical
characteristics and practical reasons of the location [3].
An alternative in these circumstances is the weight estimate, for which there are different
methodologies. One of them is the method of counting the fingers of both hands, which can
also be represented by an age-based equation [6]. Age-based formulas are the oldest methods
for estimating weight, with several equations available [7–14].
There are formulas based on body measurements to estimate the actual weight of children
and adolescents such as mid-arm circumference (MAC), humerus length, and body height [4,
5, 15–21].
We can assume that the weight estimation principles used in both age-based equations
and the finger counting methodare more associated with the expected weight than the actual
weight, since they do not consider body measures with the explanatory power of body weight.
However, in some aspects, the actual weight is the most critical evaluation parameter, since it
is necessary to medication dosages or in the correct selection of medical equipment. Moreover,
it is also necessary to identifyweight disorders as early as possible.
Other body measurements can also be associated with actual body weight, and the study of
new equations can bring a new scenario for weight estimation both in the clinical area and in
primary care. Thus, this study aimed to propose and validate equations for estimating the
weight of Brazilian adolescents based on anthropometric variables related to body weight,
including the neck circumference measure, never before used in weight estimation formulas,
given its practicality and ease of collection.
Materials and methods

This was a primary, observational, cross-sectional, quantitative, and analytical study developed
based on a database created in 2018 related to a preliminary project approved by the Research
Ethics Committee of the University of Marı́lia. This database contains data from 662 adoles-
cents aged 10 to 19 years, on which it was possible to apply statistical tests. For the construction
of the database, the minimum number of samples was determined [22] considering a descrip-
tive study of the variable weight. The parameters used for the calculation were: 99% (confi-
dence level); 5 kg (total width of confidence interval); and, 20 kg (standard deviation of the
variable), totaling a minimum sample size of 425 students.

Tais adolescents foram recrutados em public and private schools in the city of Marı́lia/SP/
Brazil, with prior authorization from the school director. In these educational institutions, all
adolescent students were invited to participate by sending an invitation letter to their parents
or guardians. Those who agreed with the adolescent’s participation returned the signed Free
and Informed Consent Form, plus information about medications in use and the presence of
disease. Adolescents who had the consent of their parents or guardians but who had diabetes,
thyroid disease or anomalies in the head and neck region, or who were still in the gestational
period were excluded.
From the database, information on sex, birth date, height (m) and neck circumference
(NC) (cm) were used in the tests of the explanatory power of variations in the measured
weight. This is justified based on proposing formulas for estimating weight with the least num-
ber of variables to meet the need for speed and practicality in clinical and emergency units. In
addition, the measured weight (kg) was also used as a reference. The measurement of weight
and height was performed according to the recommended techniques [23, 24]. Body weight
was collected using a platform-type digital scale, with a maximum capacity of 200 kg. Height
was measured with the aid of a portable collapsible statemeter. The NC was obtained with the
adolescent standing and the head elevated to acquire the midpoint between the lower part of
the chin and the manubrium sternal bone. Afterwards, the adolescent’s head was placed in the
Frankfurt position and an inextensible tape measure was applied perpendicularly around the
neck, exactly on top of the previously obtained midpoint. When the male adolescent had an
evident laryngeal prominence, the measurement was taken just below it. This technique was
adapted from the one used by Preis et al. [25] and Vasques et al. [26]. The research team
responsible for collecting the anthropometric data was trained to determine the agreement of
the measurements taken by its components in relation to an experienced professional. To eval-
uate the calibration of the team, the statistical methods of precision and accuracy proposed by
Habicht, 1974 [27] were used.
Age was calculated in days by the difference between the date of assessment of the measures
and the birth date. Information on the sexual maturity stage that was available in the database
was also included.
The nutritional diagnosis of adolescents was determined using the anthropometric indica-
tor of body mass index (BMI) for age, which was classified based on the reference standards of
the Ministry of Health [1]. In the preliminary study, the stage of sexual maturity was defined
by self-assessment, according to the criteria defined by [28]. Although it is a subjective evalua-
tion and with some limitations, it is the most suitable for population surveys due to the diffi-
culty of being obtained by medical evaluation [29]. Stage one corresponds to prepubertal
development and growth, while stages two to four correspond to the progression from puberty
to full maturity (stage five) [28].
The database was separated by sex and divided into two parts, with 70% data reserved for
the proposal of formulas (n = 462) and 30% (n = 200) for the validation step. This separation
of the database was performed using the randomization method available in the spreadsheet.
Additionally, the validation was also performed considering the stages of Tanner’s sexual
maturity.
Prior to constructing the formulas, variables were described through the estimation of
the means, median, standard deviation, minimum and maximum values of each population
(girls and boys) evaluated. Subsequently, Student’s t-test or Mann Whitney test was applied
to check for differences between the values of the variables in these populations. The choice
of tests was based on the presence/absence of normality indicated by the Kolmogorov-Smir-
nov test. The nutritional diagnosis was compared between the sexes, using the Chi-square
test.

