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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction</span></p><p class="elsevierStylePara"> Body mass index &#40;BMI&#41;&#44; body weight divided by height squared&#44; is an anthropometric index that is widely used in the diagnosis of obesity&#46; It is one of the criteria for estimating cardiovascular risk&#46; The value above which an individual is considered obese is 30 kg&#47;m<span class="elsevierStyleSup">2</span>&#46; While this index is very valid for the general population&#44; doubts arise in athletes because it includes total body weight&#44; i&#46;e&#46;&#44; the sum of the fat component and the lean component&#59; we remember that obesity is defined as an abnormal or excessive accumulation of fat that may harm health&#46;<span class="elsevierStyleSup">1</span> Someone who does sport will undergo more or less hypertrophy of the skeletal muscles&#44; basically depending on how they train and their level of training&#44;<span class="elsevierStyleSup">2&#44;3</span> which may or may not be accompanied by a loss of body fat&#46; An athlete may therefore have a high BMI without having a dangerous excess of body fat&#44; or their BMI may be overestimated if the classical classification is applied&#46;</p><p class="elsevierStylePara"> Other anthropometric indexes apart from BMI have been defined to improve the diagnosis of obesity&#46; These include the conicity index&#44;<span class="elsevierStyleSup">4</span> the body shape index5 and body perimeter measurements of the waist&#44; hips and thigh&#44; or the ratio between them or with height&#46; They are used to estimate fat and its central or peripheral location&#46;<span class="elsevierStyleSup">6</span> Different cut-off points have been set according to their association with cardiovascular and overall mortality in longitudinal studies&#46;<span class="elsevierStyleSup">7&#44;8</span> An additional problem is the different standardisation of some measurements&#44; such as waist perimeter&#44; which may be measured at different levels of the abdomen&#46;<span class="elsevierStyleSup">9</span></p><p class="elsevierStylePara"> Anthropometrics estimates body fat by using regression equations created on the basis of skinfolds&#44; deriving from the relationship between subcutaneous fat and visceral fat&#46; Withers et al&#46;<span class="elsevierStyleSup">10&#44;11</span> developed a specific equation for athletes&#44; taking hydrostatic weighing as its benchmark&#46; The problem arises when there is a great excess of subcutaneous fat&#44; as it may be difficult or technically impossible to measure skinfolds&#46;</p><p class="elsevierStylePara"> The aim of this work is to determine the relationship between adiposity indexes and the amount of body fat estimated by anthropometrics in athletes with a BMI in the obesity range&#44; establishing which indexes would be the most valid for this type of population&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Material and methods</span></p><p class="elsevierStylePara"> A retrospective observational study was undertaken of the athletes who visited our centre from 1993 to 2015&#44; selecting those who fulfilled the following criteria&#58; a BMI equal to or greater than 30 kg&#47;m<span class="elsevierStyleSup">2</span>&#44; above 16 years of age and Caucasian&#46; Ten athletes were then excluded from the sample&#44; as it was not possible to measure the total profile of their skinfolds &#40;5 women and 5 men&#41;&#46; The sample was therefore composed of 173 athletes &#40;151 men and 22 women&#41;&#44; with an average age of 23&#46;3 &#177; 4&#46;9 years old&#44; who had been competing for 9&#46;8 &#177; 5 years and who trained for 16&#46;6 &#177; 7&#46;1 hrs per week&#46; The sports they practiced were classified as team sports &#40;A&#41;&#58; basketball &#40;n &#61; 3&#41;&#44; handball &#40;n &#61; 5&#41;&#44; rugby &#40;n &#61; 33&#41; and water polo &#40;n &#61; 2&#41;&#59; sports in which competition is divided into weight categories &#40;B&#41;&#58; weight lifting &#40;n &#61; 21&#41;&#44; judo &#40;n &#61; 43&#41;&#44; karate &#40;n &#61; 1&#41;&#44; wrestling &#40;n &#61; 16&#41; and taekwondo &#40;n &#61; 1&#41;&#59; throwing sports in athletics &#40;C&#41;&#58; hammer &#40;n &#61; 11&#41;&#44; shot-put &#40;n &#61; 11&#41;&#44; discus &#40;n &#61; 3&#41;&#59; and technical sports &#40;D&#41;&#58; fencing &#40;n &#61; 2&#41;&#44; golf &#40;n &#61; 2&#41;&#44; archery &#40;n &#61; 1&#41;&#44; target shooting &#40;n &#61; 17&#41; and sailing&#44; Finn &#40;n &#61; 1&#41;&#46;</p><p class="elsevierStylePara"> The following anthropometric protocol variables were included&#58; weight&#44; height&#44; sitting height and 5 body perimeters&#58; the neck &#40;measured immediately above the thyroid cartilage larynx prominence&#41;&#44; abdominal 1 &#40;measured at the natural waist&#41;&#44; abdominal 2 &#40;measured at the umbilical level&#41;&#44; the hips &#40;at the maximum circumference around the buttocks&#41; and the thigh &#40;at the point midway between the groin fold and the upper edge of the patella&#41;&#59; and 7 skin-folds&#58; triceps&#44; subscapula&#44; biceps&#44; abdominal&#44; supraspinal&#44; the anterior thigh and medial leg&#46; Weight and height are measured at the start of the morning before eating&#44; without shoes and with minimum clothing&#46; Skinfolds were taken 3 times&#44; giving the average value of the measurements that were outside the range of technical error in measurement&#46; The anthropometric material used as well as the technique followed the recommendations of the International Society for the Advancement of Kinanthropometry &#40;ISAK&#41;&#44;<span class="elsevierStyleSup">12</span> except for the measurement of thigh and abdominal 2 perimeter&#46;<span class="elsevierStyleSup">13</span></p><p class="elsevierStylePara"> The following anthropometric indexes were calculated&#58; abdominal 1&#47;height &#40;C1&#47;T&#41;&#44; abdominal 2&#47;height &#40;C2&#47;T&#41;&#44; abdominal 1&#47;sitting height &#40;C1&#47;TS&#41;&#44; abdominal 2&#47;sitting height &#40;C2&#47;TS&#41;&#44; abdominal 1&#47;hips &#40;C1&#47;C&#41;&#44; abdominal 2&#47;hips &#40;C2&#47;C&#41;&#44; abdominal 1&#47;thigh &#40;C1&#47;M&#41;&#44; abdominal 2&#47;thigh &#40;C2&#47;M&#41;&#44; body mass index &#40;BMI&#58; weight&#44; kg&#47;height m<span class="elsevierStyleSup">2</span>&#41;&#44; SHBMI &#40;weight&#44; kg&#47;sitting height m<span class="elsevierStyleSup">2</span>&#41;&#44; weighted index &#40;WI&#58; weight<span class="elsevierStyleSup">1&#47;3</span>&#44; kg&#47;height&#44; cm &#42; 100&#41;&#44; conicity index &#40;CI&#58; abdominal&#160; 1&#160; &#40;m&#41;&#47;0&#46;109&#160; &#42;&#160; &#8730;&#40;weight&#44;&#160; kg&#160; &#42;&#160; height&#44;&#160; m&#41;<span class="elsevierStyleSup">2</span>&#44; body shape index &#40;BSI&#58; abdominal 1 m&#47;BMI<span class="elsevierStyleSup">2&#47;3</span> &#42; height<span class="elsevierStyleSup">1&#47;2</span> m&#41;<span class="elsevierStyleSup">3</span>&#46; Body density &#40;BD&#41; was estimated using Withers<span class="elsevierStyleSup">8&#44;9</span> equations and&#160; then&#160; by&#160; Siri&#8217;s&#160; formula&#44;&#160; 1962&#160; &#40;&#91;4&#46;95&#47;DC&#93;&#160; &#8722;&#160; 4&#46;5&#41;&#160; &#42;&#160; 100&#41;&#160; giving the percentage