Is BAI better than BMI in estimating the increment of lumbar lordosis for the Caucasian population?

Abstract

BACKGROUND:

One of the complications of obesity is low back pain, frequently associated with postural disorders. Body adiposity index (BAI) can be calculated without weighing, which may be rendered useful in settings where measuring accurate body weight is problematic.

OBJECTIVE:

The aim of this study was to compare two indices of somatic structure, i.e., BAI and BMI regarding their accuracy (specific and sensitive) in predicting postural aberrations.

METHODS:

The study group comprised of 1281 participants aged 20–22 years, who were students from universities in southern Poland. Anteroposterior spinal curvatures were measured using the Rippstein plurimeter. All subjects were measured for body height (BH) and mass, waist and hip circumference (WC and HC, respectively).

RESULTS:

In both male and female groups classified according to BAI cut-off points, a significant linear relationship was noted for the lumbar lordosis angle, i.e., the latter increased along with the BAI increase. The analysis of variance confirmed statistically significant differences in lordosis angles in both groups (women $f=$ 19.6, $p<$ 0.001; men $f=$ 21.18, $p<$ 0.001). These data evidenced a weak relationship between LL and the BAI. Pearson correlation coefficient (r) between LL and BAI was 0.2 and 0.21 for men and women, respectively.

CONCLUSIONS:

We concluded that, contrary to BAI, BMI value did not indicate a significant difference in lumbar lordosis angle between normal weight and obese participants (women and men).

Keywords

Body adiposity index Rippstein plurimeter thoracic kyphosis increments of angles spine

Table 1
Characteristics (mean $\pm$ SD and range) of the study participants

	Men ( $n=$ 539)		Women ( $n=$ 742)
	Mean $\pm$ SD	Range	Mean $\pm$ SD	Range
Age (years)	19.6 $\pm$ 1.2	18.2–22.4	19.8 $\pm$ 0.9	18.1–22,6
Weight (kg)	74.9 $\pm$ 12.4	49.3–139	58.7 $\pm$ 8.8	39.4–108.5
Height (cm)	180.6 $\pm$ 6.27	161–202	166.8 $\pm$ 6.1	151.0–189.5
BMI (kg/m ${}^{2}$ )	22.94 $\pm$ 3.3	14.7–40.6	21.1 $\pm$ 2.9	14.1–41.3
BAI (%)	22.1 $\pm$ 3.9	9.2 $\pm$ 35.3	26.0 $\pm$ 3.64	46.0–14.9
KTH ( ${}^{\circ}$ )	37.5 $\pm$ 8.5	9–64	35.7 $\pm$ 8.5	5–62
LL ( ${}^{\circ}$ )	30.4 $\pm$ 9.4	4–60	34.4 $\pm$ 8.6	10–60

1. Introduction

Over the past decades, a gradual increase has been observed in overweight and obesity. This phenomenon mainly concerns highly industrialised societies and is mostly related to disadvantageous changes in lifestyles. Unhealthy eating habits and low levels of physical activity have been indicated as the most common causes of obesity [1]. Obesity is a risk factor for a large number of diseases affecting both the quality and length of human life. One of the complications of obesity is low back pain, frequently associated with postural disorders. Back pain is a common condition which has been described as a serious public health problem [2]. Epidemiological evidence shows that low back pain is a multifactorial problem. Abnormal spinal curvatures and body mass index (BMI) over 25 were correlated to low back pain [3]. It has been estimated that over 80% of the population will report low back pain at some point in life [4]. Investigations in Poland and other countries showed that the main risk factors for the development of low back pain syndrome are body height (women over 170 cm and men over 180 cm), overweight and obesity, hip abduction and hamstrings flexibility, age from 40 to 59 years, inefficiency of abdominal and dorsal muscles, postural defects (scoliosis, hyperlordosis, unequal length of the extremities) [6, 7, 8]. It is therefore important to estimate the relationships between BMI, body adiposity index (BAI) and angle of lumbar lordosis and thoracic kyphosis in healthy Caucasians (men and women). However, BMI measurement is known to have limited accuracy, and it is different for males and females with similar % body adiposity. BMI is particularly inaccurate in subjects with elevated lean body mass, such as athletes, and cannot be generalized among different ethnic groups [9, 10, 11]. To address this limitation, Bergman et al. defined an alternative index, i.e., BAI, in samples of Mexican-Americans and African-Americans [12]. BAI can be calculated without weighing, which may render it useful in settings where measuring accurate body weight is problematic. As confirmed by recent studies, the BAI estimates % adiposity and cardiovascular risk [9, 10, 11, 12], but we aimed to assess the predictive value of this indicator with respect to the angles of lumbar lordosis and thoracic kyphosis.