Equations for weight estimation were obtained using multiple stepwise linear regression
considering the level of significance of 1% for the input and output of selected variables (age,
height, and NC). To determine the equations, we sought to evaluate possible linear and qua-
dratic relationships between the weight and the input variables.
The quality of the estimative of weight were performed with descriptive analysis, mean dif-
ference between the measured and estimated values and the respective 99% confidence interval
(99% CI). In the concordance analysis, the Bland-Altman plot, the coefficient of determination
(R2), root mean square error (RMSE), intraclass correlation coefficient (ICC), and its respec-
tive 99% CI were used. To verify the magnitude of errors in each equation, the graphical analy-
sis of standardized residuals and the Shapiro-Wilk test were used to check the adequacy of the
proposed model with the necessary statistical assumptions [30]. The R2 indicates the percent-
age of the variation in the measured weight that the proposed estimation model explains.
According to Lima et al. [30], values greater than 0.7 indicate that the equation can be consid-
ered adequate for estimating weight. For all analyses, 1% was adopted as the significance value.
The relative frequency of errors ((predicted–observed)/observed) was also verified as a func-
tion of age and sex, with an error below 10% being considered acceptable.
After defining the formulas, they were tested and validated using the rest of the data (30%).
For validation were used the mean difference between the measured and estimated values and
the respective 99% confidence interval (99% CI), the coefficient of determination (R2), root
mean square error (RMSE), intraclass correlation coefficient (ICC), and its respective 99% CI
were used. The software R [31] was used for statistical analyses.
This research project was approved by the Research Ethics Committee of the University of
Marı́lia (protocol number 3,682,722).
Results
Proposed weight estimation formulas
Data from 462 adolescents (70% of total sample) were used, of which 64% were girls. The vari-
ables Age and BMI presented normal distribution (p>0.01), while the variables weight, height
and NC did not present normal distribution (p<0.01). The two groups, girls and boys, did not
differ in BMI (Table 1). However, the boys had higher weight, height, and NC measurement
(p <0.01).
The determination of the nutritional diagnosis indicated a predominance of eutrophy;
although 35% of girls and 37% of boys were overweight (overweight or obese), a diagnosis also
present in 36% general sample (Table 1).
The differences observed between girls and boys for some anthropometric measures
(Table 1) support different formulas for estimating weight for both sexes.
Multiple linear regression models were applied to the variables age, height and NC to
develop formulas for estimating weight. Based on the value of R2, for the girls’ group, these var-
iables together presented explanatory power of the measured weight variation greater than
70% (0.7), while for the boys’ group, the combined explanatory power was greater than 75%
(0.75) (Table 2).
The variable NC was the first selected by the model in both cases, being responsible for
64.74% (R2 = 0.6474) of the variation in the weight of the group of girls and 71.09% (R2 =
0.7109) in the group of boys, the latter using the squared NC values. Height was the second
variable to enter the model, being responsible for an additional explanation of 8.35% and
3.28% for girls and boys (squared height), respectively. Finally, the age variable contributes
with an additional explanation of 1.67% (girls) and 2.81% (boys) (Table 2).