of fat&#46; BD&#58; women&#58; 1&#46;17484-0&#46;07229 &#42; &#40;log &#91;triceps &#43; subscapula &#43; supraspinal &#43; medial leg&#93;&#44; in mm&#41;&#59; men&#58; 1&#46;0988-0&#46;0004 &#42; &#40;triceps &#43; biceps &#43; subscapular &#43; supraspinal &#43; abdominal &#43; anterior thigh &#43; me-dial leg&#44; in mm&#41;&#46; Calculating fat weight and lean weight&#44; in absolute values and as a ratio with height squared&#46; A categorical variable was defined according to percentage of fat&#44; classifying it as in the high risk range &#40;the presence of obesity&#41; when it was over the 97th percentile set in the population of athletes&#44;<span class="elsevierStyleSup">2</span> which corresponds in men to 22&#37; and 29&#37; in women&#59; the others are considered to in the low risk range &#40;the absence of obesity&#41;&#46;</p><p class="elsevierStylePara"> Statistical descriptions of the results were prepared&#44; for the total sample and according to sex and sports group&#46; The Student t test and ANOVA &#40;post hoc by Bonferroni&#41; were used to detect possible differences between them&#44; taking the uniformity of variances into account &#40;Levene&#8217;s test&#41;&#44; while variables with a distribution that did not fulfil the normality criteria &#40;Kolmogorow-Smirnov&#41; were subjected to the Mann-Witney U test and the Kruskal-Wallis test&#46; Pearson&#8217;s chi-squared test was used to analyse the different proportions of the groups established according to their risk group&#46; ROC curves were then used to determine exactitude &#40;sensitivity &#91;S&#93; and specificity &#91;E&#93;&#41; by using the area under the curve &#40;ABC&#41; of the different variables and indexes with the range of risk assigned according to body fat&#46; This study was only performed for the sample of men&#44; as the sample of women was small &#40;n &#61; 22&#41;&#46; According to Swets&#44;<span class="elsevierStyleSup">14</span> a low level of exactitude is considered to stand at from 0&#46;5-0&#46;7&#59; a useful level of exactitude is from 0&#46;7-0&#46;9&#59; and a high level of exactitude is &#62; 0&#46;9 ABC&#46; Scores with an ABC in the range of usefulness and a 95&#37; CI&#44; were considered when calculating the cut-off point using Youden&#8217;s J point &#40;the maximum value obtained of the sum of sensitivity plus specificity minus one&#41;&#46;<span class="elsevierStyleSup">15</span> The value for statistical significance was above <span class="elsevierStyleItalic">P</span> &#60; &#46;05&#46; Version 19 of the IBM SPSS program was used for statistical analysis&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Results</span></p><p class="elsevierStylePara"> The general anthropometric characteristics of the total sample of 173 athletes are shown according to sex in Table 1&#46; Significant differences were found between the male and female samples&#44; as the men had higher values except for age&#44; abdominal perimeter 2&#44; hips and thigh&#44; while they were similar for the abdominal skinfold&#46; The greatest differences in the skinfold profiles arose in the skinfolds of the limbs&#46;</p><p class="elsevierStylePara"><img alt="Table 1&#46; Direct anthropometric variables" src="276v52n193-90460849fig1.jpg"></img></p><p class="elsevierStylePara"> The adiposity scores and body weight components are shown in Table 2&#46; Statistically significant differences were found between men and women in&#58; C2&#47;T&#44; C2&#47;TS&#44; C1&#47;C&#44; C2&#47;C&#44; C1&#47;M&#44; WI&#44; IC and BSI&#44; as the men had lower scores in the first two indexes and higher scores than the women in the others&#46; In body composition the men had significantly more fat-free mass in absolute values and also relative to height &#40;FFMI&#41; as well as a lower percentage of body fat relative to total weight and relative to height &#40;FMI&#41; than the women&#46;</p><p class="elsevierStylePara"><img alt="Table 2&#46; Derived anthropometric variables" src="276v52n193-90460849fig2.jpg"></img></p><p class="elsevierStylePara"> Table 3 shows the body composition scores according to type of sport and sex&#46;</p><p class="elsevierStylePara"><img alt="Table 3&#46; Body composition according to sport and sex" src="276v52n193-90460849fig3.jpg"></img></p><p class="elsevierStylePara"> Except for BMI&#44; there are statistically significant differences in the sample of men between those who do different sports&#46; While those who do technical sports have a higher percentage of fat and fat index &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41; that differs significantly from those who do the other sports &#40;<span class="elsevierStyleItalic">P</span> &#60; &#46;0001&#41;&#44; while in absolute terms &#40;kg&#41; the difference arose in those who do team sports &#40;<span class="elsevierStyleItalic">P</span> &#60; &#46;0001&#41; and weight categories &#40;<span class="elsevierStyleItalic">P</span> &#60; &#46;007&#41;&#46; The smallest lean component in absolute terms and as a ratio of height occurs in those who do technical sports&#44; with significant differences from the other groups &#40;<span class="elsevierStyleItalic">P</span> &#60; &#46;0001&#41;&#46; They are followed by sports governed by weight categories&#44; which also differed in absolute terms from those who do throwing sports and team sports &#40;<span class="elsevierStyleItalic">P</span> &#60; &#46;001&#41; and in connection with height with those who do throwing sports &#40;<span class="elsevierStyleItalic">P</span> &#60; &#46;034&#41;&#46; The comparison could not be made post hoc in the sample of women due to the small number of athletes who do each type of sport&#46; The group who do throwing sports had the smallest fat component and the largest lean component&#44; in absolute as well as in relative terms&#46;</p><p class="elsevierStylePara"> When the athletes are grouped according to risk &#40;percentile of fat percentage&#41;&#44; 48 &#40;27&#46;7&#37;&#41; were found to be at high risk and 125 &#40;72&#46;3&#37;&#41; are at low risk&#46; Significant differences were&#160; found&#160; &#40;&#967;<span class="elsevierStyleSup">2</span> &#61; 4&#46;375&#44; <span class="elsevierStyleItalic">P</span> &#61; &#46;036&#41; and the percentage of high risk was higher in the women &#40;90&#46;9&#37;&#41; as opposed to the men &#40;69&#46;5&#37;&#41;&#46; Significant differences also emerged according&#160;to&#160;type&#160;of&#160;sport&#160;&#40;&#967;<span class="elsevierStyleSup">2</span> &#61; 14&#46;14&#44; <span class="elsevierStyleItalic">P</span> &#61; &#46;003&#41;&#44; in team sports 58&#46;1&#37;&#59; in sports with weight categories 74&#46;4&#37;&#59; in throwing sports 64&#37;&#59; and in technical sports 100&#37; of the athletes were in the high risk range&#46;</p><p class="elsevierStylePara"> Table 4 shows the ABC and confidence interval of the ROC curves&#44; in which the dichotomous state variable&#44; the presence&#160;or&#160;absence&#160;of&#160;obesity&#160;&#40;percentage&#160;of&#160;fat&#160;&#8805;&#160;percentile&#160; 97&#41; this was compared with the direct anthropometric variables and anthropometric scores&#46; The variables which discriminate the most are printed in bold type&#46; As was pointed out in material and methods&#44; this was only undertaken in the sample of men as the sample of women was small&#46; The variables with a 95&#37; confidence interval with their lower limit&#160;at&#160;a&#160;figure&#160;of&#160;&#8805;&#160;0&#46;7&#160;and&#160;therefore&#160;of&#160;greater&#160;diagnostic&#160; usefulness were&#58; the skinfolds&#44; abdominal perimeter 2&#44; abdominal indexes 1 and 2 in comparison with standing or sitting height and the BMI&#46; Figure 1 shows the ROC curves&#44; while Table 5 shows the cut-off points of the variables with the greatest exactitude to determine the existence of obesity in men&#44; showing sensitivity&#44; specificity and Youden&#8217;s index&#46;</p><p class="elsevierStylePara"><img alt="Table 4&#46; Area under curve &#40;ABC&#41; for variables and anthropometric indexes in the male sample" src="276v52n193-90460849fig4.jpg"></img></p><p class="elsevierStylePara"><img alt="Figure 1&#46; ROC curves&#46; Upper graph&#58; anthropometric perimeters and indexes&#46; Lower graph&#58; skinfolds&#46;" src="276v52n193-90460849fig6.