Systematization of approaches to assessing nutritional status based on anthropometry and bioimpedance analysis of body composition

BMI values, both higher and lower than the age- and sex-appropriate norm, are associated with an increased mortality risk. At low BMI values, mortality increases primarily due to a decrease in lean body mass, while at high values, it increases due to an increase in fat mass. Using a method that combines assessment of body mass index and body fat percentage, it is possible to avoid diagnostic errors and identify conditions such as false obesity, the gracile and muscular body types typical of athletes, and hidden obesity, which is often detected in young people with physical inactivity or poor diet. This article proposes a classification and codification of true and hidden nutritional status conditions based on BMI gradations and body fat percentage. We examine a pattern of intersection of BMI and body fat percentage cutoff values against two-dimensional age-sex centiles in the space of fat free mass and fat mass indices, reflecting the prevalence of common and rare variants of combined nutritional status in the population. For diagnostic purposes, this pattern can be applied to the field of actual values of FMI, FFMI, BMI, and%FM for a specific age-sex group.

1. Demidova T. Yu., Kislyak O.A., Starodubova A.V., Nikitin I.G., Ushanova F.O. Beyond BMI: discussing a new concept for defining and diagnosing clinical obesity. Medical Council. 2025; 19 (6): 78–90. (In Russ.). DOI: 10.21518/ms2025-183

2. Twig G, Yaniv G, Levine H, Leiba A, Goldberger N, Derazne E, Ben-Ami Shor D, Tzur D, Afek A, Shamiss A, Haklai Z, Kark JD. Body-Mass Index in 2.3 Million Adolescents and Cardiovascular Death in Adulthood. N Engl J Med. 2016 Jun 23; 374 (25): 2430–40. DOI: 10.1056/NEJMoa1503840

3. Aune D, Sen A, Prasad M, Norat T, Janszky I, Tonstad S, Romundstad P, Vatten LJ. BMI and all cause mortality: systematic review and non-linear dose-response meta-analysis of 230 cohort studies with 3.74 million deaths among 30.3 million participants. BMJ. 2016 May 4; 353: i2156. DOI: 10.1136/bmj.i2156

4. Komaroff M. For Researchers on Obesity: Historical Review of Extra Body Weight Definitions. J Obes. 2016; 2016: 2460285. DOI: 10.1155/2016/2460285

5. Romero-Corral A, Montori VM, Somers VK, Korinek J, Thomas RJ, Allison TG, Mookadam F, Lopez-Jimenez F. Association of bodyweight with total mortality and with cardiovascular events in coronary artery disease: a systematic review of cohort studies. Lancet. 2006 Aug 19; 368 (9536): 666–78. DOI: 10.1016/S0140-6736(06)69251-9

6. Angerås O, Albertsson P, Karason K, Råmunddal T, Matejka G, James S, Lagerqvist B, Rosengren A, Omerovic E. Evidence for obesity paradox in patients with acute coronary syndromes: a report from the Swedish Coronary Angiography and Angioplasty Registry. Eur Heart J. 2013 Feb; 34 (5): 345–53. DOI: 10.1093/eurheartj/ehs217

7. Das SR, Alexander KP, Chen AY, Powell-Wiley TM, Diercks DB, Peterson ED, Roe MT, de Lemos JA. Impact of body weight and extreme obesity on the presentation, treatment, and in-hospital outcomes of 50,149 patients with ST-Segment elevation myocardial infarction results from the NCDR (National Cardiovascular Data Registry). J Am Coll Cardiol. 2011 Dec 13; 58 (25): 2642–50. DOI: 10.1016/j.jacc.2011.09.030

8. Clinical Guidelines «Obesity in Children» (CR2024). Available at: https://cr.minzdrav.gov.ru/preview-cr/229_3 (accessed: 03.02.2026). (In Russ.).

9. WHO Child Growth Standards, developed in 2007. Available at: https://www.who.int/tools/child-growth-standards ; https://www.who.int/tools/growth-reference-data-for-5to19-years/indicators/weight-for-age-5to10-years ; https://www.who.int/tools/growth-reference-datafor-5to19-years (accessed: 03.02.2026). (In Russ.).