Table 1. Description of the sample of adolescents used in the proposal of formulas for weight estimation.
Variables Girls (n = 296) Boys (n = 166) p-value
Mean±standard deviation(median)
Age (years) 14.5±2.1 (15.0) 14.8±2.2 (15.0) 0.2241�
Weight (kg) 57.0±13.7 (55.2) 62.4±16.3 (59.1) 0.0002��
Height (m) 1.6±0.1 (1.6) 1.7±0.1 (1.7) <0.0001��
Neck circumference (cm) 31.4±2.5 (31.0) 34.5±3.2 (34.4) <0.0001��
2
BMI (kg/m ) 22.3±4.8 (21.5) 22.0±4.2 (20.9) 0.5852�
��
Nutritional diagnosis n (%) Lean 7 (2%) 7 (4%) 0.323��
Normal weight 186 (63%) 98 (59%)
Overweight 62 (21%) 30 (18%)
Obesity 41 (14%) 31 (19%)
Kg = kilos. m = meters. cm = centimeters.

�
Student’s t-test of independence.
��
Mann Whitney: independent samples.
��
Chi-square test.
��
Classification according to Brazil [1].
https://doi.org/10.1371/journal.pone.0273824.t001
These data support the possibility of proposing formulas for estimating weight in adoles-
cents with a small number of variables, in addition to being easily obtainable in clinical or
emergency practice.
The graphic summary in Fig 1 shows the formulas developed to estimate weight in adoles-
cents, as a function of sex, according to data in (Table 2). These were called “Rucco Formulas
—Adolescents”.
The final model for both groups reached R2 values above 0.70, 0.75 for girls and 0.77 for
boys. It is worth mentioning that R2 values greater than 0.7 indicate that the proposed formula
can be considered adequate for estimating weight [30].
Through the data used to construct the formulas, a preliminary check of the quality of the
estimates of the proposed models was performed Table 3 and Fig 2. For both groups, the mean
values of the measured and estimated weights are practically coincident, presenting only a
greater homogeneity in estimated data (lower values of standard deviation) concerning the
Table 2. Multiple linear regression models for estimating weight (kg) in adolescents.
Variables Estimated parameter SE p-value R2
Girls (n = 296)
Intercept -131.63091 7.75506 <0.0001
NC (cm) 3.71482 0.17865 <0.0001 0.6474
Height (m) 37.57813 5.28514 <0.0001 0.7309
Age (days) 0.00209 0.00049182 <0.0001 0.7476
Boys (n = 166)
Intercept -15.28545 4.10176 0.0003
NC2 (cm) 0.04888 0.00344 <0.0001 0.7109
Height2 (m) 14.30315 2.26142 <0.0001 0.7437
Age (days) -0.00414 0.00095778 <0.0001 0.7718
2
NC = neck circumference. m = meters. cm = centimeters. SE = standard error; R = coefficient of determination.

Fig 1. Proposed formulas for estimating adolescent weight, according to sex. Weight (kg). A = age (days). H = height (m). NC = neck circumference
(cm).
https://doi.org/10.1371/journal.pone.0273824.g001
Table 3. Quality of the estimates of the proposed formulas for estimating adolescent weight.
Girls (n = 296) Boys (n = 166)
Mean (SD) of the measured weight (kg) 55.2 (10.8) 60.3 (13.3)
Mean (SD) of the estimated weight (kg) 55.2 (9.33) 60.3 (11.7)
Difference (SD) between mean values of the measured and estimated 7.3×10−7 (5.4) 1.3 × 10−6 (6.4)
weights (kg)
99% CI difference (-0.85; 0.85) (-1.33; 1.33)
R2 0.75 0.77
RMSE 5.41 6.3
ICC (p-value) 0.86 0.87
(4.81×10−81) (1.7×10−50)
99% CI (ICC) (0.81; 0.89) (0.81; 0.91)
SD = standard deviation. 99% CI = 99% difference confidence interval. R2 = coefficient of determination.

RMSE = root mean square error. ICC = intraclass correlation coefficient.
measured data, demonstrating a slight smoothing of the estimates. The low values of RMSE
and the high values of CCI (> 0.8) also reinforce the quality of the proposed formulas.
The assumptions of the regression analyses were tested to observe the validity of the proposed
formulas. The Shapiro-Wilk test confirmed the residual normality of the models proposed for
Fig 2. Weight values observed and estimated by the proposed formulas. kg = kilos.

