Body composition, energy expenditure and physical activity

Comparison of bioimpedance spectroscopy and dual energy X-ray absorptiometry for assessing body composition changes in obese children during weight loss



Obesity and age influence the reliability of dual energy X-ray absorptiometry scanning (DEXA) and bioimpedance spectroscopy (BIS). Both are used in clinical settings, but have not been compared for measurements in obese children. We compared DEXA and BIS for evaluating body composition and inherent changes in obese children before and after a 10-month weight loss programme.


DEXA and BIS were used to evaluate 130 patients at baseline and 75 at follow-up. We tested agreement between the two techniques using Bland–Altman plots and proportional bias using Passing–Bablok regressions.


The Bland–Altman plots showed wide agreement limits before and after weight loss and when monitoring longitudinal changes. At baseline, the Passing–Bablok regressions revealed a proportional bias for all body compartments. After significant weight loss no proportional bias was found for fat mass and percentage, although BIS systematically underestimated fat mass by 2.9 kg. Longitudinally, no proportional bias was found in the measured changes of absolute fat, fat-free mass and fat-free percentage between both methods, although BIS systematically underestimated fat and fat-free mass by 2.6 and 0.7 kg, respectively.


While BIS and DEXA are not interchangeable at baseline, the agreement between the two improved after significant weight loss. Proportional changes in fat mass, fat-free mass and fat-free percentage were similar for both techniques. BIS is a viable alternative to DEXA for future paediatric obesity studies measuring treatment effect at group levels, but is not superior to DEXA and cannot be used for monitoring individual changes due to wide limits of agreement.

Access options

Rent or Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.

Fig. 1: Bland–Altman plots comparing the BCM- and DEXA-derived measurements of the four body compartments before and after treatment.
Fig. 2: Passing–Bablok regressions comparing the BCM- and DEXA-derived measurements of the four body compartments before and after treatment.
Fig. 3


  1. 1.

    Malecka-Tendera E, Mazur A. Childhood obesity: a pandemic of the twenty-first century. Int J Obes. 2006;30:S1–3.

    Google Scholar 

  2. 2.

    Andreoli A, Garaci F, Cafarelli FP, Guglielmi G. Body composition in clinical practice. Eur J Radio. 2016;85:1461–8.

    Google Scholar 

  3. 3.

    Javed A, Jumean M, Murad MH, Okorodudu D, Kumar S, Somers VK, et al. 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;10:234–44.

    CAS  PubMed  Google Scholar 

  4. 4.

    Hendel HW, Gotfredsen A, Andersen T, Højgaard L, Hilsted J. Body composition during weight loss in obese patients estimated by dual energy X-ray absorptiometry and by total body potassium. Int J Obes Relat Metab Disord. 1996;20:1111–9.

    CAS  PubMed  Google Scholar 

  5. 5.

    Brownbill RA, Ilich JZ. Measuring body composition in overweight individuals by dual energy x-ray absorptiometry. BMC Med Imaging. 2005;5:1.

    PubMed  PubMed Central  Google Scholar 

  6. 6.

    Sopher AB, Thornton JC, Wang J, Pierson RN, Heymsfield SB, Horlick M. Measurement of percentage of body fat in 411 children and adolescents: a comparison of dual-energy X-ray absorptiometry with a four-compartment model. Pediatrics. 2004;113:1285–90.

    PubMed  PubMed Central  Google Scholar 

  7. 7.

    Smith-Ryan AE, Mock MG, Ryan ED, Gerstner GR, Trexler ET, Hirsch KR. Validity and reliability of a 4-compartment body composition model using dual energy x-ray absorptiometry-derived body volume. Clin Nutr. 2017;36:825.

    PubMed  Google Scholar 

  8. 8.

    Cox-Reijven P, van Kreel B, Soeters P. Accuracy of bioelectrical impedance spectroscopy in measuring changes in body composition during severe weight loss. J Parenter Enter Nutr. 2002;26:120–7.

    Google Scholar 

  9. 9.

    Moissl UM, Wabel P, Chamney PW, Bosaeus I, Levin NW, Bosy-Westphal A, et al. Body fluid volume determination via body composition spectroscopy in health and disease. Physiol Meas. 2006;27:921.

    PubMed  Google Scholar 

  10. 10.

    Wabel P, Chamney P, Moissl U, Jirka T. Importance of whole-body bioimpedance spectroscopy for the management of fluid balance. Blood Purif. 2009;27:75–80.