10. de Onis M, Lobstein T. Defining obesity risk status in the general childhood population: which cutoffs should we use? Int J Pediatr Obes. 2010 Dec; 5 (6): 458–60. DOI: 10.3109/17477161003615583

11. Romero-Corral A, Somers VK, Sierra-Johnson J, Thomas RJ, Collazo-Clavell ML, Korinek J, Allison TG, Batsis JA, Sert-Kuniyoshi FH, Lopez-Jimenez F. Accuracy of body mass index in diagnosing obesity in the adult general population. Int J Obes (Lond). 2008 Jun; 32 (6): 959–66. DOI: 10.1038/ijo.2008.11

12. Okorodudu DO, Jumean MF, Montori VM, Romero-Corral A, Somers VK, Erwin PJ, Lopez-Jimenez F. Diagnostic performance of body mass index to identify obesity as defined by body adiposity: a systematic review and meta-analysis. Int J Obes (Lond). 2010 May; 34 (5): 791–9. DOI: 10.1038/ijo.2010.5

13. Wiklund P, Törmäkangas T, Shi Y, Wu N, Vainionpää A, Alen M, Cheng S. Normal-weight obesity and cardiometabolic risk: A 7-year longitudinal study in girls from prepuberty to early adulthood. Obesity (Silver Spring). 2017 Jun; 25 (6): 1077–1082. DOI: 10.1002/oby.21838

14. Buss J. Limitations of body mass index to assess body fat. Workplace Health Saf. 2014 Jun; 62 (6): 264. DOI: 10.1177/216507991406200608

15. Canda, Alicia. Deportistas de alta competición con índice de masa corporal igual o mayor a 30 kg/m2. ¿Obesidad o gran desarrollo muscular? Apunts. Medicina de l’Esport. 2017; 52 (193): 29–36. https://doi.org/10.1016/j.apunts.2016.09.002

16. Ivanova I.V., Chernaya N.L. Dependence of anthropometric indicators in adolescents on birth weight. Rossijskij vestnik perinatologii i pediatrii. 2010; 5: 79–82. (In Russ.).

17. Soboleva N.P., Rudnev S.G., Nikolayev D.V., Eryukova Т.A., Kolesnikov V. A., Melnitchneko O.A., Ponomareva E.G., Starunova O.A., Sterlikov S.A. The bio-impedance screening of population in health centers: prevalence of surplus body mass and obesity. Russian Medical Journal. 2014; 4: 4–13. (In Russ.).

18. De Lorenzo A., Deurenberg P., Pietrantuono M., Di Daniele N., Cervelli V., Andreoli A. (2003). How fat is obese? Acta Diabetologica. 2003; 40 (S1): s254–s257. DOI: 10.1007/s00592-003-0079-x

19. Abramowitz M.K., Sharma D., Folkert V.W. Hidden Obesity in Dialysis Patients: Clinical Implications. Semin Dial. 2016 Sep; 29 (5): 391–5. DOI: 10.1111/sdi.12516

20. Hačková L., Gažarová M., Kijovská M. Normal weight obesity – hidden obesity behind a normal BMI: application of composite body composition indices in nutritional status evaluation in Slovak females. Rocz Panstw Zakl Hig. 2025; 76 (3): 221–231. https://doi.org/10.32394/rpzh/213375

21. Kalra S., Arora S., Kapoor N. Hidden Obesity. J Pak Med Assoc. 2023; 73 (4): 937–938. DOI: 10.47391/JPMA.23-28

22. Zhang YX, Chen J, Liu XH. Screening of central obesity among normal-weight children and adolescents in Shandong, China. Br J Nutr. 2021 Sep 28; 126 (6): 950–955. DOI: 10.1017/S0007114520004882

23. Marques-Vidal P, Pécoud A, Hayoz D, Paccaud F, Mooser V, Waeber G, Vollenweider P. Normal weight obesity: relationship with lipids, glycaemic status, liver enzymes and inflammation. Nutr Metab Cardiovasc Dis. 2010 Nov; 20 (9): 669–75. DOI: 10.1016/j.numecd.2009.06.001

24. Kim MK, Han K, Kwon HS, Song KH, Yim HW, Lee WC, Park YM. Normal weight obesity in Korean adults. Clin Endocrinol (Oxf). 2014 Feb; 80 (2): 214–20. DOI: 10.1111/cen.12162

25. Romero-Corral A, Somers VK, Sierra-Johnson J, Korenfeld Y, Boarin S, Korinek J, Jensen MD, Parati G, Lopez-Jimenez F. Normal weight obesity: a risk factor for cardiometabolic dysregulation and cardiovascular mortality. Eur Heart J. 2010 Mar; 31 (6): 737–46. DOI: 10.1093/eurheartj/ehp487

26. Rolland Y, Lauwers-Cances V, Cristini C, Abellan van Kan G, Janssen I, Morley JE, Vellas B. Difficulties with physical function associated with obesity, sarcopenia, and sarcopenic-obesity in community-dwelling elderly women: the EPIDOS (EPIDemiologie de l’OSteoporose) Study. Am J Clin Nutr. 2009 Jun; 89 (6): 1895–900. DOI: 10.3945/ajcn.2008.26950

27. Sommer I, Teufer B, Szelag M, Nussbaumer-Streit B, Titscher V, Klerings I, Gartlehner G. The performance of anthropometric tools to determine obesity: a systematic review and meta-analysis. Sci Rep. 2020 Jul 29; 10 (1): 12699. DOI: 10.1038/s41598-020-69498-7