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 1&#46; </span>ROC curves&#46; Upper graph&#58; anthropometric perimeters and indexes&#46; Lower graph&#58; skinfolds&#46;</p><p class="elsevierStylePara"><img alt="Table 5&#46; Cut-off&#160;points&#160;of&#160;variables&#160;with&#160;ABC&#160;95&#37;&#160;CI&#160;&#8805;&#160;0&#46;7&#46;&#160;Male&#160;sample" src="276v52n193-90460849fig5.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion</span></p><p class="elsevierStylePara"> Athletes are differentiated by their bodily composition&#44; due to their increased muscle development&#44; although this depends on the type of sport they practice&#46; It is more common to find a fat percentage in the range of obesity in sports-women than it is in sportsmen with a high BMI&#46; In technical sports bodily composition does not significantly affect performance&#44; so it is more common to find obese sportsmen and women&#44; followed by athletes who compete in the highest weight categories&#44; as they achieve a higher body mass not only at the expense of fat-free mass but also the fat component&#46; While a BMI in the obesity range is more frequent in throwing sport athletes or those who compete in team sports&#44; this is due to their increased lean component or fat-free mass&#46; In our study approximately 72&#37; of the athletes would have been incorrectly classified by the BMI&#44; as their percentage of fat was in the normal range&#46; The same BMI &#40;33 kg&#47;m<span class="elsevierStyleSup">2</span>&#41; corresponds to an average percentage of fat of 26&#46;7&#37; in men and 33&#37; in women&#46; The BMI therefore does not discriminate according to bodily composition&#44; so it is necessary in athletes to differentiate between the fat and lean components&#46;</p><p class="elsevierStylePara"> ROC curve analysis in the sample of men indicates&#44; as may have been expected&#44; that skinfolds are the most closely correlated with the presence of obesity&#46; Of the folds on the trunk the one with the greatest discriminatory power is the supraspinal fold &#40;85&#46;3&#37; correct diagnosis of high risk of obesity&#44; and 90&#46;2&#37; correct diagnosis of low risk of obesity&#41;&#44; followed by the subscapular fold &#40;87&#46;4&#37; high risk and 85&#46;4&#37; low risk&#41;&#46; Of the limb skinfolds&#44; the adipose panniculus located on the triceps classifies individuals with a high degree of exactitude &#40;84&#46;2&#37; high risk and 85&#46;4&#37; low risk&#41;&#44; followed by the fold in the medial leg &#40;76&#46;8&#37; high risk and 95&#46;1&#37; low risk&#41;&#46; Men have more subcutaneous fat on the trunk than they do on their limbs &#40;android distribution&#41;&#44; and when there is an excess of adipose panniculus fat is initially deposited at this level&#46; The folds measured at an abdominal level are the largest&#44; and therefore they are also harder to measure if the abdomen is rounded&#46; When there is a major excess of body fat&#44; the skinfolds become larger in general&#46; The triceps skinfold is very accessible and determining this will be able to indicate whether or not there is obesity&#46;</p><p class="elsevierStylePara"> Of the abdominal perimeters&#44; the one measured at umbilical &#40;C2&#41; level was a better diagnostic criterion than the one measured at the natural waist &#40;C1&#41; &#40;95&#37; CI&#58; 0&#46;728-0&#46;880 vs&#46; 95&#37; CI&#58; 0&#46;662-0&#46;832&#41;&#59; both measurements increased in precision when they were associated with height &#40;95&#37; CI&#58; 0&#46;784-0&#46;916 vs 95&#37; CI&#58; 0&#46;738-0&#46;881&#41;&#46; It should be emphasised that differences only exist between the sexes in terms of body perimeter at the level of the abdomen in C1 &#40;not C2&#41; and neck perimeter&#44; while the indexes show greater dysmorphism with the same BMI&#46; The lack of agreement on standardisation of abdominal perimeter is a problem when using cut-off points&#44; as these may differ from one location to another&#46; This also has to be taken into account for other indexes such as conicity and body shape&#44; as well as in the equations that include them to estimate body fat&#46; Following the recommendations of the National Institute of Health &#40;NIH&#41;&#44;<span class="elsevierStyleSup">16</span> the Spanish Society for the Study of Obesity &#40;SEEDO&#41; recommends measuring this at the upper part of the iliac crest&#44; as this bone reference point is more stable&#44; setting the cut-off point for increased cardiovascular risk at &#62; 102 cm and &#62; 88 cm&#44; for men and women&#44; respectively&#46; Nevertheless&#44; this point is hard to locate&#44; and more so if the individual is obese&#44; as this is one of the places where the most adipose panniculus accumulates&#46; The problem with measuring at umbilical level arises when there is so much excess fat that a flap forms which tends to descend due to gravity&#46; Such cases of extreme obesity are rare in athletes&#46; The ISAK<span class="elsevierStyleSup">12</span> sets the waist perimeter at the level of the natural waist&#44; known as C1&#44; and it is better to evaluate this in association with the subject&#8217;s height&#46; The cut-off point for the perimeter measured at umbilical level is &#62; 101&#46;5 cm in our sample of men&#44; which is similar to the one set for the general population by the SEEDO&#46; Our data also indicate that this variable is independent of the BMI values obtained&#44; as other authors<span class="elsevierStyleSup">17</span> have pointed out&#46; In connection with cardiovascular risk&#44; Mason and Katzmarzyk<span class="elsevierStyleSup">18</span> calculated the cut-off point at 100 cm for any abdominal level&#44; except for the minimum waist which they set at 97 cm&#44; although with different S and E depending on the location&#46; Differences may also exist between ethnic groups&#46;<span class="elsevierStyleSup">19</span> As we stated above&#44; the relationship of the abdominal perimeter with the height of the subject increases the ABC of ROC curves&#44; so that the cut-off point is set for men at 0&#46;53 and 0&#46;57&#44; C1&#47;T and C2&#47;T respectively&#46; Although these are more sensitive than BMI they are less specific&#44; with a higher Youden index &#40;C2&#47;T&#58; 0&#46;60 vs&#46; BMI&#58; 0&#46;46&#41;&#46; For the general population the cut-off point set