Fig 3. Graphical analysis of formula residuals for adolescent weight estimates. kg = kilos.
girls (p = 0.0930) and boys (p = 0.0374). The graphical analysis of the standardized residuals as
a function of the weights estimated by the proposed equations (Fig 3) shows the presence of
homogeneity in residual variances, as well as the absence of extreme values and outliers, thus
meeting the assumptions of the regression analyses and, consequently, the validity of formulas.
The Bland-Altman plots showed a strong consistency between the observed and the pre-
dicted. Between the weight observed and the estimated weight (Fig 4) the limits of agreement
(Reference Range for difference), for the girls was -13.989 to 13.989 and for the boys was
-16,414 to 16,414. The Mean difference was -0.000 (CI -0.85 to 0.85) and -0.000 (CI -1.33 to
1.33), for girls and boys, respectively. It is also noted that the percentage of correct answers
(errors below 10%) shows little variation according to age and sex (Table 4), and, in general,
84% of the estimated samples are located within the tolerable limit (10%) for both sexes.
Validation of the proposed formulas for weight estimation

For the formula validation stage, data from 200 adolescents (30% of the sample) from the origi-
nal database were used.
Fig 4. Bland-Altman plots for weight and estimate weight. Label: Bland-Altman plot for the agreement between estimated weight and observed
weight. Data triangles represent the individual children. The mean is represented by the centered line, and the upper and lower lines represent the
standard deviation and the 99% CIs for the agreement between the 2 methods.

Table 4. Frequency distribution of estimation errors below 10% and the relationship with age and sex.
Age (year) Girls Boys
10 1 (100.0%) 3 (100.0%)
11 12 (75.0%) 6 (85.7%)
12 31 (83.8%) 18 (81.8%)
13 25 (83.3%) 12 (80.0%)
14 21 (95.5%) 8 (88.9%)
15 45 (86.5%) 20 (76.9%)
16 48 (80.0%) 18 (90.0%)
17 32 (86.5%) 34 (85.0%)
18 15 (88.2%) 11 (91.7%)
19 2 (66.7%) 1 (50.0%)
Total 232 (84.4%) 131 (84.0%)
The comparison between the data from the sample of adolescents used for the proposal of
the formulas with that used in the validation indicates the absence of a significant difference
for the variables analyzed (Table 5), confirming that the process of random selection of sam-
ples for the proposal and samples for validation was performed correctly.
In this stage of validation of the proposed formulas, considering the values of R2, we can
conclude that the models proposed for adolescent girls and boys (Fig 1) are adequate to esti-
mate the weight since they reached R2 values greater than 0.7 [30], being 0.76 for girls and 0.71
for boys (Table 6).
Moreover, the quality of the estimates of the proposed formulas (Table 6) was checked. For
both studied groups, the mean values of the measured and estimated weights are close and
present a greater homogeneity in the estimated data (lower standard deviation value) in rela-
tion to the measured data, demonstrating the smoothing of the estimates. The low values of
RMSE and the high values of ICC (> 0.8), confirm the accuracy of the models proposed for
estimating the weight of adolescents.
Table 5. Description of the two samples of adolescents used in the proposal and validation of the formulas developed for weight estimation.
Variables Sample used in the proposal (n = 462) Sample used in the validation (n = 200) p-value
Mean ± standard deviation(mediana)
Age (years) 14.6±2.1 (15.0) 14.6±2.2 (15.0) 0.8791�
Weight (kg) 59.9±14.9 (57.1) 57.7±13.8 (56.6) 0.3072�
Height (m) 1.6±0.1 (1.6) 1.6±0.1 (1.6) 0.1824�
Neck circumference (cm) 32.5±3.1 (32.0) 32.4±2.9 (32.0) 0.6832�
2
BMI (kg/m ) 22.2±4.6 (21.3) 22.0±4.3 (21.3) 0.6716�
Nutritional diagnosis�� n (%) Lean 14 (3%) 4 (2%) 0.9873��
Normal weight 284 (61%) 125 (63%)
Overweight 92 (20%) 39 (20%)
Obesity 72 (16%) 32 (16%)
Kg = kilos. m = meters. cm = centimeters.

�
Student’s t-test of independence.
��
Chi-square test.
��
Classification according to Brazil [1].