The aim of this study was to verify whether there was a relationship between the physiological curvature of the thoracic and lumbar spine and BAI and BMI indices. We assumed that BAI might be a more sensitive predictor of lumbar hyperlordosis than BMI. An additional objective of our research was to determine the relationship of increased lumbar lordosis (LL) and thoracic kyphosis (ThK) with body height or body weight among young adults of the Caucasian population.

2. Materials and methods

2.1 Participants

The study was comprised of 742 women and 539 men (a total of 1281 participants) aged 18–22 years, who were students from universities in southern Poland and had a Caucasian background. Participants took part in different forms of obligatory physical activity classes. All subjects were healthy, and the majority (70%) of them were not aware of their postural deformities. During interviews, they did not report any cardiometabolic problems and 75.7% had BMI $>$ 25. The inclusion criterion was no sport history. The characteristics of the participants are listed in Table 1.

All students provided written informed consent to participate in the study. Anthropometric measurements were taken in a separate room. The study was approved by the Ethics Committee and complied with the updated version of the Declaration of Helsinki. After having read and signed an informed consent form, the subjects were scheduled for a testing session at the University of Economics and Academy of Physical Education in Poland.

2.2 Procedures

This was a cross-sectional analytical study where the participants were measured only once. The examinations were carried out in the morning. Anteroposterior spinal curvatures were measured using the Rippstein plurimeter, a tool for quick, accurate and inexpensive assessment of children and adolescents’ posture in the sagittal and transverse planes, which can be used to complement physical examination (orthopedics, pediatrics) and rehabilitation. This apparatus enables quick and easy measurements and ensures the reproducibility of the results even when the examinations are carried out by different examiners. The results are read directly from the apparatus, yielding two values of angular deflection. The first value is the angle of thoracic kyphosis, measured between the kyphosis peak Th ${}_{12}$ and Th ${}_{1}$ . The other value is lumbar lordosis angle measured between L ${}_{5}$ and Th ${}_{12}$ . Thoracic kyphosis and lumbar lordosis were evaluated by means of a V plurimeter with the patient free-standing without any postural correction [13, 14]. Measurements were done by two examiners to minimize inter-observer differences, see Fig. 1. The value 30 $\pm$ 5 was considered as normal kyphosis and lordosis [14, 15].

Table 2
Mean and standard deviation ( $\pm$ SD) of the anthropometric variables by BAI cut-off points (men and women)

