Relationship between adiposity and body size reveals limitations of BMI

The aims of this study were to assess 1) whether the stature-adjusted body mass index (BMI) is a valid proxy for adiposity across both athletic and nonathletic populations, and 2) whether skinfold measurements increase in proportion to body size, thus obeying the principle of geometric similarity. The research design was cross-sectional, allowing the relationship between skinfold calliper readings (at eight sites and between specific athletic and nonathletic groups, n = 478) and body size (either mass, stature, or both) to be explored both collectively, using proportional allometric MANCOVA, and individually (for each site) with follow-up ANCOVAs. Skinfolds increase at a much greater rate relative to body mass than that assumed by geometric similarity, but taller subjects had less rather than more adiposity, calling into question the use of the traditional skinfold-stature adjustment, 170.18/stature. The best body-size index reflective of skinfold measurements was a stature-adjusted body mass index similar to the BMI. However, sporting differences in skinfold thickness persisted, having controlled for differences in body size (approximate BMI) and age, with male strength- and speed-trained athletes having significantly lower skinfolds (32% and 23%, respectively) compared with controls. Similarly, female strength athletes had 29% lower skinfold measurements compared to controls, having controlled for body size and age. These results cast serious doubts on the validity of BMI to represent adiposity accurately and its ability to differentiate between populations. These findings suggest a more valid (less biased) assessment of fatness will be obtained using surface anthropometry such as skinfolds taken by experienced practitioners following established procedures.     

Body composition and fat distribution among older Jat females: A rural–urban comparison

The aim of the present cross-sectional study is to describe and compare age related changes in body composition and fat patterning among rural and urban Jat females of Haryana State, India. A total of 600 females (rural = 300, urban = 300), ranging in age from 40 to 70 years were selected by the purposive sampling method. Body weight, height, two circumferences (waist and hip) and skinfold thickness at five different sites (biceps, triceps, calf, subscapular, and supra-iliac) were taken on each participant. To study total adiposity, indices such as body mass index (BMI), grand mean thickness (GMT), total body fat and percentage fat were analyzed statistically. The fat distribution pattern was studied using waist/hip ratio, subscapular/triceps ratio and responsiveness of five skinfold sites towards accumulation of fat at different sites with advancing age. Results indicate a decline in almost every dimension including level of fatness between the mid-fourth and mid-fifth decades of life in both rural and urban females. Urban Jat females were heavier (57.36 kg vs. 56.07 kg, p > 0.05) and significantly taller (1553.3 mm vs. 1534.5 mm, p < 0.001) than their rural counterparts. Urban females also exhibited higher mean values for both the circumferences, five skinfold thicknesses as well as for lean body mass, total fat and percentage fat than the rural females. This is also evident from their higher mean values for body mass index and grand mean thickness. Waist/hip ratio values in rural and urban females showed upper body fat predominance, with urban females having relatively more abdominal fat. Results of subscapular/triceps ratio showed that rural and urban females gained proportionally similar amounts of subcutaneous fat at trunk and extremity sites until 45 years of age. Subsequently trunk skinfolds increased relatively more in thickness. The magnitude of this increase was comparatively greater in rural females up to 55 years and among urban females from 55 to 70 years. The profiles of subcutaneous fat accumulation and sensitivity of each skinfold site also revealed more fat deposition in the trunk region compared to extremities in both rural and urban females. The present study demonstrated differential rates of fat redistribution among rural and urban females.     

Body composition and fat distribution pattern of urban elderly females, Delhi, India

The present study was conducted on females (n = 279) in the age range of 51-89 year, living in the urban dwellings of Delhi, India. Another group of 21-25 years old young adult females was taken as a control group. A total of 14 anthropometric measurements were taken: stature, sitting height, weight, skinfold thickness at nine different sites over the body and body girths such as upper arm, waist and hip circumference. Indices like body mass index, grand mean thickness, waist-hip ratio were computed to assess the body composition. Fat profile and responsiveness of different skinfold sites towards fat accumulation were studied to find out the regional fat distribution with advancing age. Redistribution of body fat was found to take place with increasing age. A relative preponderance of upper body fat was visible among elderly subjects. However, a clear reverse trend was observed in the young control group females. Significant differences were observed with regards to the body composition and fat profile between young adult females and test group females. Abdomen and the sub-scapular area were reported to be the most sensitive sites for fat deposition as the age advanced. The stature and sitting height showed significant decline with age. All the indices of adiposity i.e. grand mean thickness, waist-hip ratio and body mass index revealed significant changes in elderly females when compared with young adult control group females.     