Table 6. Quality of estimates of the proposed equations for estimating adolescent weight.
Girls (n = 125) Boys (n = 75)
Mean (SD) of the measured weight (kg) 57.04 (13.30) 58.77 (14.49)
Mean (SD) of the estimated weight (kg) 56.47 (10.10) 58.95 (12.36)
Difference (SD) between mean values of the measured and estimated weights 0.57 (6.87) -0.19 (7.03)
(kg)
99% CI difference (-1.04; 2.17) (-2.33; 1.96)
R2 0.76 0.71
RMSE 6.87 6.99
ICC (p-value) 0.83 0.86
(6.9×10−34) (1.9×10−24)
99% CI (ICC) (0.74; 0.89) (0.77; 0.92)
SD = standard deviation. 99% CI = 99% confidence interval. R2 = coefficient of determination. RMSE = root mean
square error. ICC = intraclass correlation coefficient.
To check the validation of the proposed formulas for adolescents at different stages of sex-
ual maturity, these were tested according to such staging. Among the 125 girls in the sample
used in the validation stage, 1 (1%) was at the prepubertal stage of sexual maturity (stage 1),
while the others were at the pubertal stage, with 98 (78%) at stage 2 and 26 (21%) at stage 3.
Among the 75 boys in the sample used for validation, 5 (7%) were at the prepubertal stage of
sexual maturity (stage 1) and 70 were already at the pubertal stage, with 48 (64%) at stages 2
and 22 (29%) at stage 3. Thus, considering the low number of adolescents at the prepubertal
stage, we opted for the analyses according to stages 2 and 3 of sexual maturity, pubertal stage.
The proposed equations remained adequate to estimate girls’ weight at stage 2 and boys at
stage 3 (R2>0.7). However, in the other stage of both sexes, this adequacy was not achieved,
having a 65% (R2 = 0.65) capacity to adjust the weight in girls at stage 3 and 68% in boys at
stage 2 (Table 6), that is, less than 70% (R2 <0.7), which is the ideal value. However, in a posi-
tive way, the low values of RMSE and the high values of ICC (> 0.8) confirm the accuracy of
the proposed equations for estimating the weight of adolescents regardless of the stage of sex-
ual maturity. It is worth mentioning that the equations were proposed considering a global
model, with a loss of accuracy and precision expected when considering only one stratum of
the original population. Moreover, regardless of the stage of sexual maturity, the mean values
of the measured and estimated weights are close (Table 7).
Table 7. Quality of the estimates of the proposed equations for estimating the weight of adolescents, according to the stage of sexual maturity.
Girls Boys
Stage 2 (n = 98) Stage 3 (n = 26) Stage 2 (n = 48) Stage 3 (n = 22)
Mean (SD) of the measured weight (kg) 55.89 (12.62) 62.36 (14.14) 57.88 (13.50) 64.30 (14.62)
Mean (SD) of the estimated weight (kg) 56.0 (9.84) 59.20 (8.91) 57.64 (11.56) 65.66 (10.59)
Difference (SD) between mean values of the measured and estimated weights (kg) -0.20 (6.14) 3.16 (8.73) 0.24 (7.61) -1.36 (5.94)
99% CI difference (-1.83; 1.43) (-1.61; 7.93) (-2.71; 3.19) (-4.94; 2.23)
R2 0.77 0.65 0.68 0.88
RMSE 6.11 9.12 7.53 5.96
ICC (p-value) 0.85 (8.1×10−30) 0.71 (1.4×10−5) 0.82 (1.8×10−3) 0.89 (3.2×10−9)
99% CI (ICC) (0.76; 0.91) (0.34; 0.89) (0.65; 0.91) (0.69; 0.96)
2
SD = standard deviation. 99% CI = 99% confidence interval. R = coefficient of determination. RMSE = root mean square error. ICC = intraclass correlation coefficient.