28. Javed A, Jumean M, Murad MH, Okorodudu D, Kumar S, Somers VK, Sochor O, Lopez-Jimenez F. Diagnostic performance of body mass index to identify obesity as defined by body adiposity in children and adolescents: a systematic review and meta-analysis. Pediatr Obes. 2015 Jun; 10 (3): 234–44. DOI: 10.1111/ijpo.242

29. Costa-Urrutia P, Vizuet-Gámez A, Ramirez-Alcántara M, Guillen-González MÁ, Medina-Contreras O, Valdes-Moreno M, Musalem-Younes C, Solares-Tlapechco J, Granados J, Franco-Trecu V, Rodriguez-Arellano ME. Obesity measured as percent body fat, relationship with body mass index, and percentile curves for Mexican pediatric population. PLoS One. 2019 Feb 25; 14 (2): e0212792. DOI: 10.1371/journal.pone.0212792

30. Wiklund P, Törmäkangas T, Shi Y, Wu N, Vainionpää A, Alen M, Cheng S. Normal-weight obesity and cardiometabolic risk: A 7-year longitudinal study in girls from prepuberty to early adulthood. Obesity (Silver Spring). 2017 Jun; 25 (6): 1077–1082. DOI: 10.1002/oby.21838

31. Drapkina O.M., Drozdova L. Yu., Egorov V.A., Ivanova E.S., Kalinina A.M., Rakovskaya Yu.S., Kontsevaya A.V., Eliashevich S.O. Standard operating procedure (SOP) for the management of patients with risk factors of overweight and class 1–2 obesity in health centers. Primary Health Care (Russian Federation). 2025; 2 (4): 231–259. (In Russ.). DOI: 10.15829/3034-4123-2025-103

32. Drapkina O.M., Maksimova O.A., Sheptulina A.F., Dzhioeva O.N. Bioimpedance analysis of body composition: what should general practitioner know? The Russian Journal of Preventive medicine. 2022; 25 (10): 91–96. (In Russ.). https://doi.org/10.17116/profmed20222510191

33. Martynova A.A., Pryanichnikov S.V. The functional state of the body in workers engaged in mining in the Arctic zone. Hygiene and Sanitation. 2024; 103 (8): 857–863. (In Russ.). https://doi.org/10.47470/0016-9900-2024-103-8-857-863

34. Tutelyan V.A., Nikityuk D.B., Sharafetdinov H.H. Healthy nutrition – the basis of a healthy lifestyle and the prevention of chronic non-communicable diseases. «Youth Health: New Challenges and Prospects». Monograph: in 5 volumes / edited by N.F. Gerasimenko, P.V. Glybochko, I.E. Esauenko, V.I. Popov, V.I. Starodubov, V.A. Tutelyan. Moscow: Nauchnaya Kniga Publishing House, 2019. Vol. 3: Technologies for reducing health risks. Prevention and medical examination. Healthy nutrition. P. 203–227. ISBN: 978-5-6043289-2-7. (In Russ.).

35. Shtina I.E., Valina S.L., Ustinova O. Yu., Alekseev V.B., Eisfel’d D.A., Luzhetskii K.P. Peculiarities of metabolic processes and vegetative status in children with an excess fraction of body fat mass. Hygiene and Sanitation. 2020; 99 (8): 841–847. (In Russ.). https://doi.org/10.47470/0016-9900-2020-99-8-841-847

36. Heitmann B., Erikson H., Ellsinger B.-M., Mikkelsen K., Larsson B. (2000). Mortality associated with body fat, fat-free mass and body mass index among 60-year-old Swedish men–a 22-year follow-up. The study of men born in 1913. International Journal of Obesity. 2000; 24 (1): 33–37. DOI: 10.1038/sj.ijo.0801082

37. Bigaard J, Frederiksen K, Tjønneland A, Thomsen BL, Overvad K, Heitmann BL, Sørensen TI. Body fat and fat-free mass and all-cause mortality. Obes Res. 2004 Jul; 12 (7): 1042–9. DOI: 10.1038/oby.2004.131.

