Triceps

norms
A. Roberto

skin fold and

for assessment
Frisancho,

Ph.D.3

ABSTRACT

derived

upper arm muscle

size
of nutritional
status12

Basect

on a cross-sectional

from the United

arm circumference

sample

of 12,396

States Ten-State
Nutrition Survey
and triceps skin fold are reported.

white

subjects

0 to 44 years,
for right
measurements
for each

of 1968-1970,

aged

percentiles

defmed

by

the

age

of

amount of subcutaneous
and protein
reserve.
characterized

13

years,

and

fat and degree

However,

by

adulthood,

males

of muscularity

measurements

exceed

in children
of

females

by

reflects

subcutaneous

about

56%.

the individual

fat

among

The

calorie

populations

by a low

degree of fatness
may not be a sensitive
indicator
of nutritional
status
and growth.
On the other hsnd, measurements
of muscularity
in children
do serve as an
adequate
general
index
of nutritional
status
and growth
in size.
Am. J. Clin. Nutr. 27:
1052-1058,
1974.

the size of the muscle

mass is an
indicator
of protein
reserve,
measurement
of
limb
muscle
size
has
been
used
currently
to assess
the nutritional
status
of
children
(1-3).
These
evaluations
are usually
made
through
comparison
of the estimated
upper
arm muscle
circumference
of a given
population
against
the standard
(1). It must
be
noted,
however,
that
this
standard
for
muscle
circumference
for the ages of 1 to 60
months
was calculated
using the arm circumference
of Polish
children
(reported
in 1964)
and the triceps
skin folds of British
children
(reported
in 1955 (4) and 1962 (5)). In the
same manner,
the muscle
circumference
for
children
6 to 15 years was estimated
from the
arm circumference
of British
children
(reported
in 1955 (4, 5)) and the triceps
skin folds of
children
in the United
States
obtained
prior to
World
War II and reported
in 1941 (6). It is
quite
evident
that
normative
data
derived
through
this procedure
are not applicable
in
terms of time or population.
Clearly,
there is a
crucial
need
for
the development
of more
appropriate
estimates
of muscle
size. Therefore,
the
purpose
of this
article
is to provide
estimates
of upper
arm
muscle
size derived
Because

indirect

1052

TheAmerican

Journal

of Clinical Nutrition

from
folds
States.

the arm circumference

of the white
population

Materials

and triceps
skin
in the United

methods

and

Sample
This study is based on a cross-sectional sample

of

5,637 males and 6,759 females aged 0 to 44 years,

derived
from the Ten-State
Nutrition
Survey of
1968-1970.
This survey
was
probability
sample
of families
viduals
residing
in the states
Kentucky,
ington,

Michigan,
California,

New

based
on a stratified
and unrelated
indiof Texas,
Louisiana,

York,

Massachusetts,

West Virginia,

and

Wash-

South

Carolina.

The sampling
families
living

procedure
included
a large proportion
of
who,
according
to the 1960 census, were
in low-income areas and a small proportion
of

families

living

Although

the

From

ment,

in middleprimary

the

The

Center

and upper-income
interest

for

Human

University

of

Michigan
48104.
2Supported
in part by
with the Center
for Disease

and

with

the

use

Growth

Contract
Control,

Survey

Human

Growth

Professor

of Anthropology.

areas (7).

each

state
and

Michigan,

of raw data

Nutrition

Ann

was

Develop-

Arbor,

HSM 21 72-522
Atlanta,
Georgia,

from

the Ten-State

of 1968-1970.

Associate

27: OCTOBER

in

Scientist

and

1974,

pp.

Development

1052-1058.

of

the

and

Center
for
Associate

Printed in U.S.A.