Discussion
The application of multiple linear regression models used in this study indicated that the vari-
ables NC, height, and age together presented explanatory power for the variation of the mea-
sured weight above 70% in the sample of adolescent girls and above 75% in the sample of boys.
These data supported the proposal of formulas for estimating weight in adolescents with a
small number of variables, which are easily obtained in clinical or emergency practice. When
the proposed formulas were submitted for validation, they showed high agreement, indicating
that they were adequate for estimating the weight of adolescents of both sexes since they
reached R2 values greater than 0.7 [30], being 0.76 for girls and 0.71 for boys. When validated
according to the stage of sexual maturity, the formulas maintained low values of RMSE as well
as high values of ICC (> 0.8), confirming their accuracy for estimating the weight of adoles-
cents regardless of the stage of sexual maturity.
Other studies have proposed and validated formulas for estimating the weight of children
and adolescents. For children, a pioneering research was carried out in 1986 in the United
States by James Broselow, who developed a method for estimating weight in children based on
height, called Broselow tape [20]. The study had the participation of 1,002 American children,
571 boys, and 431 girls. Lubitz et al. [20] analyzed the accuracy of this tape, and the results
obtained in the linear regression analysis indicated R2 values of 0.94. However, when the data
were grouped into weight ranges for analysis, there was a wide variation in the values of R2
obtained for children from 3.5 to 10 kg, 10 to 25 kg, and over 25 kg, which were 0.79, 0.86, and
0.21, respectively [20]. Broselow tape was also investigated for accuracy in a sample of 300 chil-
dren aged 1 to 10 years in the city of Manchester, England. In this study, this tape had an R2
value of 0.85 [7]. Graves et al. [32], based on a research with Australian children, concluded
that Broselow tape, although precise, can erroneously classify up to 60% of non-white children
and with a higher risk in older children.
The most widespread age-based weight estimation equation is the formula developed in
the United Kingdom by the Advanced Pediatric Life Support Group/European Resuscitation
Council, known as the APLS formula, indicated for use in the age group from one to 10 years
[33]. However, it was observed that this formula is not adequate, since it underestimates the
weight in one fifth of children with an error greater than 10% [34]. In comparing the use of
Broselow tape and the APLS formula to estimate weight, Argall et al. [7] reported that both
methods underestimated the actual weight, with an average bias of -3.52 kg for the APLS for-
mula and -2.74 kg for the Broselow tape.
Theron et al. [8] proposed age-based formulas to estimate the weight of children under ten
years of age in New Zealand, and they reached an R2 of 0.78, that is, with explanatory power
for the variation in measured weight of 78%.
Tinning and Acworth has also proposed Age-based formulas in order to estimate the weight
of children, which are also known as Best Guess. To do this, they used data from 70,181 Aus-
tralian children divided into three age groups: under 12 months, 1 to 4 years, and 5 to 14 years.
Three equations were generated using regression analysis. The value of R2 for children under
12 months was 0.76, for the group of 1 to 4 years of age, the value was 0.60 and for the group of
5 to 14 years of age, the value was 0.65 [10].
Age-based formulas are the oldest methods for estimating weight in children. However,
the weight estimated utilizing these formulas is not necessarily associated with the actual
weight but with the expected weight given the principle used in the models. Thus, equations
based on body measurements began to be proposed to estimate adolescents’ actual weight. In
a pioneering way, Cattermole et al. [4] proposed a formula using the anthropometric variable
MAC to estimate weight. The study was based on 1,370 Chinese children from 1 to 11 years

old, and the proposed formula proved to be suitable for that purpose, reaching an R2 value
of 0.96
In 2012, the Mercy Method was developed, using the humerus length and the MAC to
estimate the weight [5]. To develop the Mercy Method, anthropometric data from children
between two months and 16 years old, extracted from the National Health and Nutrition
Examination Survey (NHANES) corresponding to 1999 to 2008, were used, totaling 17,328
children in the development stage and 1,938 in the validation. The R2 value obtained by this
method was 0.98, higher than other previously published weight estimation methods, includ-
ing the Australian Resuscitation Council equations [35] (R2 = 0.74), Theron et al. [8] (R2 =
0.7), Cattermole et al. [4] (R2 = 0.87), Tinning; Acworth [10] (R2 = 0.76), Broselow Tape (R2 =
0.95) [36], among others analyzed in this study.
There is also a method for estimating weight from a tape that is based on height and MAC,
which has been validated in 1,800,322 children between six months and five years of age. Data
were collected from nutritional surveys carried out during the years 1992 to 2017, in 51 low-
and middle-income countries (not including Brazil) and with a high prevalence of acute and
chronic malnutrition [19]. These authors used Kappa and Bland-Altman statistics as measures
of method accuracy, and the standard deviation and the 95% confidence interval of the esti-
mates were used as precision measures. Statistical analysis evidenced that it is an accurate and
precise method.
More recently, age- and MAC-based weight estimation formulas have been proposed from
a sample of 861 Argentinian children aged between 2 and 18 years. These formulas achieved
an R2 value of 0.87 for females and 0.92 for males, and the Bland-Altman plots showed strong
consistency between observed and predicted weight values [21].
In this study, the proposed and validated formulas are for estimating the weight of adoles-
cents, including the age group of 10 to 19 years. It is noted that there are no predictive equa-
tions including this age group that use NC, making such formulas attractive as they fill a gap of
need in clinical and emergency practice.
There are indeed other methods available and suitable for estimating weight;however, the
formulas proposed here, in addition to covering an age range not covered by other studies,
were created based on a national database, which makes the sample more accurate as to the
economic, social and ethnic characteristics of Brazilian adolescents. Proposing and validating
new equations based on body measurements capable of predicting current weight and based
on a representative sample of Brazilian adolescents greatly benefit national clinical practice.
Study limitations
The formulas proposed here were validated in a sample of healthy adolescents and may present
limitations of precision and accuracy when applied to adolescents with body deformities. The
present equations were originated on Brazilian population. Caution should be exercised when
applying these equations to adolescents of other countries. The equations were based on data
from previously sampled population that possibly vary widely. Because of this, caution should
be exercised when it is used at an individual clinical level.
Strengths
It is one of the largest cross-sectional studies to develop weight equations for adolescents, to
our knowledge, the first to design equations to estimate weight exclusively in adolescents and
developed for low- and middle-income counties where it is more difficult to access appropriate
scales in emergency care settings. Weight, can be estimated in adolescents when it, cannot be
obtained directly. Another advantage is that the equations designed to estimate weight uses