Parameters	Underweight ( $n=$ 49)		Healthy ( $n=$ 665)		Overweight ( $n=$ 25) and obese ( $n=$ 3)		Healthy ( $n=$ 96)		Overweight ( $n=$ 329)		Obese ( $n=$ 114)
	Women ( $n=$ 742)						Men ( $n=$ 539)
BH (cm)	171.2	$\pm$ 6.65	166.6	$\pm$ 5.8	161.2	$\pm$ 4.16	183.7	$\pm$ 6.2	180.6	$\pm$ 5.7	177.6	$\pm$ 6.22
BM (kg)	54.6	$\pm$ 7.56	58.7	$\pm$ 8.36	74.3	$\pm$ 11.41	72.1	$\pm$ 9.11	72	$\pm$ 10.37	86.1	$\pm$ 15.38
Fat (%)	18.58	$\pm$ 6.94	23.9	$\pm$ 6.45	33.4	$\pm$ 6.97	12	$\pm$ 4.02	12.6	$\pm$ 4.46	21.3	$\pm$ 5.4
WC (cm)	66.2	$\pm$ 4.38	70.7	$\pm$ 6.21	80.3	$\pm$ 9.55	71.2	$\pm$ 9.99	80.4	$\pm$ 7.28	90.5	$\pm$ 11.79
WHR	0.79	$\pm$ 0.06	0.75	$\pm$ 0.05	0.74	$\pm$ 0.07	0.83	$\pm$ 0.1	0.83	$\pm$ 0.06	0.84	$\pm$ 0.08
BAI	19.61	$\pm$ 1.17	26.1	$\pm$ 2.78	35.3	$\pm$ 2.66	16.36	$\pm$ 2.2	22.04	$\pm$ 1.6	27.25	$\pm$ 2.13
KTh ( ${}^{\circ}$ )	34.6	$\pm$ 8.31 ${}^{1}$	34.6	$\pm$ 8.21 ${}^{1}$	36.9	$\pm$ 7.73 ${}^{1}$	37.4	$\pm$ 8.05 ${}^{1}$	37.3	$\pm$ 8.7 ${}^{1}$	36.3	$\pm$ 8.68 ${}^{1}$
LL ( ${}^{\circ}$ )	30.3	$\pm$ 7.16*	33.2	$\pm$ 7.99*	38.9	$\pm$ 8.46*	26.9	$\pm$ 8.38*	30	$\pm$ 9.54*	32.7	$\pm$ 9.07*

${}^{1}$ Insignificant by Kruskal-Wallis test; * statistically significant at $p<$ 0.001 by Kruskal-Wallis test.

Figure 1.

Measurement by Rippstein plurimeter.

Measurements included body height (BH), waist and hip circumference (WC and HC) (cm). Body weight (kg) was determined using a stand-on bioimpedance analyzer (BIA) Tanita BC 420SMA (Tanita Corporation, Japan). The study was performed according to a standard protocol recommended by the manufacturer: in the fasted state, in light clothing, without shoes and socks with clean feet. The participants were instructed not to eat at least 2 hours before the measurement. The Analyzer samples periods of 5-second resistance values (Rx) and the reactance of their volume (Xc). This is the basis for calculating body composition by a computer program relative to age, sex and body height [16]. Body height was also used to estimate body fat percentage. BMI was calculated by the formula: BMI = body weight [kg]/body height [m ${}^{2}$ ]. BAI was calculated by the formula: (BAI $=$ hip circumference [cm]/(body height [m]) ${}^{1.5}$ –18) [12, 17].

For the measurement of body height, a wall-mounted stadiometer with standard scales was used with the accuracy of 0.5 cm. Body height was measured to the nearest mm. WC (cm) and HC (cm) were measured with an anthropometric tape over light clothing. Waist circumference was measured at the minimum circumference between the iliac crest and the rib cage whereas hip girth was measured at the maximum width over the greater trochanters. Waist to hip ratio (WHR) and waist to height ratio (WHtR) were then calculated. A measurement of waist to hip ratio (WHR) is an appropriate method of identifying patients with abdominal fat accumulation. WHO recommends the use of the waist circumference measurement because it is closely correlated with BMI and WHR, and it is an approximate index of intra-abdominal fat mass and total body fat [15]. Standard BMI ranges ( $>$ 25) and BAI cut-off points (rates for women $>$ 35% and for men $>$ 22%) were used to identify obese and overweight participants [12, 17].