is somewhat lower at 0&#46;50&#44; and there is now general awareness of the message that you should &#8220;keep your waist circumference at less than half your height&#8221;&#46;<span class="elsevierStyleSup">20</span></p><p class="elsevierStylePara"> Hip perimeter had a higher ABC than when it was calculated in association with abdominal perimeter &#40;C1&#47;C&#44; C2&#47;C&#41; and was greater than thigh perimeter and neck perimeter&#44; in a range of low diagnostic utility&#46; The ratio between waist and hip perimeter is defined to categorise central obesity&#44; which is indicated by a value higher than 0&#46;90 and 0&#46;85&#44; in men and women&#44; respectively&#46;<span class="elsevierStyleSup">21</span> This has now fallen into disuse because better associations with morbidity and mortality are obtained when the abdominal zone is evaluated absolutely&#46; Nor do thigh perimeter indexes increase precision in association with the BMI for the presence of obesity&#46;</p><p class="elsevierStylePara"> In connection with the anthropometric indexes where only general variables of weight and height apply&#44; BMI and WI&#44; one squared and the other cubed&#44; only the BMI is within the range of diagnostic utility &#40;95&#37; CI&#58; 0&#46;700-0&#46;847&#41;&#44; placing the cut-off point in the sample of men at 32&#46;8 kg&#47;m<span class="elsevierStyleSup">2</span>&#44; i&#46;e&#46;&#44; almost 3 kg per square metre more than in the general population&#46; The new conicity and body shape indexes&#44; which also include the perimeter of the abdomen&#44; do not improve exactitude as obesity predictors and are even inferior to the BMI&#46; They are therefore not useful variables for discriminating the existence of obesity&#44; as least in the population of athletes&#46;</p><p class="elsevierStylePara"> Different proportions of trunk and leg length may affect the cut-off point selected&#44; given that the greater part of body fat is located in the trunk&#46; Due to this&#44; for Asian individuals different BMI intervals have been set to classify its different degrees&#46;<span class="elsevierStyleSup">22</span> In our work the exactitude of the indexes calculated with sitting height instead of using standing height did not increase diagnostic capacity&#46;</p><p class="elsevierStylePara"> In connection with the reference values for the Spanish population of athletes&#44;<span class="elsevierStyleSup">2</span> the cut-off points are located in percentile 99 for the BMI&#44; in percentile 95 for the triceps and anterior thigh&#44; in percentile 97 for the biceps&#44; and for all the other folds between percentiles 97-99&#46; Respecting references to the general Spanish population of similar age and sex&#44; the triceps is at percentile 85 and the subscapular one in percentiles 95&#46;<span class="elsevierStyleSup">23</span> And in relation with the American population&#44; our cut-off point would be located in percentile 85 and in percentile 90&#44; for the triceps and subscapular&#44; respectively&#46;<span class="elsevierStyleSup">24</span></p><p class="elsevierStylePara"> A large sample of women is necessary to be able to study the ROC curves&#44; checking the validity of the anthropometric indexes and setting the cut-off points&#46; It may be more feasible to repeat this study and selecting women with a BMI indicating overweight &#40;&#62; 25 kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; as in comparison with men at the same BMI the women have a smaller lean component in absolute as well as relative terms&#44; so that their cut-off point should be lower&#46; More precise studies of body composition are also necessary&#44; such as magnetic resonance imaging and computed tomography&#44; for better quantification of the lean and fatty components in the population of athletes&#44; together with their relationship with classic anthropometric variables&#46;</p><p class="elsevierStylePara"> Those individuals who regularly practice sport or physical exercise and who have a BMI indicating obesity&#44; above all if the sport is not purely technical&#44; should not be classified as such without first using complementary measures to estimate their body fat&#46; Anthropometry is an easy and economical technique which allows us to measure skinfolds and use them to estimate the lean and fatty components&#46; For individuals who are overweight skinfolds should only be measured where this is technically feasible&#44; complementing the study by measuring abdominal perimeter in comparison with their height&#46; It is advisable to use the cut-off points set specifically for their ethnic group&#46; In athletes even a BMI of 32&#46;8 kg&#47;m<span class="elsevierStyleSup">2</span> may be considered to indicate overweight&#44; due mainly to their fat-free or lean component&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflict of interests</span></p><p class="elsevierStylePara"> The author has no conflict of interests to declare&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Acknowledgements</span></p><p class="elsevierStylePara"> I would like to thank the athletes who came for sports medical check-ups&#44; the doctors with grants who have worked during these years in the department&#44; and my colleague Susana Higueras for her help in everyday work&#46;</p><hr></hr><p class="elsevierStylePara"> Received 9 August 2016&#59;<br></br> accepted 12 September 2016</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">e-mail address&#58; </span><a href="mailto&#58;alicia&#46;canda&#64;aepsad&#46;gob&#46;es" class="elsevierStyleCrossRefs">alicia&#46;canda&#64;aepsad&#46;gob&#46;es</a></p>"
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        "resumen" => "<p class="elsevierStylePara"> El objetivo del trabajo fue determinar en los deportistas con IMC en rango de obesidad la relaci&#243;n entre &#237;ndices de adiposidad y grasa corporal estimada por antropometr&#237;a y establecer cu&#225;les ser&#237;an los m&#225;s v&#225;lidos para esta poblaci&#243;n&#46;</p> <p class="elsevierStylePara"> Se realiz&#243; un estudio retrospectivo de los deportistas con IMC igual o mayor de 30 kg&#47; m<span class="elsevierStyleSup">2</span>&#46; La muestra fue de 173 deportistas &#40;151 varones y 22 mujeres&#41;&#44; edad de 23&#44;3 &#177; 4&#44;9 a&#241;os&#44; con 9&#44;8 &#177; 5 a&#241;os en competici&#243;n y un entrenamiento de 16&#44;6 &#177; 7&#44;1 h&#47;semana&#46; El protocolo incluy&#243; 15 variables y se calcularon los &#237;ndices antropom&#233;tricos relacionados con la adiposidad y la grasa corporal&#46; Mediante las curvas ROC&#44; se comprob&#243; el grado de exactitud diagn&#243;stica en relaci&#243;n con la obesidad &#40;porcentaje de grasa elevado&#41;&#46;</p> <p class="elsevierStylePara"> Las variables antropom&#233;tricas con mayor &#225;rea bajo la curva fueron los pliegues cut&#225;- neos&#44; y de estos el supraespinal &#40;IC 95&#37;&#58; 0&#44;889-0974&#41; con un punto de corte de 21 mm&#44; seguidos del per&#237;metro de abdomen en relaci&#243;n con la talla &#40;IC 95&#37;&#58; 0&#44;784-0&#44;916&#41; con un punto de corte de 0&#44;57&#46; De los deportistas&#44; el 72&#37; hubieran sido mal catalogados de obesidad por su IMC&#44; estableci&#233;ndose que hasta un IMC de 32&#44;8 kg&#47;m<span class="elsevierStyleSup">2</span> en varones puede considerarse como sobrepeso