Downloaded from ajcn.nutrition.org by guest on September 26, 2014

upper
From these
individual,
the arm muscle
diameter,
arm muscle
circumference,
and arm muscle
area
were
calculated.
Thereafter,
age- and sex-specific
percentiles
for all three estimates
of muscle size
were obtained.
The development
of subcutaneous
fat, as indicated
by the triceps
skin fold, in
males
is characterized
by slow
apposition,
while
in females, is continuous throughout
childhood,
adolescence,
and adulthood.
Sexual
dimorphism
in triceps
skin fold is defined
by
the age of 3 years,
and by adulthood,
females
exceed males by 83%. The muscle area in the
upper arm during
childhood
exhibits
considerable
changes
with age. Sexual
dimorphism
is

UPPER
malnutrition

ARM

CIRCUMFERENCE

AND

among

Ten-State

the poor,
the universe
of the
Survey does not include all of the
groups
within a state, nor is it restricted
poor.
Rather,
the target population
also

Nutrition

lower-income
to only the

included
middle- and upper-income
individuals
who,
because of changes in residential
patterns since 1960,
were living in the selected
areas when the survey was
conducted
(7). The mean
sample included
in this study

average
income
was $13,122.

for

the

TRICEPS

is more prevalent
in males than in females
may result in an overestimation
of male muscle
an

increasing

anthropometric
of body

meaand

size

degree

as the

cross-sectional

(14),

it

area

to

configura-

tion approaches
rectangularity.
Third, the equations
do not take into
account
variations
in skin
fold
compressibility.
Clegg and Kent (15) indicate that
female triceps skin-fold
compressibility
is 4.8% greater
than that of the male. In this study
the
average
skin-fold was 7 mm and the maximum
value was 21
According

skin-fold

The survey included

standard
surements
for the
assessment

1053

FOLDS

arm

mm.
Measurements

SKIN

mation
of

of female

3.1

to these data,

compressibility
mm.

muscle

However,

the

could

result

circumference

the

estimates

of muscle

size

can

status. In this article, we report information for the upper arm circumference
and triceps skin
folds for the whole sample of whites who participated

be affected
percentile)

in the Ten-State Nutrition Survey.

1) Upper
arm
circumference
measured
to the nearest
millimeter

the skin-fold
thickness
is over 21
mm. Fourth, as the measurements
of skin folds and
upper arm circumference
were taken
by several
technicians, the magnitude
of the measurement
error
cannot be quantified.

nutritional

with the right arm hanging

relaxed.

was taken
midway
between
and olecranon process.

the

2)

Triceps

skin

fold

The measurement
tip

of the

(millimeters)

was

acromion

measured

of muscle

size

The following three estimates of muscle size were

derived:
1) Arm muscle diameter (millimeters)
was
estimated

by

computation

Arm

muscle

(8-10)

as follows:

diameter
(mm)
arm circumference

(mm)

triceps

2) Arm

muscle

computation
Arm

muscle

3) Arm
as follows:
Arm

size

(1,

circumference
2, 11)

(mm)

-ir

muscle area (mm2)

It must be noted
in the upper
arm

reasons.

First,

the

(mm)

was derived by

(mm)

arm circumference

area

fold

as follows:

circumference

muscle

skin

(mm2)

that

(triceps

the

are only
circumference

skin fold)

was calculated (12, 13)

(arm

diameter2)

calculations
approximations
of muscle

because

skin-fold

compressibil-

to

the nearest tenth of a millimeter with a Lange

Skin-fold Caliper having
a pressure
of 10 g/mm2
of
contact surface area. The measurement
was taken on
the back of the arm and midway between the point of
the acromion and olecranon process while the arm was
hanging relaxed.
Estimates

adequate
comparisons
ity increases
when

upper levels (95th

and may prevent

of muscle
for
does

four
not

include
an estimate
of bone
diameter,
and any
variation in humeral diameter
is therefore not accountable.
The
deletion
of humeral
diameter
in the
calculation
may result in an overestimation
of male in
relation to female values, as male humeri are on the
average greater in diameter
than those of the female,
regardless of the nutritional status of the population.
Second,
the equations
assume
that the upper arm is
cylindrical
in form,
an assumption
subject
to some
inaccuracy.
For example,
because
flattening
of the