NC, which is a simple and reliable measure. Furthermore, the equation includes adolescents
from 2 to 19 years of age, making it useful for the full pediatric age range.
Conclusion
The proposed formulas use a small number of easily obtainable variables, which indicates the
practicality and feasibility of using them safely. They present adequate accuracy and precision,
and for these reasons they are a viable option for estimating the weight of Brazilian adolescents
unable to have their weight measured.
Complementary studies are required to assess the applicability of these formulas for esti-
mating weight in adolescents from Brazil and other countries.
Author Contributions
Conceptualization: Daniel Meyer Coracini, Cláudia Rucco Penteado Detregiachi, Sandra
Maria Barbalho, Daniel De Bortoli Teixeira.
Data curation: Daniel Meyer Coracini.
Formal analysis: Daniel Meyer Coracini, Daniel De Bortoli Teixeira.
Investigation: Daniel Meyer Coracini, Cláudia Rucco Penteado Detregiachi.
Methodology: Daniel De Bortoli Teixeira.
Supervision: Cláudia Rucco Penteado Detregiachi.
Writing – original draft: Daniel Meyer Coracini, Cláudia Rucco Penteado Detregiachi, San-
dra Maria Barbalho, Daniel De Bortoli Teixeira.
Writing – review & editing: Daniel Meyer Coracini, Cláudia Rucco Penteado Detregiachi,
Sandra Maria Barbalho, Daniel De Bortoli Teixeira.
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PLOS ONE

Design and validation of equations for weight

Accepted: August 16, 2022 Methods

Competing interests: The authors have declared

PLOS ONE | https://doi.org/10.1371/journal.pone.0273824 February 2, 2023 1 / 14

Materials and methods

PLOS ONE | https://doi.org/10.1371/journal.pone.0273824 February 2, 2023 2 / 14

PLOS ONE | https://doi.org/10.1371/journal.pone.0273824 February 2, 2023 3 / 14

PLOS ONE | https://doi.org/10.1371/journal.pone.0273824 February 2, 2023 4 / 14

Kg = kilos. m = meters. cm = centimeters.

PLOS ONE | https://doi.org/10.1371/journal.pone.0273824 February 2, 2023 5 / 14

SD = standard deviation. 99% CI = 99% difference confidence interval. R2 = coefficient of determination.

PLOS ONE | https://doi.org/10.1371/journal.pone.0273824 February 2, 2023 6 / 14

Validation of the proposed formulas for weight estimation

PLOS ONE | https://doi.org/10.1371/journal.pone.0273824 February 2, 2023 7 / 14

Kg = kilos. m = meters. cm = centimeters.

PLOS ONE | https://doi.org/10.1371/journal.pone.0273824 February 2, 2023 8 / 14

PLOS ONE | https://doi.org/10.1371/journal.pone.0273824 February 2, 2023 9 / 14

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