debido predominantemente a su componente magro o libre de grasa&#46;</p> <p class="elsevierStylePara"> Para diagnosticar la obesidad en los deportistas&#44; la grasa corporal debe ser estimada mediante la toma de los pliegues cut&#225;neos o&#44; en su defecto&#44; mediante la medici&#243;n de la circunferencia de cintura en relaci&#243;n con la talla&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"> The aim of this paper is to examine athletes whose BMI is in the obesity range&#44; and to determine the relationship between their adiposity indices and their body fat measured by anthropometry&#44; while establishing which would be the most valid for this population&#46;</p> <p class="elsevierStylePara"> A retrospective study was carried out on athletes with a BMI of 30 kg&#47;m<span class="elsevierStyleSup">2</span> or higher&#46; The sample consisted of 173 athletes &#40;151 males and 22 females&#41;&#44; aged 23&#46;3<span class="elsevierStyleBold"> &#177; </span>4&#46;9<span class="elsevierStyleBold"> years</span>&#44; with 9&#46;8<span class="elsevierStyleBold"> &#177; </span>5 years in competition&#44; training 16&#46;6<span class="elsevierStyleBold"> &#177; </span>7&#46;1 hours&#47;week&#46; The protocol included 15 variables and the calculation of anthropometric indices related to adiposity and body fat&#46; ROC curves were used to check the level of diagnostic accuracy in relation to obesity &#40;high fat percentage&#41;&#46;</p> <p class="elsevierStylePara"> The anthropometric variables with the greatest area under the curve were skinfolds and&#44; in particular&#44; supraspinale skinfolds &#40;95&#37; CI&#58; 0&#46;899-0&#46;974&#41;&#44; with a cut-off point of 21 mm&#46; These were followed by waist circumference to height ratio &#40;95&#37; CI&#58; 0&#46;784-0&#46;916&#41; with a cut-off point of 0&#46;57&#46; As many as 72&#37; of the athletes would have been wrongly classified as obese by their BMI&#46; It was established that a BMI of up to 32&#46;8 kg&#47;m<span class="elsevierStyleSup">2</span> may be considered as overweight for males&#44; mainly due to their lean or fat-free mass&#46;</p> <p class="elsevierStylePara"> In order to diagnose obesity in athletes&#44; body fat should be assessed by means of skin-fold measurements or&#44; failing that&#44; by measuring waist circumference to height ratios&#46;</p>"
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Top level athletes with a body mass index of 30 or higher. Obesity or good muscle development?
Deportistas de alta competición con índice de masa corporal igual o mayor a 30 kg/m 2. ¿Obesidad o gran desarrollo muscular?
Alicia Candaa
a Agencia Española de Protección de la Salud en el Deporte, Madrid, Spain
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without shoes and with minimum clothing&#46; Skinfolds were taken 3 times&#44; giving the average value of the measurements that were outside the range of technical error in measurement&#46; The anthropometric material used as well as the technique followed the recommendations of the International Society for the Advancement of Kinanthropometry &#40;ISAK&#41;&#44;<span class="elsevierStyleSup">12</span> except for the measurement of thigh and abdominal 2 perimeter&#46;<span class="elsevierStyleSup">13</span></p><p class="elsevierStylePara"> The following anthropometric indexes were calculated&#58; abdominal 1&#47;height &#40;C1&#47;T&#41;&#44; abdominal 2&#47;height &#40;C2&#47;T&#41;&#44; abdominal 1&#47;sitting height &#40;C1&#47;TS&#41;&#44; abdominal 2&#47;sitting height &#40;C2&#47;TS&#41;&#44; abdominal 1&#47;hips &#40;C1&#47;C&#41;&#44; abdominal 2&#47;hips &#40;C2&#47;C&#41;&#44; abdominal 1&#47;thigh &#40;C1&#47;M&#41;&#44; abdominal 2&#47;thigh &#40;C2&#47;M&#41;&#44; body mass index &#40;BMI&#58; weight&#44; kg&#47;height m<span class="elsevierStyleSup">2</span>&#41;&#44; SHBMI &#40;weight&#44; kg&#47;sitting height m<span class="elsevierStyleSup">2</span>&#41;&#44; weighted index &#40;WI&#58; weight<span class="elsevierStyleSup">1&#47;3</span>&#44; kg&#47;height&#44; cm &#42; 100&#41;&#44; conicity index &#40;CI&#58; abdominal&#160; 1&#160; &#40;m&#41;&#47;0&#46;109&#160; &#42;&#160; &#8730;&#40;weight&#44;&#160; kg&#160; &#42;&#160; height&#44;&#160; m&#41;<span class="elsevierStyleSup">2</span>&#44; body shape index &#40;BSI&#58; abdominal 1 m&#47;BMI<span class="elsevierStyleSup">2&#47;3</span> &#42; height<span class="elsevierStyleSup">1&#47;2</span> m&#41;<span class="elsevierStyleSup">3</span>&#46; Body density &#40;BD&#41; was estimated using Withers<span class="elsevierStyleSup">8&#44;9</span> equations and&#160; then&#160; by&#160; Siri&#8217;s&#160; formula&#44;&#160; 1962&#160; &#40;&#91;4&#46;95&#47;DC&#93;&#160; &#8722;&#160; 4&#46;5&#41;&#160; &#42;&#160; 100&#41;&#160; giving the percentage of fat&#46; BD&#58; women&#58; 1&#46;17484-0&#46;07229 &#42; &#40;log &#91;triceps &#43; subscapula &#43; supraspinal &#43; medial leg&#93;&#44; in mm&#41;&#59; men&#58; 1&#46;0988-0&#46;0004 &#42; &#40;triceps &#43; biceps &#43; subscapular &#43; supraspinal &#43; abdominal &#43; anterior thigh &#43; me-dial leg&#44; in mm&#41;&#46; Calculating fat weight and lean weight&#44; in absolute values and as a ratio with height squared&#46; A categorical variable was defined according to percentage of fat&#44; classifying it as in the high risk range &#40;the presence of obesity&#41; when it was over the 97th percentile set in the population of athletes&#44;<span class="elsevierStyleSup">2</span> which corresponds in men to 22&#37; and 29&#37; in women&#59; the others are considered to in the low risk range &#40;the absence of obesity&#41;&#46;</p><p class="elsevierStylePara"> Statistical descriptions of the results were prepared&#44; for the total sample and according to sex and sports group&#46; The Student t test and ANOVA &#40;post hoc by Bonferroni&#41; were used to detect possible differences between them&#44; taking the uniformity of variances into account &#40;Levene&#8217;s test&#41;&#44; while variables with a distribution that did not fulfil the normality criteria &#40;Kolmogorow-Smirnov&#41; were subjected to the Mann-Witney U test and the Kruskal-Wallis test&#46; Pearson&#8217;s chi-squared test was used to analyse the different proportions of the groups established according to their risk group&#46; ROC curves were then used to determine exactitude &#40;sensitivity &#91;S&#93; and specificity &#91;E&#93;&#41; by using the area under the curve &#40;ABC&#41; of the different variables and indexes with the range of risk assigned according to body fat&#46; This study was only performed for the sample of men&#44; as the sample of women was small &#40;n &#61; 22&#41;&#46; According to Swets&#44;<span class="elsevierStyleSup">14</span> a low level of exactitude is considered to stand at from 0&#46;5-0&#46;7&#59; a useful level of exactitude is from 0&#46;7-0&#46;9&#59; and a high level of exactitude is &#62; 0&#46;9 ABC&#46; Scores with an ABC in the range of usefulness and a 95&#37; CI&#44; were considered when calculating the cut-off point using Youden&#8217;s J point &#40;the maximum value obtained of the sum of sensitivity plus specificity minus one&#41;&#46;<span class="elsevierStyleSup">15</span> The value for statistical significance was above <span class="elsevierStyleItalic">P</span> &#60; &#46;05&#46; Version 19 of the IBM SPSS program was