Results

and

Table

Arm

1 gives
arm

upper

discussion

the

circumference

percentiles
and

for
triceps

the

mid-

skin

fold.

circumference

As shown
by the 50th percentile
values,
the
circumference
between
the age of 1 and 5
years increases
approximately
11% in girls and
15% in boys.
Between
6 and 13 years,
the
increase
in boys is almost
32% and 34% in girls;
between
14 and
30 years,
males
show
an
increase
of 27%, whereas
in females
this equals
only 13%.
These
data
suggest
that
the arm
circumference
either
during
childhood
(1 to 5 years)
or adolescence
is not independent
of age as is
currently
assumed.
Nevertheless,
it must
be
noted
that, for example,
compared
with height
or weight
during
childhood,
the arm circumference
shows
a small
change.
Therefore,
as
indicated
by other
investigators
(1-3,
13, 16)
evaluations
of nutritional
status
based
on arm
circumference
during
childhood
may not require an exact knowledge
of age.
arm

Triceps
Boys
triceps

skin fold
at the age of 2 years
skin
fold
of 10 mm

have
(for

a median
the 50th

percentile),
which
thereafter
declines
gradually,
and
at approximately
the age of 8 years,
reaches
its lowest
value (8 mm). After this age,
they exhibit
a slow increase,
and by the age of
12 years,
reach a peak of 11 mm. This is the

Downloaded from ajcn.nutrition.org by guest on September 26, 2014

(millimeters) was
with a steel tape

significantly
at the
of the distribution

greater
female
in an underestiby an average

1054

FRISANCHO

TABLE

Percentiles

whites

for

upper

arm

of the Ten-State

circumference

Nutrition

and

Survey

triceps

skin

folds

for

of 1968-1970
Triceps

Age
group

0.0-0.4

17.5-24.4
24.5-34.4
34.5-44.4

0.3
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
21
30
40

circumference

No.

5th

15th

41

113

120

140
177
210
208
262
264
309
301
287
315
294
294
266
207
179
166
142
545
679
616

128
141
144
143
146
151
154
161
165
170
177
184
186
198
202
217
230
250
260
259

137
147
150
150
155
159
162
168
174
180
186
194
198
211
220
232
238
264
280
280

152
157
161
165
169
172
176
185
190
200
208
216
230
243
253
262
275
292
310
312
Females