Longitudinal measurements of blood volume and essential body mass in human subjects.

Repeated determinations of blood volume and body density were made on 34 Chinese subjects (28 men and 6 women) in Taiwan over a period of 12 yr, as the mean age increased from 31 to 43 yr. Essential body mass calculated from body density and body weight showed no significant change over the 12-yr period. Changes in body weight (mean gain equals 6.0 kg) were attributable to alterations in adipose tissue weight, the density of which was found to be 0.948 g/cm3. In two-thirds of the subjects the second blood volume increased by more than 5% over the first determination, and the mean blood volume for all subjects increased by 7.5% (P less than 0.01). Correlation of the blood volume data with the findings on essential body mass and adipose tissue mass suggests that blood content per unit tissue mass increased in the second determination. This interpretation is supported by the increase in nutrient availability in Taiwan over the 12-yr period, and it may explain the lack of blood volume increase in an earlier longitudinal study on American subjects with stable nutrient availability.     

Gender differences in fat patterning in children living in Ankara

Body composition is an excellent indicator for assessing obesity and nutritional status of both individuals and populations. Youth obesity has important health and social implications, because a large proportion of adult obesity has its origin in childhood. Numerous studies report that adverse levels of cardiovascular diseases risk factors are associated with adiposity in children. Concerning the Turkish population there is up to now only limited information with regard to adiposity in children. The aim of this study was therefore to determine the anthropometric and body composition characteristics and to investigate sex differences in fat patterning including fat distribution in a group of children living in Ankara. The present study evaluated the body composition of 332 boys and 269 girls aged between 8 and 11 years, attending public schools. It was carried out by a cross-sectional study and was focused on that anthropometric variables, which reflect body fat and fat-free mass. Anthropometric measurements including height, weight, triceps and subscapular skinfolds thickness were carried out on these children. The body mass index (BMI) was also calculated. The measurements were used to estimate the two-compartment model of body composition: fat-free mass (FFM) and body fat (BF) from skinfold equations. The mean fat percentage in boys is highest at 11 years (16.8%) and lowest at 10 years (15.6%). In girls these figures come to 18.2% and 17.1%, respectively. Girls of these age groups have a significantly larger percentage of body fat and skinfold thickness. At this young age there is therefore clear evidence of sexual dimorphism in fat patterning, as girls are showing a greater subcutaneous adiposity, which is mainly contributed by the triceps fat. The body fat (kg) increases in both sexes all over the investigated age groups. The Pearson correlation matrix showed a high significant relation between the anthropometric measurements (p < 0.01). The present study confirms the findings that sexual dimorphism of fat patterning in children is to be seen in the age of 8 - 11 years. It furthermore presents basic data of body composition, which could serve as reference data in other studies on the Turkish population.     

Subcutaneous adiposity and relative fat patterning in adult white and migrant asian males in Britain

A comparative study of subcutaneous adiposity and relative fat patterning in adult White (n=262) and migrant Indian (n=39) and Pakistani (n=100) males living in Peterborough, Cambridgeshire revealed no significant difference in the level of generalised adiposity (measured as body mass index) between the ethnic groups. However, Asians had significantly higher means for all five truncal skinfolds; for all upper body: upper extremity, upper body: lower extremity, central body: upper extremity and central body: lower extremity skinfold rations; more total subcutaneous adiposity; and significantly more subcutaneous fat in subscapular, suprailiac and abdomen regions relative to total subcutaneous fat. However, Asian men had significantly less subcutaneous fat in all the extremity sites relative to total subcutaneous adiposity and lower mean forearm subcutaneous adiposity. Discriminant analysis revealed that 80.6% of all individuals were correctly classfied, with Whites being grouped more correctly than Asians. Suprailiac/forearm and suprailiac/triceps skinfold ratios, height, weight, age, body mass index, and subscapular, midauxillary, chest and medial calf skinfolds were among the most important discriminating variables/ratios of the three ethnic groups.     