used for statistical analysis&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Results</span></p><p class="elsevierStylePara"> The general anthropometric characteristics of the total sample of 173 athletes are shown according to sex in Table 1&#46; Significant differences were found between the male and female samples&#44; as the men had higher values except for age&#44; abdominal perimeter 2&#44; hips and thigh&#44; while they were similar for the abdominal skinfold&#46; The greatest differences in the skinfold profiles arose in the skinfolds of the limbs&#46;</p><p class="elsevierStylePara"><img alt="Table 1&#46; Direct anthropometric variables" src="276v52n193-90460849fig1.jpg"></img></p><p class="elsevierStylePara"> The adiposity scores and body weight components are shown in Table 2&#46; Statistically significant differences were found between men and women in&#58; C2&#47;T&#44; C2&#47;TS&#44; C1&#47;C&#44; C2&#47;C&#44; C1&#47;M&#44; WI&#44; IC and BSI&#44; as the men had lower scores in the first two indexes and higher scores than the women in the others&#46; In body composition the men had significantly more fat-free mass in absolute values and also relative to height &#40;FFMI&#41; as well as a lower percentage of body fat relative to total weight and relative to height &#40;FMI&#41; than the women&#46;</p><p class="elsevierStylePara"><img alt="Table 2&#46; Derived anthropometric variables" src="276v52n193-90460849fig2.jpg"></img></p><p class="elsevierStylePara"> Table 3 shows the body composition scores according to type of sport and sex&#46;</p><p class="elsevierStylePara"><img alt="Table 3&#46; Body composition according to sport and sex" src="276v52n193-90460849fig3.jpg"></img></p><p class="elsevierStylePara"> Except for BMI&#44; there are statistically significant differences in the sample of men between those who do different sports&#46; While those who do technical sports have a higher percentage of fat and fat index &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41; that differs significantly from those who do the other sports &#40;<span class="elsevierStyleItalic">P</span> &#60; &#46;0001&#41;&#44; while in absolute terms &#40;kg&#41; the difference arose in those who do team sports &#40;<span class="elsevierStyleItalic">P</span> &#60; &#46;0001&#41; and weight categories &#40;<span class="elsevierStyleItalic">P</span> &#60; &#46;007&#41;&#46; The smallest lean component in absolute terms and as a ratio of height occurs in those who do technical sports&#44; with significant differences from the other groups &#40;<span class="elsevierStyleItalic">P</span> &#60; &#46;0001&#41;&#46; They are followed by sports governed by weight categories&#44; which also differed in absolute terms from those who do throwing sports and team sports &#40;<span class="elsevierStyleItalic">P</span> &#60; &#46;001&#41; and in connection with height with those who do throwing sports &#40;<span class="elsevierStyleItalic">P</span> &#60; &#46;034&#41;&#46; The comparison could not be made post hoc in the sample of women due to the small number of athletes who do each type of sport&#46; The group who do throwing sports had the smallest fat component and the largest lean component&#44; in absolute as well as in relative terms&#46;</p><p class="elsevierStylePara"> When the athletes are grouped according to risk &#40;percentile of fat percentage&#41;&#44; 48 &#40;27&#46;7&#37;&#41; were found to be at high risk and 125 &#40;72&#46;3&#37;&#41; are at low risk&#46; Significant differences were&#160; found&#160; &#40;&#967;<span class="elsevierStyleSup">2</span> &#61; 4&#46;375&#44; <span class="elsevierStyleItalic">P</span> &#61; &#46;036&#41; and the percentage of high risk was higher in the women &#40;90&#46;9&#37;&#41; as opposed to the men &#40;69&#46;5&#37;&#41;&#46; Significant differences also emerged according&#160;to&#160;type&#160;of&#160;sport&#160;&#40;&#967;<span class="elsevierStyleSup">2</span> &#61; 14&#46;14&#44; <span class="elsevierStyleItalic">P</span> &#61; &#46;003&#41;&#44; in team sports 58&#46;1&#37;&#59; in sports with weight categories 74&#46;4&#37;&#59; in throwing sports 64&#37;&#59; and in technical sports 100&#37; of the athletes were in the high risk range&#46;</p><p class="elsevierStylePara"> Table 4 shows the ABC and confidence interval of the ROC curves&#44; in which the dichotomous state variable&#44; the presence&#160;or&#160;absence&#160;of&#160;obesity&#160;&#40;percentage&#160;of&#160;fat&#160;&#8805;&#160;percentile&#160; 97&#41; this was compared with the direct anthropometric variables and anthropometric scores&#46; The variables which discriminate the most are printed in bold type&#46; As was pointed out in material and methods&#44; this was only undertaken in the sample of men as the sample of women was small&#46; The variables with a 95&#37; confidence interval with their lower limit&#160;at&#160;a&#160;figure&#160;of&#160;&#8805;&#160;0&#46;7&#160;and&#160;therefore&#160;of&#160;greater&#160;diagnostic&#160; usefulness were&#58; the skinfolds&#44; abdominal perimeter 2&#44; abdominal indexes 1 and 2 in comparison with standing or sitting height and the BMI&#46; Figure 1 shows the ROC curves&#44; while Table 5 shows the cut-off points of the variables with the greatest exactitude to determine the existence of obesity in men&#44; showing sensitivity&#44; specificity and Youden&#8217;s index&#46;</p><p class="elsevierStylePara"><img alt="Table 4&#46; Area under curve &#40;ABC&#41; for variables and anthropometric indexes in the male sample" src="276v52n193-90460849fig4.jpg"></img></p><p class="elsevierStylePara"><img alt="Figure 1&#46; ROC curves&#46; Upper graph&#58; anthropometric perimeters and indexes&#46; Lower graph&#58; skinfolds&#46;" src="276v52n193-90460849fig6.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 1&#46; </span>ROC curves&#46; Upper graph&#58; anthropometric perimeters and indexes&#46; Lower graph&#58; skinfolds&#46;</p><p class="elsevierStylePara"><img alt="Table 5&#46; Cut-off&#160;points&#160;of&#160;variables&#160;with&#160;ABC&#160;95&#37;&#160;CI&#160;&#8805;&#160;0&#46;7&#46;&#160;Male&#160;sample" src="276v52n193-90460849fig5.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion</span></p><p class="elsevierStylePara"> Athletes are differentiated by their bodily composition&#44; due to their increased muscle development&#44; although this depends on the type of sport they practice&#46; It is more common to find a fat percentage in the range of obesity in sports-women than it is in sportsmen with a high BMI&#46; In technical sports bodily composition does not significantly affect performance&#44; so it is more common to find obese sportsmen and women&#44; followed by athletes who compete in the highest weight categories&#44; as they achieve a higher body mass not only at the expense of fat-free mass but also the fat component&#46; While a BMI in the obesity range is more frequent in throwing sport athletes or those who compete in team sports&#44; this is due to their increased lean component or fat-free mass&#46; In our study approximately 72&#37; of the athletes would have been incorrectly classified by the BMI&#44; as their percentage of fat was in the normal range&#46; The same BMI &#40;33 kg&#47;m<span class="elsevierStyleSup">2</span>&#41; corresponds to an average percentage of fat of 26&#46;7&#37; in men and 33&#37; in