46

skin fold

percentiles,

percentiles,

mm

50th

85th

95th

5th

15th

Males
134

147

153

168
170
175
180
185
188
194
205
217
228
240
253
270
279
302
300
306
330
344
345

175
180
182
190
199
198
212
233
262
255
276
291
297
321
320
335
326
354
366
371

5
5
6
5
5
5
4
5
5
5
6
5
5
5
4
4
4
4
4
4

7
7
7
6
6
6
6
6
6
6
7
7
6
6
6
5
5
5
6
6

mm

50th

85th

95th

12

15

9
10
9
9
8
8
8
8
9
10
10
11
10
10
9
9
8
10
11
12

13

15

13

14

12
12
12
11
11
12
14
16
17
19
18
17
19
20
14
18
21
22

14
14
16
15
14
17
19
22
25
26
25
22
26
27
20
25
28
28

0.0-0.4

0.3

107

118

127

145

150

0.5-1.4

172

125

134

146

162

170

8
9

12
12

13
15

1.5-2.4
2.5-3.4

2
3

143
145
150
155
158
162
166
175
181
186
196
204
214
216
224
224
233
243
250

155
157
162
i69
170
178
183
192
203
210
220
230
240
245
249
250
260
275
286

171
169
176
185
187
199
207
222
236
251
256
270
284
281
286
291
297
324
340

6
6

7
7

10
10

13
12

15
14

136
137
145
149
148
153
158
166
170
173
185
186
201
205
211
207
215
230
232

180
176

3.5-4.4

172
163
215
233
259
273
270
284
276
268
267
229
184
197
187
142
836
1153
933

184

10

12

14

195
202
216
231
255
263
280
275
294
306
310
322
328
329
361
374

6
6
6
6
6
6
7
6
7
8
8
8

7
7
7
7
7
8
8
9
9
10
11
10
12
12
12
14

10
10
10
10
11
12
12
13
14
15
16
15
16
17
19
22

13
12
13
15
17
19
20
20
23
22
24
23
26
25
29
32

16
15
17
19
24
24
29
25
30
28
30
27
31
31
36
39

4.5-5.4
5.5-6.4
6.5-7.4
7.5-8.4
8.5-9.4
9.5-10.4
10.5-11.4
11.5-12.4
12.5-13.4
13.5-14.4
14.5-15.4
15.5-16.4
16.5-17.4
17.5-24.4
24.5-34.4
34.5-44.4

5
6
7
8
9
10
11
12
13
14
15
16
17
21
30
40

so-called
preadolescent
fat wave
(1 7). After
boys
reach
this
age,
the triceps
skin
fold
declines
until they are 17 years old, when they
attain
a low value of 8 mm. The median
value
for adults
is only between
10 and 12 mm. In

9
9
9
10

contrast,
females
between
2 and 8 years remain
stable.
Thereafter,
they show a rapid increase,
reaching
a median
value of 16 mm by the age of
1 5 years,
and during
adulthood
the median
values are between
17 and 22 mm.

Downloaded from ajcn.nutrition.org by guest on September 26, 2014

0.5-1.4
1.5-2.4
2.5-3.4
3.5-4.4
4.5-5.4
5.5-6.4
6.5-7.4
7.5-8.4
8.5-9.4
9.5-10.4
10.5-11.4
11.5-12.4
12.5-13.4
13.5-14.4
14.5-15.4
15.5-16.4
16.5-17.4

Age
Midpoint,
years

Arm

UPPER
Muscle

ARM

CIRCUMFERENCE

AND

size

SKIN

FOLDS

1055

muscle
area from age 1 to 12 years increases
steadily.
This trend,
however,
is not noticeable
when
the size of the muscle
is expressed
in
terms
of diameter
and
circumference.
For
example,
between
1 and 5 years in boys and

Tables
2 and 3 give the percentiles
for the
diameter,
circumference,
and area of muscle,
These data show that in both boys and girls, the
TABLE
2
Percentiles
for upper arm diameter
whites of the Ten-State
Nutrition