Table 3

Mean and standard deviation ( $\pm$ SD) of the anthropometric variables by BMI cut-off points (men and women)

Women (

n=

742)

Men (

n=

539)

Parameters

Underweight (

n=

100)

Healthy (

n=

574)

Overweight

(

n=

58) and

obese (

n=

10)

Underweight (

n=

28)

Healthy (

n=

396)

Overweight

(

n=

93) and

obese (

n=

22)

167.3

\pm

5.92

166.6

\pm

6.1

166.8

\pm

6.27

179.4

\pm

6.99

180.3

\pm

6.1

181.3

\pm

6.24

48.8

\pm

4.22

58.7

\pm

6.25

76.7

\pm

8.14

57.3

\pm

4.92

71.2

\pm

7.58

92.4

\pm

11.62

Fat %

15.5

\pm

5.08

\pm

4.99

35.6

\pm

4.21

6.6

\pm

2.87

12.6

\pm

3.82

22.1

\pm

4.76

64.3

\pm

3.79

70.5

\pm

5.16

81.6

\pm

7.5

70.9

\pm

4.02

78.5

\pm

7.68

91.6

\pm

13.29

WHR

0.73

\pm

0.05

0.75

\pm

0.05

0.77

\pm

0.06

0.79

\pm

0.05

0.83

\pm

0.07

0.85

\pm

0.1

BMI

17.43

\pm

0.93

21.14

\pm

1.7

27.58

\pm

2.79

17.78

\pm

0.62

21.87

\pm

1.7

28.08

\pm

3.03

KTh

35.3

\pm

8.49

{}^{1}

34.5

\pm

8.16

{}^{1}

35.5

\pm

8.19

{}^{1}

\pm

10.4

{}^{1}

37.4

\pm

8.43

{}^{1}

36.1

\pm

8.55

{}^{1}

\pm

8.51

{}^{1}

33.1

\pm

7.84

{}^{1}

35.2

\pm

{}^{1}

31.7

\pm

10.38

{}^{1}

29.7

\pm

9.48

{}^{1}

30.5

\pm

8.87

{}^{1}

${}^{1}$ Insignificant by Kruskal-Wallis test; * statistically significant at $p<$ 0.001 by Kruskal-Wallis test.

Table 4

The Pearson’s correlation between somatic parameters, BAI and thoracic kyphosis and lumbar lordosis angles in women and men

Parameters	Group by BAI	Body height	Body weight	Waist circum.	Hip circum.	Fat (%)	BAI
Women
	O&Ow	$-$ 0.02	0.00	0.05	0.05	$-$ 0.02	0.08
KTh	Healthy	$-$ 0.02	0.00	0.05	0.05	$-$ 0.02	0.08
	Underweight	0.08	0	$-$ 0.10	0.13	$-$ 0.06	0.14
	All	$-$ 0.02	0.03	0.06	0.08* $p=$ 0.04	0.01
	O&Ow	0.08	0.09	0.30	0.22	0.21	0.21
LL	Healthy	$-$ 0.04	0.04	0.03	0.11* $p=$ 0.007	0.05
	Underweight	$-$ 0.04	$-$ 0.21	$-$ 0.25	0.03	$-$ 0.21	0.14
	All	$-$ 0.07	0.08* $p=$ 0.033	0.09* $p=$ 0.016	0.18* $p<$ 0.001	0.09* $p=$ 0.012
Men
	Obesity	0.08	0.02	0.09	$-$ 0.05	0.07	0.01
KTh	Overweight	0.09	$-$ 0.03	$-$ 0.08	$-$ 0.13* $p=$ 0.02	$-$ 0.03
	Healthy	$-$ 0.05	0.00	0.08	0.04	0.01	0.05
	All	0.07	$-$ 0.03	$-$ 0.04	$-$ 0.08	$-$ 0.02	$-$ 0.06
	Obesity	$-$ 0.05	$-$ 0.07	$-$ 0.04	$-$ 0.11	0.07	0.15
LL	Overweight	$-$ 0.05	$-$ 0.13* $p=$ 0.016	$-$ 0.14* $p=$ 0.014	$-$ 0.19* $p=$ 0.001	$-$ 0.03	0.02
	Healthy	$-$ 0.03	$-$ 0.04	$-$ 0.01	$-$ 0.10	0.04	0.07
	All	$-$ 0.10* $p=$ 0.017	$-$ 0.02	0.02	$-$ 0.01	0.15* $p=$ 0.001

${}^{*}$ Statistically significant, KTh – thoracic kyphosis angle, LL – lumbar lordosis angle, O&Ow – obesity and overweight.