湖南土家族成人的皮褶厚度和体成分分析

本项目采用人体测量法,测量了976名(男性528人,女性448人)湖南土家族成人的身高、体质量以及肱三头肌、肩胛下、髂前上和小腿内侧皮褶的厚度,并根据公式计算体密度、体脂率、脂肪质量、脂肪质量指数、瘦体质量和瘦体质量指数。结果显示随年龄增长,小腿内侧皮褶厚度值逐渐减小,肱三头肌、肩胛下和髂前上棘皮褶以及体脂率、脂肪质量、瘦体质量、体质量指数、脂肪质量指数和瘦体质量指数值先增大后减小,体密度值先减小后增大;各年龄组中体密度、瘦体质量及其指数值女性明显低于男性,4项皮褶厚度值以及体脂率、脂肪质量及其指数值女性高于男性;与布朗族等24个族群比较,湖南土家族成人皮褶厚度处于中等水平,与门巴族、珞巴族、僜人、彝族等族群的亲缘关系较近。     

Income, birth order, siblings, and anthropometry

The purpose of the present cross-sectional study was to examine the relationship and effect of monthly household income, birth order, and number of siblings on adult body dimensions, adiposity index, and body composition among adult Bengali females. One hundred seventy-one adult Bengali females, age 20.35 +/- 1.51 years (mean +/- SD; range: 18-21 years) from Kolkata (formerly Calcutta) were studied. Anthropometric measures (weight, height, waist circumference, hip circumference, and triceps, biceps, subscapular, suprailiac, and medial calf skinfold thicknesses) were taken from all participants using standard protocols. BMI and log10 of the sum of the five skinfold thicknesses were computed subsequently. Percentage of body fat was estimated from the triceps skinfold thickness following the equation of Durnin and Womersley (1974), and fat mass was then calculated. Results of the correlation analysis revealed that monthly household income had significant (p < 0.05) positive association with all anthropometric variables. Birth order and number of siblings showed significant (p < 0.05) inverse association. The correlation of monthly household income with anthropometric variables was much stronger for number of siblings and birth order. The results of the analysis of variance showed that monthly household income, birth order, and number of siblings (tertiles used to categorize all variables) had significant effects (p < 0.05) on anthropometric variables, indicating differences in adult body dimensions, the adiposity index, and body composition in relation to income, birth order, and number of siblings.     

Comparison of ultrasound and skinfold measurements in assessment of subcutaneous and total fatness

Ultrasound (A-scan mode) and skinfold methods were evaluated in the measurement of subcutaneous fat thickness and prediction of total fat weight (by whole body potassium counting). Based on intraobserver correlations on 39 men at 15 body sites, skinfold caliper measurements were more reproducible than ones obtained by ultrasound. Measurements made with the two techniques at the same site typically produced different mean estimates of fat thickness. However, scores were often highly correlated with each other, indicating similar relative rankings of subjects by each technique. Skinfolds were more highly correlated with total fat weight than were ultrasound measurements, but body weight and anthropometric measures had even higher correlations with total fat weight. Anthropometric measurements were highly correlated with fatness because of their association with body weight, and when this relationship was statistically controlled for, they typically lost their predictive effectiveness. Multiple regression analyses revealed that the best predictors of fat weight were body weight along with skinfold and ultrasound measurements. These results suggest that skinfolds are a more effective means of assessing subcutaneous fat than ultrasound, especially when the large difference in cost of equipment is considered.     

Body composition in Division I football players

This study assessed body composition of Division I football players (n = 69) and compared the findings with previously reported data to ascertain whether the increase in player total body mass that has been observed over the past 10 years has been accompanied by an increase in body fat. Body composition was determined by hydrostatic weighing and the measurement of skinfold thicknesses. Total body mass, skinfold thicknesses, and body fat were greater in the current players than in players in studies conducted in the early 1980s and early 1990s. Body fat varied significantly across playing position, with the defensive backs, offensive backs, and receivers being the leanest and the offensive linemen and tight ends the most fat. There was no significant relationship between body composition and playing year or scholarship status, nor were any differences observed between ethnic groups. Of important clinical relevance was the finding that the linemen (offensive, defensive) and tight ends were on average greater than 25% body fat, the borderline for obesity in this age group. Much of this fat was deposited in the abdominal region, a significant finding when one considers the high correlation between abdominal obesity and ischemic heart disease and stroke. The current findings suggest that more attention needs to be given to the nature of the increase in body mass being achieved by today's football player to minimize long-term negative health consequences, and the findings reemphasize the need identified in earlier studies of the importance of detraining programs for these athletes.     