TRICEPS

and upper arm circumference for

Survey of 1968-1970
Arm

muscle

circumfer

diameter

percentiles,

mm

5th

15th

50th

85th

0.3

26

30

34

40

42

81

32

34

39

44

46

100

2
3
4
5
6
7

35
36
38
39
40
41

37
38
39
41
43
43

40
42
43
45
47
48

44
46
48
50
51
52

46
48
50
53
53

8
9

44
44

46
46

50
51

55
58

10
11
12
13
14
15
16

45
48
49
51
53
55
59

48
50
52
54
58
59
65

53
55
58
62
67
70
73

17

66

69

21
30
40

69
70
71

74
77
76

0.3
1
2
3

27
31
34
34

29
32
36
37

33
37
40
41

37

36

38

38

40

38

41

7
8

39
41

ence perce ntiles,

mm

Age

midpoint,
years

95th

5th

15th

50th

85th

95th

94
108

106
123

125
137

133
146

111
114
118
121

117
121
124

127
132
135

138
145
151

146
152
157

130

141

156

166

127

134

146

159

55
59
64

130
138
138

137

151

164

144

158

174

167
173
185

143

161

182

200

59
62
66
71
74
80
83

64

142

152

168

186

202

67
70
77
84

150
153
159
167

158
163
169
182

174
181
195
211

194
207
224

211
221
242

234

265

86
89

173
186

185
205

220
229

252
260

271
281

78

86

92

206

217

245

271

290

82
86
86

91

97

217

232

258

286

305

94

100

220

241

270

295

315

96

101

222

239

270

300

318

92
102

104

115

126

117

128

135

Females
40

86
97

42

41
44
44
46

43
46
46
48

105
108
114

112
116
120

125
128
132

140
138
146

146
143
152

44

48

51

119

124

138

151

160

45

49

53

121

129

140

155

165

42
44

47
48

52
53

56

123

132

146

162

175

138

151

168

186

45

50

56

59
62

129

43

136

143

157

176

193

10

44

47

52

58

11
12
13
14
15

44
48
49
53
52

48
51
53
56
55

55
57
59
61
62

62
64
66
70
70

62
67

139
140

147
152

163
171

182
195

196
209

68
71
74
74

150

161

179

200

212

155

165

185

206

225

166
163

175

193

221

234

173

195

220

232

16

54

57

64

72

83

171

178

200

227

260

17
21
30
40

54
54
56
57

56
58
60
61

62
65
68
69

71
73
78
80

77
80
87
89

171
170
177
180

177
183
189
192

196
205
213
216

223
229
245
250

241
253
272
279

The age group

#{176}

and n are the same

as in Table

1.

Downloaded from ajcn.nutrition.org by guest on September 26, 2014

Males

FRISANCHO

1056
TABLE
3
Percentiles
for arm muscle

area of whites

derived

from

the Ten-State

Nutrition

Survey

Male arm
muscle

Age
midpoint,
years

5th

a re percent

15th

50th

Female
muscle

iles, mm
85th

95th

1,244
1,500

1,414

5th

arm

a rea percentil

15th

es, mm

50th

85th

95th

866
1,084

1,058

1,272

1,304

1,460

1,551
1,516

1,693
1,628

522

703

1
2

791
978

928
1,082

1,284

1,525

1,686

885

991

1,027

1,163

1,384

1,670

1,842

928

1,068

1,106

1,224

1,451

1,805

1,973

1,040

1,143

1,390

1,693

1,828

1,171

1,342

1,579

1,930

2,193

1,119

1,227

1,516

1,825

2,045

1,275

1,435

1,700

2,019

2,220

1,163

1,333

1,563

1,902

2,174

1,342

1,485

1,815

2,152

2,386

1,213

1,384

1,700

2,096

2,433

8
9
10

1,506

1,647
1,637
1,832

1,987
2,074
2,239

2,398
2,645
2,753

2,729
3,188
3,239

1,322
1,473
1,528

1,513
1,625
1,727

1,818
1,955
2,115

2,239
2,477
2,637

2,758
2,978
3,066

11

1,801

1,987

2,406

3,000

3,544

1,551

1,842

12
13

1,874
2,012

2,126
2,273

1,781
1,905
2,186

2,052
2,178
2,430

3,486
3,582

2,645

3,902
4,661
5,601

3,018
3,183

2,231
2,375
2,741
3,373

3,401
3,998
4,358

2,335
2,558

14
15
16
17

2,603
3,013
3,544

2,711
2,952

3,382
3,883

4,014
4,358

2,729
3,331
3,743

3,867
4,184
4,771

5,060
5,363
5,826

5,826
6,266
6,713

2,126
2,316
2,316

2,387
2,510
2,502

3,031
3,198
3,058

3,838
4,096
3,968

4,279
5,386
4,612

21
30

3,748
3,837

4,273
4,634

5,315
5,802

6,529
6,912

7,411
7,918

2,289
2,486

2,679
2,856

3,341
3,606

4,164
4,772

5,089
5,889

40

3,938

4,563

5,820

7,183

8,041

2,566

2,926

3,724

4,991

6,195

a The

1,608

age group

and

n are the

1,201

same

as in Table

591
756

1,690

670
821

1,241

1,298

1.