Figure 2.

Lumbar lordosis angle in underweight, healthy (norm) and overweight and obese women based on BAI.

Figure 3.

Lumbar lordosis angle in healthy (norm), overweight and obese men based on BAI.

2.3 Statistical analysis

Statistical analysis were performed by means of STATISTICA 10 software (StatSoft. Inc.). Results are presented as mean $\pm$ SD for normally distributed data and as geometric means with a 95% confidence interval. Pearson’s correlation coefficients were computed for BAI, BMI, % FAT ( $>$ 33% for women and $>$ 20% for men), fat mass, WC ( $>$ 80 cm for women and $>$ 95 cm for men), HC, WHR, and WHtR for each sex group. The normality of thoracic kyphosis and lumbar lordosis distributions was verified using the chi-squared test. Due to non-normal distribution, thoracic kyphosis and lumbar lordosis angles were compared between the three groups (BMI- or BAI-based) using the Kruskal-Wallis test by ranks. The level of statistical significance was set at 5%. The prevalence of overweight and obesity based on BMI or BAI was compared using the statistical structure index (SSI).

3. Results

Classification of the study subjects according to BMI and BAI cut-off points revealed significant differences between the male and female groups. In men, overweight and obesity was markedly more frequent according to BAI compared to BMI cut-off points (443 vs. 115). An analysis of SSI confirmed the statistical significance of the differences at $p<$ 0.0001. The female group exhibited opposite results, i.e., overweight and obesity were markedly more frequent according to BMI than BAI (68 vs. 28). However, no significant differences were found in the thoracic kyphosis angle in women and men classified according to BAI and BMI. Lumbar lordosis angle differed in men and women classified based on BAI cut-off points (Tables 2 and 3).

In both male and female groups classified according to BAI cut-off points, a significant linear relationship was noted for the lumbar lordosis angle, i.e., with the latter increasing along with the BAI increase (Figs 2 and 3). The analysis of variance confirmed statistically significant differences in the lordosis angles in both sex groups (women $f=$ 19.6, $p<$ 0.001; men $f=$ 21.18, $p<$ 0.001) (Table 3).

An analysis of the Pearson’s coefficient revealed a correlation ( $r=$ 0.21 for women and $r=$ 0.2 for men; $p<$ 0.05) between lumbar lordosis angle and the BAI; a very weak correlation was also noted for females between thoracic kyphosis angle and the BAI. Detailed analysis of the Pearson’s correlations in women and men groups classified according to the BAI is presented in Table 4.

4. Discussion

The present study is a continuation of a prospective follow-up of young and healthy students. Conclusions regarding the sensitivity and specificity of the BAI for this group had already been presented [18]. The aim of this study was to verify whether there was a relationship between the physiological curvature of the thoracic and lumbar spine and BAI and BMI indices.

Our results revealed significant differences in lumbar lordosis angle between the BAI-based groups (Table 2), i.e., BAI increase was associated with an increase in lumbar lordosis. The opposite tendency was observed in BMI-based groups. Lang-Tapia et al. found that overweight and obese groups had smaller lumbar lordosis (19.4 $\pm$ 11.1 and 20.9 $\pm$ 11.8, respectively) and larger thoracic kyphosis (42.7 $\pm$ 8.9 and 42.8 $\pm$ 9.4, respectively) compared with non-overweight participants (25.1 $\pm$ 12.4 and 40.6 $\pm$ 9.2 ${}^{\circ}$ for lumbar lordosis and thoracic kyphosis, respectively; all $p<$ 0.05) [19]. Zwierzchowska et al. concluded that the high statistical correlation between BAI and body fat percentage in overweight and obese participants indicated that BAI may be highly specific [18]. This was confirmed by the results obtained for a Spanish Mediterranean population [11]. Considering the 35% and 25% cut-off points for women and men, respectively, it has been observed that BAI overestimates obesity in men and underestimates obesity in women. However, it should be noted that BMI also underestimates obesity in women [18].