    PubMed  PubMed Central  Google Scholar 

  11. 11.

    Dasgupta I, Keane D, Lindley E, Shaheen I, Tyerman K, Schaefer F, et al. Validating the use of bioimpedance spectroscopy for assessment of fluid status in children. Pediatr Nephrol. 2018;33:1601–7.

    PubMed  PubMed Central  Google Scholar 

  12. 12.

    Matthie JR. Bioimpedance measurements of human body composition: critical analysis and outlook. Expert Rev Med Devices. 2008;5:239–61.

    PubMed  Google Scholar 

  13. 13.

    Roelants M, Hauspie R, Hoppenbrouwers K. References for growth and pubertal development from birth to 21 years in Flanders, Belgium. Ann Hum Biol. 2009;36:680–94.

    CAS  PubMed  Google Scholar 

  14. 14.

    Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ. 2000;320:1240.

    PubMed  PubMed Central  Google Scholar 

  15. 15.

    Jaworski M, Pludowski P. Precision errors, least significant change, and monitoring time interval in pediatric measurements of bone mineral density, body composition, and mechanostat parameters by GE Lunar Prodigy. J Clin Densitom. 2013;16:562–9.

    PubMed  Google Scholar 

  16. 16.

    Margulies L, Horlick M, Thornton JC, Wang J, Ioannidou E, Heymsfield SB. Reproducibility of pediatric whole body bone and body composition measures by dual-energy X-ray absorptiometry using the GE Lunar Prodigy. J Clin Densitom. 2005;8:298–304.

    PubMed  Google Scholar 

  17. 17.

    Bazzocchi A, Ponti F, Albisinni U, Battista G, Guglielmi G. DXA: Technical aspects and application. Eur J Radio. 2016;85:1481–92.

    Google Scholar 

  18. 18.

    Mulasi U, Kuchnia AJ, Cole AJ, Earthman CP. Bioimpedance at the bedside: Current applications, limitations, and opportunities. Nutr Clin Pr. 2015;30:180–93.

    Google Scholar 

  19. 19.

    Bland JM, Altman DG. Measuring agreement in method comparison studies. Stat Methods Med Res. 1999;8:135–60.

    CAS  PubMed  Google Scholar 

  20. 20.

    Passing H, Bablok W. A new biometrical procedure for testing the equality of measurements from two different analytical methods. Application of linear regression procedures for method comparison studies in clinical chemistry, Part I. J Clin Chem Clin Biochem. 1983;21:709–20.

    CAS  PubMed  Google Scholar 

  21. 21.

    IBM SPSS Statistics for Macintosh, version 25 (Armonk, N.Y., USA: IBM Corp).

  22. 22.

    Addinsoft. XLSTAT statistical and data analysis solution. Long Island, NY, USA. 2019.

  23. 23.

    Fors H, Gelander L, Bjarnason R, Albertsson-Wikland K, Bosaeus I. Body composition, as assessed by bioelectrical impedance spectroscopy and dual-energy X-ray absorptiometry, in a healthy paediatric population. Acta Paediatr. 2007;91:755–60.

    Google Scholar 

  24. 24.

    Ellegård L, Bertz F, Winkvist A, Bosaeus I, Brekke HK. Body composition in overweight and obese women postpartum: bioimpedance methods validated by dual energy X-ray absorptiometry and doubly labeled water. Eur J Clin Nutr. 2016;70:1181–8.

    PubMed  Google Scholar 

  25. 25.

    Pateyjohns IR, Brinkworth GD, Buckley JD, Noakes M, Clifton PM. Comparison of three bioelectrical impedance methods with DXA in overweight and obese men. Obesity 2006;14:2064–70.

    PubMed  Google Scholar 

  26. 26.

    Svantesson U, Zander M, Klingberg S, Slinde F. Body composition in male elite athletes, comparison of bioelectrical impedance spectroscopy with dual energy X-ray absorptiometry. J Negat Results Biomed. 2008;7:1.

    PubMed  PubMed Central  Google Scholar 

  27. 27.

    Moissl U, Wabel P, Chamney PW, Bosy-Westphal A, Korth O, Mueller M. et al. Validation of a 3C model for determination of body fat mass. J Am Soc Nephrol. 2007;18:257A.

    Google Scholar 

  28. 28.