38. Rubino F, Cummings DE, Eckel RH, Cohen RV, Wilding JPH, Brown WA, Stanford FC, Batterham RL, Farooqi IS, Farpour-Lambert NJ, le Roux CW, Sattar N, Baur LA, Morrison KM, Misra A, Kadowaki T, Tham KW, Sumithran P, Garvey WT, Kirwan JP, Fernández-Real JM, Corkey BE, Toplak H, Kokkinos A, Kushner RF, Branca F, Valabhji J, Blüher M, Bornstein SR, Grill HJ, Ravussin E, Gregg E, Al Busaidi NB, Alfaris NF, Al Ozairi E, Carlsson LMS, Clément K, Després JP, Dixon JB, Galea G, Kaplan LM, Laferrère B, Laville M, Lim S, Luna Fuentes JR, Mooney VM, Nadglowski J Jr, Urudinachi A, Olszanecka-Glinianowicz M, Pan A, Pattou F, Schauer PR, Tschöp MH, van der Merwe MT, Vettor R, Mingrone G. Definition and diagnostic criteria of clinical obesity. Lancet Diabetes Endocrinol. 2025 Mar; 13 (3): 221–262. DOI: 10.1016/S2213–8587 (24) 00316-4. Epub 2025 Jan 14. Erratum in: Lancet Diabetes Endocrinol. 2025 Mar; 13 (3): e6. DOI: 10.1016/S2213-8587(25)00006-3

39. Nikolaev D.V. Bioimpedance analysis of the human body composition: Lectures / D.V. Nikolaev, S.P. Shchelykalina. M.: RIO TSNIIOIZ, 2016. 152 p. ISBN5-94116-026-1 (In Russ.).

40. Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Committee. World Health Organ Tech Rep Ser. 1995; 854: 1–452.

41. Gallagher D, Heymsfield SB, Heo M, Jebb SA, Murgatroyd PR, Sakamoto Y. Healthy percentage body fat ranges: an approach for developing guidelines based on body mass index. Am J Clin Nutr. 2000; 72 (3): 694–701. DOI: 10.1093/ajcn/72.3.694

42. Rudnev S.G., Ivanova A.E., Godina E.Z., Zubko A.V., Starodubov V.I. Development of criteria for assessing the nutritional status of Moscow children and adolescents based on bioimpedance measurements. Health of the metropolis. 2024; 5 (4–2): 259–271. (In Russ.). https://doi.org/10.47619/2713–2617.zm.2024.v.5i4p2;259-271

43. Kyle UG, Genton L, Slosman DO, Pichard C. Fat-free and fat mass percentiles in 5225 healthy subjects aged 15 to 98 years. Nutrition. 2001 Jul-Aug; 17 (7–8): 534–41. DOI: 10.1016/s0899-9007(01)00555-x

44. Snitker S. Use of body fatness cutoff points. Mayo Clin Proc. Mayo Clin Proc. 2010 Nov; 85 (11): 1057; author reply 1057–8. DOI: 10.4065/mcp.2010.0583

45. Lavie C.J., Milani R.V., Ventura H.O., De Schutter A., Romero-Corral A. Use of body fatness cutoff points– reply–I. In Mayo Clinic Proceedings. 2010 Nov; 85 (11): 1057–1058. Elsevier. DOI: 10.4065/mcp.2010.0624

46. Ho-Pham LT, Campbell LV, Nguyen TV. More on body fat cutoff points. Mayo Clin Proc. 2011 Jun; 86 (6): 584; author reply 584–5. DOI: 10.4065/mcp.2011.0097

47. Биоимпедансное исследование состава тела населения России / С.Г. Руднев, Н.П. Соболева, С.А. Стерликов, Д.В. Николаев, О.А. Старунова, С.П. Черных, Т.А. Ерюкова, В.А. Колесников, О.А. Мельниченко, Е.Г. Пономарёва. М.: РИО ЦНИИОИЗ, 2014. 493 с. ISBN5-94116-018-6.

48. Laurson KR, Eisenmann JC, Welk GJ. Body fat percentile curves for U.S. children and adolescents. Am J Prev Med. 2011 Oct; 41 (4 Suppl 2): S87–92. DOI: 10.1016/j.amepre.2011.06.044

49. Dong H, Yan Y, Liu J, Cheng H, Zhao X, Shan X, Huang G, Mi J; China Child and Adolescent Cardiovascular Health (CCACH) collaboration members. Reference centiles for evaluating total body fat development and fat distribution by dual-energy x-ray absorptiometry among children and adolescents aged 3–18 years. Clin Nutr. 2021 Mar; 40 (3): 1289–1295. DOI: 10.1016/j.clnu.2020.08.012. Epub 2020 Aug 19.

50. Nikolaev D.V., Shchelykalina S.P., Kolesnikov M.V.A., Starunova O.A., Romanova V.S. Two and More Dimensional Representations of Human Body Composition Parameters, 2023 25th International Conference on Digital Signal Processing and its Applications (DSPA), Moscow, Russian Federation, 2023. P. 1–5. DOI: 10.1109/DSPA57594.2023.10113411

51. Shchelykalina S., Kolesnikov V., Nikolaev D. Promising Methods for Post-processing of BIA Estimates and Their Combined Use with Other Diagnostic Tests. Journal of Physics: Conference Series. IOP Publishing, 2025. 3014. 012002. https://doi.org/10.1088/1742-6596/3014/1/012002