girls,
there
is an increase
of nearly
35% in
muscle
area,
whereas
in diameter
or circumference,
the comparable
value amounts
to only
approximately
16%. In other
words,
estimates
of muscle
diameter
and circumference
underestimate
the magnitude
of the tissue changes.
In boys,
the
greatest
2-year
increase
in
muscle
area occurs
between
the ages of 15 and
17 years,
at which
time there is an increase
of
904
mm2
or nearly
23%. In girls, the greatest
increment
occurs
between
the ages of 12 and
14 years,
increasing
almost
15% in muscle
area
(L = 394 mm2).
Until the age of 12 years, sexual dimorphism
in terms of muscle
area is not well defined.
At
the age of 13 years,
males exceed
females
by
11% and,
during
adolescence,
this difference
increases
sharply.
By the age of 40 years, the
sexual
dimorphism
in the muscle
area is over
56%.
These
sex
differences
are
less marked
when
the muscle
size is expressed
either
in
diameter
or circumference.
Because
the
muscle
area
shows
greater
changes
with age than the diameter
or circumference,
it would
be advisable
that evaluations

of nutritional
status
of children
be based
on
estimates
of muscle
areas
as well.
With
the
nomogram
given
recently
by Gurney
and
Jelliffe
(18),
the
difficulties
of calculating
muscle
areas are simplified.
The use of skin-fold
thickness
in the assessment

of nutritional

status

of children

is based

the assumption
resulting
from

that increased
subcutaneous
either high calorie
intake

Consequently,

evaluations

on

fat,
or low
energy
expenditure,
reflects
a greater
calorie
reserve.
From
which
it follows
that
fatter
children
for
their
age are both
taller
and
developmentally
more
advanced
than
average
children
(17,
19-27).
This
generalization
is
supported
by animal
experimental
studies
mdicating
that overnutrition
speeds maturation
and
dimensional
growth
(28).
However,
we must
point
out that in some parts of the world
it
seems
likely that, as we indicated
by our studies
of Central
American
samples
(10, 29, 30), the
levels of fatness
that are considered
average
in
the United
States
populations
cannot
be found
except
in the upper
ranges of the distribution.
based

on

skin-fold

thickness

of nutritional

of children

status

from

Downloaded from ajcn.nutrition.org by guest on September 26, 2014

0.3

1,522

892

of 1968-1970

UPPER

populations
fatness
may

characterized
not be that

Experimental
that

the

either

CIRCUMFERENCE

by a low degree
of
sensitive
(10, 29, 30).

and clinical studies have

shown

in muscle
mass, determined
creatinine
output
or limb mea-

decrease

through

surements,

ARM

during

malnutrition

exhibit

have

been

met.

In other

words,

author

Kathleen
Font
of this study.

acknowledges

and Mrs. Diane

the

Clark

assistance

of

Mrs.

in the preparation

of

FOLDS

1057

W. H. Measurement

subcutaneous

fat,

with

and young
adult
males.
Med. 9: 201, 1955.
5. TANNER,
J. M., AND
Standards
for subcutaneous
Brit.

and

Brit.
R.

interpreta-

norms

for

children

J. Prevent

Social

H. WHITEHOUSE.
fat in British children.

1: 446, 1962.
R., M. A. GIRSHIK AND E. P. HUNT,
measurements
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Med.

J.

6. OBRIEN,

Body
for garment
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D. C.:

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PubI.
7.

and
pattern
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WashingU.S. Dept.
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ical Development,

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McFIE,
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FRISANCHO,
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A. R., AND S. M. GARN.

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The

tion

a child

with greater
muscle
size would
reflect
a greater
protein
reserve
than
a less muscular
one.
Indeed,
previous
investigations
have pointed
out
that
differences
in the development
of
muscle
are associated
with differences
in nutritional
background
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need
for
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this
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and protein
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in the
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would
suggest that
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is well maintained,
the protein
requirements
for growth
and body
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AND

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