The degree of lumbar lordosis was constant during puberty and young adulthood. Women are typically more lordotic although we did not observe statistically significant intergroup differences with respect to lumbar lordosis (women 34.4 $\pm$ 8.3 ${}^{\circ}$ , max $=$ 60 ${}^{\circ}$ ; min $=$ 10 ${}^{\circ}$ ; men 30 $\pm$ 9.45 ${}^{\circ}$ , max $=$ 62 ${}^{\circ}$ ; min $=$ 4 ${}^{\circ}$ ) [20]. Similarly, Korovessis, Stamatakis, and Baikousis did not report differences in lumbar lordosis between men and women [21].

Our study revealed that the BAI cut-off points of $>$ 35% for women and $>$ 22% for men indicated an increase in lumbar lordosis angle, which helped identify obese and overweight participants. These data evidence a weak relationship between LL and the BAI. Pearson product-moment correlation coefficient (r) between LL and BAI was 0.2 and 0.21 for men and women, respectively. Our results seem to confirm those of Youdas et al., who did not find any correlation between BMI and lumbar lordosis angle [22, 23]. This leads to a conclusion that, contrary to BAI, BMI value does not indicate a significant difference in lumbar lordosis angle between normal-weight and obese participants (women and men).

Cil et al. indicated that there was a significant difference among different age groups, especially at thoracolumbar, and lumbosacral sections [24]. Youdas et al., came to a similar conclusion as they did not find clinically significant differences in lumbar lordosis across age groups [22]. We only examined young adults, but according to Mac-Thiong et al., thoracic kyphosis and lumbar lordosis were weakly correlated with age while sacral slope (angle) remained stable with growth [25]. The analysis suggests that there is no correlation between tissue fat and the angle of lumbar lordosis as measured using the Rippstein plurimeter. This conclusion corresponds to that of Barbosa Milani [26].

4.1 Limitations of the study

The most obvious limitation of the study is the lack of information on pain within the locomotor system. However, the study subjects were healthy students participating in recreation and sports activities included in their study curriculum. Subsequent studies should comprise questionnaire data with detailed information regarding the condition of the subjects’ locomotor system.

5. Conclusions

Our study revealed that BAI cut-off points for Mexican-American and African-American popula-tions [12] can be suitable for the Caucasian population when estimating lumbar lordosis angles in relation to obesity for women and men. Although the correlation values for BAI were statistically significant, they were low, which was not observed for BMI. This problem needs further exploration in the context of different age and ethnic groups since previous studies have demonstrated correlations of BMI and lumbar lordosis angle mainly in the population of older adults and those with the diagnosed pathology in this region of the spine. However, no such studies have been conducted in groups of young healthy adults. It seems that BAI may be complementary to BMI in the estimation of changes in the lumbar lordosis angle and physiological abnormalities of spinal curvature in the sagittal plane.

Footnotes

Acknowledgments

We are grateful to the participants for their time and effort. The study was supported by the statutory funding from the Academy of Physical Education.

Conflict of interest

The authors declare no conflict of interest.

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Is BAI better than BMI in estimating the increment of lumbar lordosis for the Caucasian population?

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSIONS:

Keywords

Table 1 Characteristics (mean ± SD and range) of the study participants

2. Materials and methods

2.1 Participants

2.2 Procedures

Table 2 Mean and standard deviation ( ± SD) of the anthropometric variables by BAI cut-off points (men and women)

3. Results

4. Discussion

4.1 Limitations of the study

5. Conclusions

Footnotes

Acknowledgments

Conflict of interest

References

Table 1
Characteristics (mean $\pm$ SD and range) of the study participants

Table 2
Mean and standard deviation ( $\pm$ SD) of the anthropometric variables by BAI cut-off points (men and women)