women&#46; The BMI therefore does not discriminate according to bodily composition&#44; so it is necessary in athletes to differentiate between the fat and lean components&#46;</p><p class="elsevierStylePara"> ROC curve analysis in the sample of men indicates&#44; as may have been expected&#44; that skinfolds are the most closely correlated with the presence of obesity&#46; Of the folds on the trunk the one with the greatest discriminatory power is the supraspinal fold &#40;85&#46;3&#37; correct diagnosis of high risk of obesity&#44; and 90&#46;2&#37; correct diagnosis of low risk of obesity&#41;&#44; followed by the subscapular fold &#40;87&#46;4&#37; high risk and 85&#46;4&#37; low risk&#41;&#46; Of the limb skinfolds&#44; the adipose panniculus located on the triceps classifies individuals with a high degree of exactitude &#40;84&#46;2&#37; high risk and 85&#46;4&#37; low risk&#41;&#44; followed by the fold in the medial leg &#40;76&#46;8&#37; high risk and 95&#46;1&#37; low risk&#41;&#46; Men have more subcutaneous fat on the trunk than they do on their limbs &#40;android distribution&#41;&#44; and when there is an excess of adipose panniculus fat is initially deposited at this level&#46; The folds measured at an abdominal level are the largest&#44; and therefore they are also harder to measure if the abdomen is rounded&#46; When there is a major excess of body fat&#44; the skinfolds become larger in general&#46; The triceps skinfold is very accessible and determining this will be able to indicate whether or not there is obesity&#46;</p><p class="elsevierStylePara"> Of the abdominal perimeters&#44; the one measured at umbilical &#40;C2&#41; level was a better diagnostic criterion than the one measured at the natural waist &#40;C1&#41; &#40;95&#37; CI&#58; 0&#46;728-0&#46;880 vs&#46; 95&#37; CI&#58; 0&#46;662-0&#46;832&#41;&#59; both measurements increased in precision when they were associated with height &#40;95&#37; CI&#58; 0&#46;784-0&#46;916 vs 95&#37; CI&#58; 0&#46;738-0&#46;881&#41;&#46; It should be emphasised that differences only exist between the sexes in terms of body perimeter at the level of the abdomen in C1 &#40;not C2&#41; and neck perimeter&#44; while the indexes show greater dysmorphism with the same BMI&#46; The lack of agreement on standardisation of abdominal perimeter is a problem when using cut-off points&#44; as these may differ from one location to another&#46; This also has to be taken into account for other indexes such as conicity and body shape&#44; as well as in the equations that include them to estimate body fat&#46; Following the recommendations of the National Institute of Health &#40;NIH&#41;&#44;<span class="elsevierStyleSup">16</span> the Spanish Society for the Study of Obesity &#40;SEEDO&#41; recommends measuring this at the upper part of the iliac crest&#44; as this bone reference point is more stable&#44; setting the cut-off point for increased cardiovascular risk at &#62; 102 cm and &#62; 88 cm&#44; for men and women&#44; respectively&#46; Nevertheless&#44; this point is hard to locate&#44; and more so if the individual is obese&#44; as this is one of the places where the most adipose panniculus accumulates&#46; The problem with measuring at umbilical level arises when there is so much excess fat that a flap forms which tends to descend due to gravity&#46; Such cases of extreme obesity are rare in athletes&#46; The ISAK<span class="elsevierStyleSup">12</span> sets the waist perimeter at the level of the natural waist&#44; known as C1&#44; and it is better to evaluate this in association with the subject&#8217;s height&#46; The cut-off point for the perimeter measured at umbilical level is &#62; 101&#46;5 cm in our sample of men&#44; which is similar to the one set for the general population by the SEEDO&#46; Our data also indicate that this variable is independent of the BMI values obtained&#44; as other authors<span class="elsevierStyleSup">17</span> have pointed out&#46; In connection with cardiovascular risk&#44; Mason and Katzmarzyk<span class="elsevierStyleSup">18</span> calculated the cut-off point at 100 cm for any abdominal level&#44; except for the minimum waist which they set at 97 cm&#44; although with different S and E depending on the location&#46; Differences may also exist between ethnic groups&#46;<span class="elsevierStyleSup">19</span> As we stated above&#44; the relationship of the abdominal perimeter with the height of the subject increases the ABC of ROC curves&#44; so that the cut-off point is set for men at 0&#46;53 and 0&#46;57&#44; C1&#47;T and C2&#47;T respectively&#46; Although these are more sensitive than BMI they are less specific&#44; with a higher Youden index &#40;C2&#47;T&#58; 0&#46;60 vs&#46; BMI&#58; 0&#46;46&#41;&#46; For the general population the cut-off point set is somewhat lower at 0&#46;50&#44; and there is now general awareness of the message that you should &#8220;keep your waist circumference at less than half your height&#8221;&#46;<span class="elsevierStyleSup">20</span></p><p class="elsevierStylePara"> Hip perimeter had a higher ABC than when it was calculated in association with abdominal perimeter &#40;C1&#47;C&#44; C2&#47;C&#41; and was greater than thigh perimeter and neck perimeter&#44; in a range of low diagnostic utility&#46; The ratio between waist and hip perimeter is defined to categorise central obesity&#44; which is indicated by a value higher than 0&#46;90 and 0&#46;85&#44; in men and women&#44; respectively&#46;<span class="elsevierStyleSup">21</span> This has now fallen into disuse because better associations with morbidity and mortality are obtained when the abdominal zone is evaluated absolutely&#46; Nor do thigh perimeter indexes increase precision in association with the BMI for the presence of obesity&#46;</p><p class="elsevierStylePara"> In connection with the anthropometric indexes where only general variables of weight and height apply&#44; BMI and WI&#44; one squared and the other cubed&#44; only the BMI is within the range of diagnostic utility &#40;95&#37; CI&#58; 0&#46;700-0&#46;847&#41;&#44; placing the cut-off point in the sample of men at 32&#46;8 kg&#47;m<span class="elsevierStyleSup">2</span>&#44; i&#46;e&#46;&#44; almost 3 kg per square metre more than in the general population&#46; The new conicity and body shape indexes&#44; which also include the perimeter of the abdomen&#44; do not improve exactitude as obesity predictors and are even inferior to the BMI&#46; They are therefore not useful variables for discriminating the existence of obesity&#44; as least in the population of athletes&#46;</p><p class="elsevierStylePara"> Different proportions of trunk and leg length may affect the cut-off point selected&#44; given that the greater part of body fat is located in the trunk&#46; Due to this&#44; for Asian individuals different BMI intervals have been set to classify its different degrees&#46;<span class="elsevierStyleSup">22</span> In our work the exactitude of the indexes calculated with sitting height instead of using standing height did not increase diagnostic capacity&#46;</p><p class="elsevierStylePara"> In connection with the reference values for the Spanish population of athletes&#44;<span class="elsevierStyleSup">2</span> the cut-off points are located in percentile 99 for the BMI&#44; in percentile 95 for the triceps and anterior thigh&#44; in percentile 97 for