Parent-child correlation for various indices of adiposity in an endogamous Indian population

The study was conducted on 1,042 Punjabi adults and adolescent boys and girls (11-17 years) belonging to middle class families residing in Delhi, India. To study the relative influence of genetic and environmental factors on various fat measures, a set of 7 body measurements namely weight, stature and skinfold thickness at biceps, triceps, subscapular, suprailiac and medial calf measurements was taken on each subject. There was a redistribution of fat away from extremity towards the trunk, a rapid occurring process in males than in females. Increase in body mass index (BMI) with age was more pronounced in females than in males, both at adolescence and adult stage. There was an increase in grand mean thickness (GMT) calculated as mean of all five skinfold thicknesses, in adolescent girls where as in adolescent boys it fluctuated with age. The trunk/extremity ratios reflected a trend in favor of increase in trunk fat, more marked in boys than in girls. The correlations were of low magnitude, however, some skin folds displayed relatively higher value of correlation indicating that these could be determinant of adult obesity.     

Quantification of adipose tissue by MRI: relationship with anthropometric variables.

This study had two objectives: 1) to establish magnetic resonance imaging (MRI) as a tool for measuring total and regional adipose tissue (AT) distribution in humans and 2) to assess the relationship between selected anthropometric variables and MRI-measured AT. Twenty-seven healthy men varying in age [40.8 +/- 14.5 (SD) yr], body mass index (28.5 +/- 4.8), and waist-to-hip ratio (WHR, 0.96 +/- 0.07) participated in the study. Total AT volume was determined using a linear interpolation of AT areas obtained on consecutive slices (n = 41) taken from head to toe (10-mm thickness, 50-mm centers). The mean change for repeated measures of total AT volume was 2.9% (range 0.9-4.3%). Large interindividual differences were observed for total AT volume (6.9-59.3 liters), subcutaneous AT (6.3-49.8 liters), and visceral AT (0.5-8.5 liters). Visceral AT represented 18.3% of the total AT. The single best predictor of total adiposity was waist circumference (R2 = 0.92). For visceral AT volume, WHR was the strongest anthropometric correlate (r = 0.85, P less than 0.01). When controlled for age and adiposity, however, WHR explained only 12% of the variation in absolute visceral AT and less than 1% of the variation in visceral-to-subcutaneous ratio. Age was a better predictor of visceral-to-subcutaneous ratio than level of adiposity or WHR. The results of this study demonstrate that MRI offers a reliable measure of regional and total AT distribution in humans and, thus, is of value as a research tool.     

Treatment of obesity by exercise in the cold.

Six obese men aged 25 to 46 years exercised vigorously for 3 1/2 hours in a cold chamber (-34 degrees C) on 10 successive days. There was an early water loss of about 1 kg, probably due to mobilization of glycogen stores, and a subsequent fat loss of about 4 kg (as estimated from readings of skinfold thickness and confirmed by underwater weighing). The total fat loss was much greater than the calculated external energy deficit (as estimated from dietary records, an activity diary and use of a Kofranyi-Michaelis respirometer). Although some energy was "wasted" through ketosis, much of the additional energy was apparently used for synthesis of additional muscle protein. Both readings of skinfold thickness and underwater weighing indicated that the loss of adipose tissue was well sustained in the first 2 months after the exercise program. Further experiments are recommended to determine whether cold exposure makes a specific contribution to the observed weight loss, and whether this approach would be equally effective in a larger and less selected sample of obese patients.     

Regional adiposity, body composition and central body fat distribution of 10-16 years old Bengalee boys of Nimta, North 24 Parganas, West Bengal, India