    Zhou Y, Höglund P, Clyne N. Comparison of DEXA and bioimpedance for body composition measurements in nondialysis patients with CKD. J Ren Nutr. 2019;29:33–8.

    PubMed  Google Scholar 

  29. 29.

    Lim PS, Chen CH, Zhu F, Kotanko P, Jeng Y, Hu CY, et al. Validating body fat assessment by bioelectric impedance spectroscopy in Taiwanese hemodialysis patients. J Ren Nutr. 2017;27:37–44.

    PubMed  Google Scholar 

  30. 30.

    Popovic V, Zerahn B, Heaf JG. Comparison of dual energy X-ray absorptiometry and bioimpedance in assessing body composition and nutrition in peritoneal dialysis patients. J Ren Nutr. 2017;27:355–63.

    CAS  PubMed  Google Scholar 

  31. 31.

    Ward LC, Dyer JM, Byrne NM, Sharpe KK, Hills AP. Validation of a three-frequency bioimpedance spectroscopic method for body composition analysis. Nutrition. 2007;23:657–64.

    CAS  PubMed  Google Scholar 

  32. 32.

    Ellis KJ, Shypailo RJ, Wong WW. Measurement of body water by multifrequency bioelectrical impedance spectroscopy in a multiethnic pediatric population. Am J Clin Nutr. 1999;70:847–53.

    CAS  PubMed  Google Scholar 

  33. 33.

    Roemmich JN, Clark PA, Weltman A, Rogol AD. Alterations in growth and body composition during puberty. I. Comparing multicompartment body composition models. J Appl Physiol. 1997;83:927–35.

    CAS  PubMed  Google Scholar 

  34. 34.

    Wong WW, Hergenroeder AC, Stuff JE, Butte NF, O’Brian Smith E, Ellis KJ. Evaluating body fat in girls and female adolescents: advantages and disadvantages of dual-energy X-ray absorptiometry. Am J Clin Nutr. 2002;76:384–9.

    CAS  PubMed  Google Scholar 

  35. 35.

    Gately PJ, Radley D, Cooke CB, Carroll S, Oldroyd B, Truscott JG, et al. Comparison of body composition methods in overweight and obese children. J Appl Physiol. 2003;95:2039–46.

    CAS  PubMed  Google Scholar 

  36. 36.

    Goodsitt MM. Evaluation of a new set of calibration standards for the measurement of fat content via DPA and DXA. Med Phys. 1992;19:35–44.

    CAS  PubMed  Google Scholar 

  37. 37.

    Levitt DG, Beckman LM, Mager JR, Valentine B, Sibley SD, Beckman TR, et al. Comparison of DXA and water measurements of body fat following gastric bypass surgery and a physiological model of body water, fat, and muscle composition. J Appl Physiol. 2010;109:786–95.

    PubMed  PubMed Central  Google Scholar 

  38. 38.

    Birzniece V, Khaw C-H, Nelson AE, Meinhardt U, Ho KKY. A critical evaluation of bioimpedance spectroscopy analysis in estimating body composition during GH treatment: comparison with bromide dilution and dual X-ray absorptiometry. Eur J Endocrinol. 2015;172:21–8.

    CAS  PubMed  Google Scholar 

  39. 39.

    Weber DR, Leonard MB, Zemel BS. Body composition analysis in the pediatric population. Pediatr Endocrinol Rev. 2012;10:130–9.

    PubMed  PubMed Central  Google Scholar 

  40. 40.

    Wells JC, Williams JE, Chomtho S, Darch T, Grijalva-Eternod C, Kennedy K, et al. Pediatric reference data for lean tissue properties: density and hydration from age 5 to 20 y. Am J Clin Nutr. 2010;91:610–8.

    CAS  PubMed  Google Scholar 

  41. 41.

    Wang Z, Deurenberg P, Wang W, Pietrobelli A, Baumgartner RN, Heymsfield SB. Hydration of fat-free body mass: review and critique of a classic body-composition constant. Am J Clin Nutr. 1999;69:833–41.

    CAS  PubMed  Google Scholar 

  42. 42.

    Pietrobelli A, Formica C, Wang Z, Heymsfield SB. Dual-energy X-ray absorptiometry body composition model: review of physical concepts. Am J Physiol Metab. 1996;271:E941–51.

    CAS  Google Scholar 

  43. 43.