the biceps&#44; and for all the other folds between percentiles 97-99&#46; Respecting references to the general Spanish population of similar age and sex&#44; the triceps is at percentile 85 and the subscapular one in percentiles 95&#46;<span class="elsevierStyleSup">23</span> And in relation with the American population&#44; our cut-off point would be located in percentile 85 and in percentile 90&#44; for the triceps and subscapular&#44; respectively&#46;<span class="elsevierStyleSup">24</span></p><p class="elsevierStylePara"> A large sample of women is necessary to be able to study the ROC curves&#44; checking the validity of the anthropometric indexes and setting the cut-off points&#46; It may be more feasible to repeat this study and selecting women with a BMI indicating overweight &#40;&#62; 25 kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; as in comparison with men at the same BMI the women have a smaller lean component in absolute as well as relative terms&#44; so that their cut-off point should be lower&#46; More precise studies of body composition are also necessary&#44; such as magnetic resonance imaging and computed tomography&#44; for better quantification of the lean and fatty components in the population of athletes&#44; together with their relationship with classic anthropometric variables&#46;</p><p class="elsevierStylePara"> Those individuals who regularly practice sport or physical exercise and who have a BMI indicating obesity&#44; above all if the sport is not purely technical&#44; should not be classified as such without first using complementary measures to estimate their body fat&#46; Anthropometry is an easy and economical technique which allows us to measure skinfolds and use them to estimate the lean and fatty components&#46; For individuals who are overweight skinfolds should only be measured where this is technically feasible&#44; complementing the study by measuring abdominal perimeter in comparison with their height&#46; It is advisable to use the cut-off points set specifically for their ethnic group&#46; In athletes even a BMI of 32&#46;8 kg&#47;m<span class="elsevierStyleSup">2</span> may be considered to indicate overweight&#44; due mainly to their fat-free or lean component&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflict of interests</span></p><p class="elsevierStylePara"> The author has no conflict of interests to declare&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Acknowledgements</span></p><p class="elsevierStylePara"> I would like to thank the athletes who came for sports medical check-ups&#44; the doctors with grants who have worked during these years in the department&#44; and my colleague Susana Higueras for her help in everyday work&#46;</p><hr></hr><p class="elsevierStylePara"> Received 9 August 2016&#59;<br></br> accepted 12 September 2016</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">e-mail address&#58; </span><a href="mailto&#58;alicia&#46;canda&#64;aepsad&#46;gob&#46;es" class="elsevierStyleCrossRefs">alicia&#46;canda&#64;aepsad&#46;gob&#46;es</a></p>"
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            0 => "Obesidad&#59; &#205;ndice de masa corporal&#59; Pliegues cut&#225;neos&#59; Per&#237;metro de cintura"
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        "resumen" => "<p class="elsevierStylePara"> El objetivo del trabajo fue determinar en los deportistas con IMC en rango de obesidad la relaci&#243;n entre &#237;ndices de adiposidad y grasa corporal estimada por antropometr&#237;a y establecer cu&#225;les ser&#237;an los m&#225;s v&#225;lidos para esta poblaci&#243;n&#46;</p> <p class="elsevierStylePara"> Se realiz&#243; un estudio retrospectivo de los deportistas con IMC igual o mayor de 30 kg&#47; m<span class="elsevierStyleSup">2</span>&#46; La muestra fue de 173 deportistas &#40;151 varones y 22 mujeres&#41;&#44; edad de 23&#44;3 &#177; 4&#44;9 a&#241;os&#44; con 9&#44;8 &#177; 5 a&#241;os en competici&#243;n y un entrenamiento de 16&#44;6 &#177; 7&#44;1 h&#47;semana&#46; El protocolo incluy&#243; 15 variables y se calcularon los &#237;ndices antropom&#233;tricos relacionados con la adiposidad y la grasa corporal&#46; Mediante las curvas ROC&#44; se comprob&#243; el grado de exactitud diagn&#243;stica en relaci&#243;n con la obesidad &#40;porcentaje de grasa elevado&#41;&#46;</p> <p class="elsevierStylePara"> Las variables antropom&#233;tricas con mayor &#225;rea bajo la curva fueron los pliegues cut&#225;- neos&#44; y de estos el supraespinal &#40;IC 95&#37;&#58; 0&#44;889-0974&#41; con un punto de corte de 21 mm&#44; seguidos del per&#237;metro de abdomen en relaci&#243;n con la talla &#40;IC 95&#37;&#58; 0&#44;784-0&#44;916&#41; con un punto de corte de 0&#44;57&#46; De los deportistas&#44; el 72&#37; hubieran sido mal catalogados de obesidad por su IMC&#44; estableci&#233;ndose que hasta un IMC de 32&#44;8 kg&#47;m<span class="elsevierStyleSup">2</span> en varones puede considerarse como sobrepeso debido predominantemente a su componente magro o libre de grasa&#46;</p> <p class="elsevierStylePara"> Para diagnosticar la obesidad en los deportistas&#44; la grasa corporal debe ser estimada mediante la toma de los pliegues cut&#225;neos o&#44; en su defecto&#44; mediante la medici&#243;n de la circunferencia de cintura en relaci&#243;n con la talla&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"> The aim of this paper is to examine athletes whose BMI is in the obesity range&#44; and to determine the relationship between their adiposity indices and their body fat measured by anthropometry&#44; while establishing which would be the most valid for this population&#46;</p> <p class="elsevierStylePara"> A retrospective study was carried out on athletes with a BMI of 30 kg&#47;m<span class="elsevierStyleSup">2</span> or higher&#46; The sample consisted of 173 athletes &#40;151 males and 22 females&#41;&#44; aged 23&#46;3<span class="elsevierStyleBold"> &#177; </span>4&#46;9<span class="elsevierStyleBold"> years</span>&#44; with 9&#46;8<span class="elsevierStyleBold"> &#177; </span>5 years in competition&#44; training 16&#46;6<span class="elsevierStyleBold"> &#177; </span>7&#46;1 hours&#47;week&#46; The protocol included 15 variables and the calculation of anthropometric indices related to adiposity and body fat&#46; ROC curves were used to check the level of diagnostic accuracy in relation to obesity &#40;high fat percentage&#41;&#46;</p> <p class="elsevierStylePara"> The anthropometric variables with the greatest area under the curve were skinfolds and&#44; in particular&#44; supraspinale skinfolds &#40;95&#37; CI&#58; 0&#46;899-0&#46;974&#41;&#44; with a cut-off point of 21 mm&#46; These were followed by waist circumference to height ratio &#40;95&#37; CI&#58; 0&#46;784-0&#46;916&#41; with a cut-off point of 0&#46;57&#46; As many as 72&#37; of the athletes would have been wrongly classified as obese by their BMI&#46; It was established that a BMI of up to 32&#46;8 kg&#47;m<span class="elsevierStyleSup">2</span> may be considered as overweight for males&#44; mainly due to their lean or fat-free mass&#46;</p> <p class="elsevierStylePara"> In order to diagnose obesity in athletes&#44; body fat should be assessed by means of skin-fold measurements or&#44; failing that&#44; by measuring waist circumference to height ratios&#46;</p>"
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