A cross-sectional study of 502 Bengalee boys aged 10-16 years of Nimta, North 24 Parganas, West Bengal, India, was undertaken to study regional adiposity, body composition and central body fat distribution. The subjects were classified into seven age groups: 10-10.9 years (n = 74), 11-11.9 (n = 53), 12-12.9 (n = 87), 13-13.9 (n = 116), 14-14.9 (n = 58), 15-15.9 (n = 57), 16-16.9 (n = 57). In general, there was a significant linear increasing trend from 10 to 16 years for all the anthropometric variables. There was a net increase of 30.5 cm and 22.8 kg in mean height and weight, respectively, between 10 and 16 years of age. Mean BMI increased by 3.7 kg/m2 during the same period. Among circumferences, the largest increase was in hip followed by chest while the smallest increase was in mid upper arm, between 10 and 16 years of age. Subscapular skinfold showed the largest increase followed by abdomen and suprailiac skinfolds, while the increase was least in forearm skinfold. Significant linear increasing trend was observed for all the body composition measures. The largest increase in percent of body fat (PBF) was observed between ages 10 and 11 years while mean fat mass (FM), fat free mass (FFM) and fat mass index (FMI) increased the most between 14 to 15 years. However, an overall decreasing trend was observed, in mean waist-to-hip ratio (WHR) from 10 to 16 years. Boys aged 10 years had the highest mean WHR while those aged 15 years had the lowest mean WHR. There was an increase in mean WHR among 16 years old boys.     

Magnetic resonance imaging of total body fat

In this study we assessed different magneticresonance imaging (MRI) scanning regimes and examined some of theassumptions commonly made for measuring body fat content by MRI. Wholebody MRI was used to quantify and study different body fat depots in 67 women. The whole body MRI results showed that there was a significant variation in the percentage of total internal, as well as visceral, adipose tissue across a range of adiposity, which could not be predicted from total body fat and/or subcutaneous fat.Furthermore, variation in the amount of total, subcutaneous, andvisceral adipose tissue was not related to standard anthropometricmeasurements such as skinfold measurements, body mass index, andwaist-to-hip ratio. Finally, we show for the first time subjects with apercent body fat close to the theoretical maximum (68%). This studydemonstrates that the large variation in individual internal fatcontent cannot be predicted from either indirect methods or directimaging techniques, such as MRI or computed tomography, on the basis ofa single-slice sampling strategy.

     

Prediction of body density in young and middle-aged women.

The purpose of this investigation was to predict body density of young and middle-aged women and to determine if the use of a greater variety of variables, particularly those for fat in the bust and hip regions, increases the predictability of body density. Body density determined by the hydrostatic technique (dependent variable) was obtained from 83 volunteer young women and 60 middle-aged women ranging from 18 to 22 and 33 to 50 yr of age, respectively. Independent variables included 8 skinfold, 13 girth, and 7 diameter measures; age; height; weight; and bra and cup sizes. Mean body density for young women was 1.043 g/ml (SD plus or minus 0.014) and percent fat, 24.8 (SD plus or minus 6.4); 1.031 g/ml (SD plus or minus 0.015) and 29.8% (SD plus or minus 6.7) for middle aged subjects. Percent fat was calculated by the formula of Siri. Factor analysis was used to examine the dimensions measured by the independent variables as a function of age. A multiple regression model was used to develop predictions of body density from the independent variables. The best combination of four variables for predicting body density was skinfold thigh, skinfold suprailiac, cup size, skinfold suprailiac, girth waist, and skinfold thigh (R = 0.89) for middle-aged women. The data showed that the highest predictons were found by using combinations of skinfold, girth, and diameter variables; cup size also supported the need for different regression equations for different age groups.     

Stability of Adiposity Phenotypes from Childhood and Adolescence into Young Adulthood with Contribution of Parental Measures

Objective: The stability of several indicators of body composition and adipose tissue distribution over 12 years was quantified. Research Methods and Procedures: The participants were 77 boys and 76 girls who were evaluated along with their parents at baseline as children and adolescents (8 to 18 years of age) and remeasured as young adults 12 years later. Indicators of body composition included the body mass index, fat mass, fat free mass, percentage of body fat, sum of six skinfolds (SF6), and the first principal component of six age‐adjusted skinfold residuals. Relative adipose tissue distribution was represented by the second principal component of skinfold residuals and a trunk‐to‐extremity skinfold ratio, adjusted for SF6. Results: Partial interage correlations, controlling for initial age and length of follow‐up, were 0.65 and 0.59 for the body mass index, 0.59 and 0.64 for fat mass, 0.65 and 0.57 for fat free mass, 0.50 and 0.57 for percentage of body fat, 0.66 and 0.44 for SF6, 0.64 and 0.42 for the first principal component of six age‐adjusted skinfold residuals, 0.19 and 0.31 for the second principal component of skinfold residuals, and 0.41 and 0.47 for trunk‐to‐extremity skinfold ratio, adjusted for SF6, in men and women, respectively. Multiple regression analyses indicated that the significant partial R² values of parental measurements on the prediction of their offspring in young adulthood ranged from 2% to 9%. Discussion: The results indicate moderately high stability of indicators of body composition and somewhat lower stability of measures of adipose tissue distribution. Overall, parental measures offer less predictive value than do measures of childhood and adolescent body composition and adipose tissue distribution.     