    Chamney PW, Wabel P, Moissl UM, Müller MJ, Bosy-Westphal A, Korth O, et al. A whole-body model to distinguish excess fluid from the hydration of major body tissues. Am J Clin Nutr. 2007;85:80–9.

    CAS  PubMed  Google Scholar 

  44. 44.

    Broers NJH, Canaud B, Dekker MJE, van der Sande FM, Stuard S, Wabel P, et al. Three compartment bioimpedance spectroscopy in the nutritional assessment and the outcome of patients with advanced or end stage kidney disease: what have we learned so far? Hemodial Int. 2020;24:148–61.

    PubMed  PubMed Central  Google Scholar 

  45. 45.

    Waki M, Kral JG, Mazariegos M, Wang J, Pierson RN, Heymsfield SB. Relative expansion of extracellular fluid in obese vs. nonobese women. Am J Physiol Metab. 1991;261:E199–203.

    CAS  Google Scholar 

  46. 46.

    Horber FF, Thomi F, Casez JP, Fonteille J, Jaeger P. Impact of hydration status on body composition as measured by dual energy X-ray absorptiometry in normal volunteers and patients on haemodialysis. Br J Radio. 1992;65:895–900.

    CAS  Google Scholar 

  47. 47.

    Mager JR, Sibley SD, Beckman TR, Kellogg TA, Earthman CP. Multifrequency bioelectrical impedance analysis and bioimpedance spectroscopy for monitoring fluid and body cell mass changes after gastric bypass surgery. Clin Nutr. 2008;27:832–41.

    PubMed  PubMed Central  Google Scholar 

  48. 48.

    Thomson R, Brinkworth GD, Buckley JD, Noakes M, Clifton PM. Good agreement between bioelectrical impedance and dual-energy X-ray absorptiometry for estimating changes in body composition during weight loss in overweight young women. Clin Nutr. 2007;26:771–7.

    PubMed  Google Scholar 

  49. 49.

    Van Eyck A, De Guchtenaere A, Van Gaal L, De Backer W, Verhulst SL, Van Hoorenbeeck K. Clinical predictors of residual sleep apnea after weight loss therapy in obese adolescents. J Pediatr. 2018;196:189–193.e1.

    PubMed  Google Scholar 

  50. 50.

    Bruyndonckx L, Hoymans VY, De Guchtenaere A, Van Helvoirt M, Van Craenenbroeck EM, Frederix G, et al. Diet, exercise, and endothelial function in obese adolescents. Pediatrics 2015;135:e653–61.

    PubMed  Google Scholar 

  51. 51.

    Summerbell C, Ashton V, Campbell K, et al. Interventions for treating obesity in children. Cochrane Database Syst Rev. 2003;3:CD001872.

  52. 52.

    Eerens S, van der Lee J, Bael A, Trouet D, Van Hoeck K. Reproducibility of the body composition monitor in healthy children. Pediatr Nephrol.2011;26:1636.

    Google Scholar 

  53. 53.

    Wabel P, Chamney PW, Moissl U. Reproducibility of bioimpedance spectroscopy (BIS) in health and disease. Nephrol Dial Transpl. 2007;22:137.

    Google Scholar 

Download references


We would like to thank all patients and their parents for participating in our study. Furthermore, we would like to thank our colleagues from ‘Het Zeepreventorium’ and Eddy Basslé specifically for providing us with a venue in which to conduct our measurements.


This publication was made possible with financial support from the ‘Fonds voor Wetenschappelijk Onderzoek’ (FWO), FWO-TBM project number 150179.

Author information




All authors certify that they have participated in the study and take responsibility for the content. The study was designed by MY, AVE, KVH, SV, BDW, LB, MVH and ADG. Measurements were performed by MY, AVE and EV and the database was made by MY, EV and AVE. Data were analysed by EV, AVE under the supervision of SV, who has a Master’s degree in Statistics. Data interpretation was done by EV, AVE, SV, KVH, BDW and KVD. All authors were involved in the writing of the manuscript.

Corresponding author

Correspondence to Eline Vermeiren.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

The local ethics committee approved this study (EC n°B670201731779).

Informed consent

Written informed consent was obtained from the patients and their parents or legal guardians.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Vermeiren, E., Ysebaert, M., Van Hoorenbeeck, K. et al. Comparison of bioimpedance spectroscopy and dual energy X-ray absorptiometry for assessing body composition changes in obese children during weight loss. Eur J Clin Nutr 75, 73–84 (2021).

Download citation


Quick links