Comparison of body composition in middle-aged and elderly males using computed tomography

Computed tomography (CT) scans were taken of 21 middle-aged men (mean age 46.3 years) and 20 older men (mean age 69.4 years) to measure differences in body composition with age. Overall, the older men weighed 8.2 kg less than the middle-aged men, and this difference was primarily the result of their having less lean tissue. Although fat mass (by whole body potassium counting) was only slightly less in older men, there were distributional differences in fat between the age groups. Total abdomen adipose tissue area (from CT) was similar in both groups, although the subcutaneous portion of the abdomen adipose tissue was less in the older men, and they had correspondingly more adipose tissue within the abdominal cavity. Muscle areas of the leg and arm were significantly less in the older men, as were all lean tissues of the abdomen and chest. When these data were corrected for differences in body weight with age, the results were still significant, suggesting a centripetalization and internalization of fat with age. Causes of this apparent fat redistribution and decrease of lean tissue with age were not revealed by this study and are presently unknown.     

Ecogeographical associations between climate and human body composition: analyses based on anthropometry and skinfolds

In the 19th century, two "ecogeographical rules" were proposed hypothesizing associations of climate with mammalian body size and proportions. Data on human body weight and relative leg length support these rules; however, it is unknown whether such associations are attributable to lean tissue (the heat-producing component) or fat (energy stores). Data on weight, height, and two skinfold thickness were obtained from the literature for 137 nonindustrialized populations, providing 145 male and 115 female individual samples. A variety of indices of adiposity and lean mass were analyzed. Preliminary analyses indicated secular increases in skinfolds in men but not women, and associations of age and height with lean mass in both sexes. Decreasing annual temperature was associated with increasing body mass index (BMI), and increasing triceps but not subscapular skinfold. After adjusting for skinfolds, decreasing temperature remained associated with increasing BMI. These results indicate that colder environments favor both greater peripheral energy stores, and greater lean mass. Contrasting results for triceps and subscapular skinfolds might be due to adaptive strategies either constraining central adiposity in cold environments to reduce cardiovascular risk, or favoring central adiposity in warmer environments to maintain energetic support of the immune system. Polynesian populations were analyzed separately and contradicted all of the climate trends, indicating support for the hypothesis that they are cold-adapted despite occupying a tropical region. It is unclear whether such associations emerge through natural selection or through trans-generational and life-course plasticity. These findings nevertheless aid understanding of the wide variability in human physique and adiposity.     

Differences in skeletal and muscle mass with aging in black and white women

Previous cross-sectional studies using delayed gamma neutron activation analysis and whole body counting suggested that the relationship of total body calcium (TBCa) to total body potassium (TBK) (muscle mass, body cell mass) remained constant with age. This led to the hypothesis that the muscle mass and skeletal mass compartments are integrated in their response to aging. It had also been hypothesized that loss of skeletal and muscle mass was similar between races. In the current study, delayed gamma neutron activation analysis and whole body counting were performed on 90 black and 143 white women 20-69 yr of age. Black women had higher TBCa and TBK values than white women, even when the data were adjusted for age, height, and weight. TBCa was correlated with height and TBK with weight. The estimated decline of skeletal mass (TBCa) from 20 to 70 yr was 18% in black women and 19% in white women. However, the lifetime decline of TBK was only 8% for black women, compared with 22% for white women. Black women may lose TBK more slowly than TBCa with aging, compared with white women. In particular, correlation of TBCa and age was similar for blacks and whites (r = -0.44 and r = -0.54, respectively). However, for TBK these correlations were r = -0.14 and r = -0.42. These data confirm a higher musculoskeletal mass in black women and suggest that the loss of muscle mass with age may be lower in black than in white women. These ethnic differences do not support the hypothesis of an integrated musculoskeletal system, so that these two components should be considered separately. A prospective study is needed to confirm these findings.