DiscussionThe results of our study show that measurements such as body height, body weight, waistcircumference and tibia length can reliably be performed <strong>in</strong> participants <strong>with</strong> severe <strong>in</strong>tellectualand sensory disabilities (SIMD).Feasibility and reliability of the measurements depended partly on the motivation of theattendant and participant. The environment and the attitude of the attendant can <strong>in</strong>fluence aparticipant’s state of m<strong>in</strong>d. However, when a participant is stressed and moves a lot, it is difficultto take a correct measurement. When a participant is relaxed, the attendant has more time toread the measurement value, and thus the measurement will be more accurate. To measure bodyheight, the exam<strong>in</strong>er has to determ<strong>in</strong>e whether a participant is stand<strong>in</strong>g correctly, because theparticipant is unaware of his stance. The measurement process must follow the protocol, so theattendant must check that the participant’s feet are flat on the ground, that the back of his heelscontact the wall and that he is stand<strong>in</strong>g straight and is look<strong>in</strong>g forward. This process can be verydifficult for the attendant, because it is often hard for a participant to stand still for a few seconds<strong>in</strong> the correct position. For this reason, we sought another way of determ<strong>in</strong><strong>in</strong>g participant’s heightby calculat<strong>in</strong>g body height from tibia length. To accurately measure tibia length, an attendantmust have sufficient knowledge of human anatomy. We found that the feasibility of obta<strong>in</strong><strong>in</strong>gaccurate measurements from tibia lengths is much better, because the participant is allowed to siton a chair.We experienced the most problems <strong>in</strong> perform<strong>in</strong>g sk<strong>in</strong>fold measurements. Dur<strong>in</strong>g themeasurement, the participant feels a p<strong>in</strong>ch but does not understand why he or she is be<strong>in</strong>gp<strong>in</strong>ched. Hence, at that moment, the participant becomes agitated and starts mov<strong>in</strong>g. Thisrestricts measurement, because as soon as a participant feels the p<strong>in</strong>ch, it takes 2 s beforeit is possible to read the correct value. When the subject is unable to stand still, it is almostimpossible to take an accurate measurement. The sk<strong>in</strong>fold measurement process also causedan unacceptable amount of stress to most of the participants. Furthermore, the LOAs expressedas a percentage of the mean sk<strong>in</strong>fold values show that the sk<strong>in</strong>fold measurement accuracy wasunacceptable.The reliability of body weight, body height, waist circumference, sk<strong>in</strong>folds and tibia lengthmeasurements of the present study is comparable to the reliability of similar measurementsreported <strong>in</strong> other studies. This is considered to be a good result because of the complexity ofobta<strong>in</strong><strong>in</strong>g measurements <strong>in</strong> this study population. In the study of Bemben et al. (1998), thereliability of waist circumference measurements and sk<strong>in</strong>fold measurements was exam<strong>in</strong>edby determ<strong>in</strong><strong>in</strong>g the standard errors of measurement and coefficients of variation. Our waistcircumference measurements (SEM/CV: Bemben et al. [28], 0.590/0.72; the present study,0.340/0.400) and suprailiac sk<strong>in</strong>fold measurements (SEM/CV: Bemben [28], 3.120/20.73; presentstudy, 0.863/4.3) were more accurate than those reported by Bemben [28]. However, Bemben’s[28] biceps, triceps and subscapular sk<strong>in</strong>fold measurements are more accurate than ourmeasurements (SEM: Bemben [28], 0.470, 0.420, 0.590, respectively; present study, 0.622, 0.556,0.743, respectively).In the study of Stevenson et al. (2006), the reliability of anthropometric measurementswas exam<strong>in</strong>ed by determ<strong>in</strong><strong>in</strong>g the technical error and the coefficients of variation. By compar<strong>in</strong>gtheir calculations, we found that our weight, tibia length and sk<strong>in</strong>fold (triceps and subscapular)measurements are more accurate (TE: Stevenson [29], 0.08, 0.22, 0.6, 0.51, respectively;Chapter 2 | 33
present study, 0.0005, 0, 0.03, 0.07, respectively). In the study of Pr<strong>in</strong>ce [57], the ICC of waistcircumference was 0.99 (p < 0.0001) and LOAs from -5.5 to 6.7 cm was 6.1 cm. In our study, the<strong>in</strong>traclass correlation was similar. However, LOA was 4.4 cm, <strong>in</strong>dicat<strong>in</strong>g that our measures weresomewhat more sensitive for monitor<strong>in</strong>g <strong>in</strong>dividual changes. The study of Nadas [26] exam<strong>in</strong>ed<strong>in</strong>tra-observer and <strong>in</strong>ter-observer variability <strong>in</strong> waist circumference measurements and BMI. Intheir study, the difference of the means of BMI measurement 1 and 2 was 0.02 kg/m 2 , and theabsolute average difference of the BMI was 0.292 kg/m 2 . In our study, the difference of these twomeans of the BMI was 0.10 kg/m 2 , and the absolute difference between BMI values was 0.687kg/m 2 , which is less reliable, but still acceptable, accord<strong>in</strong>g to the LOAs expressed as a percentageof the means.The results of the present study also demonstrated that a considerable number ofparticipants <strong>with</strong> SIMD are overweight or obese, and are therefore at risk for develop<strong>in</strong>g healthproblems. Accord<strong>in</strong>g to the BMI and waist measurements, more of the men than women had ahealthy weight. Thus, the women <strong>in</strong> the study population were at a higher risk for develop<strong>in</strong>ghealth problems compared <strong>with</strong> the men. Based on BMI values, 10% of the female subjects wereobese and 39% were abdom<strong>in</strong>al obese, while 0% of the male clients were obese and only 7%were abdom<strong>in</strong>al obese.ConclusionsTest–retest reliability and feasibility for all measurements are acceptable <strong>in</strong> participants <strong>with</strong>SIMD. However, sk<strong>in</strong>fold measurements could not be reliably performed <strong>in</strong> these subjects.<strong>Measur<strong>in</strong>g</strong> tibia length and us<strong>in</strong>g the determ<strong>in</strong>ed formula to calculate body height from tibialength is a reliable alternative for measur<strong>in</strong>g body height. Although the feasibility of perform<strong>in</strong>gbody height measurements as outl<strong>in</strong>ed <strong>in</strong> our protocol was acceptable, the feasibility ofperform<strong>in</strong>g tibia length measurements was much better. Assess<strong>in</strong>g body fat composition <strong>in</strong> adults<strong>with</strong> SIMD through sk<strong>in</strong>fold measurements is not recommended. Furthermore, our results <strong>in</strong>dicatethat this study population has a considerable number of participants that are overweight orobese.AcknowledgementsThe research was f<strong>in</strong>anced by Hanze University Gron<strong>in</strong>gen, the Br<strong>in</strong>k, and <strong>with</strong> fund<strong>in</strong>g from theRegional Action-and-Attention Knowledge Circulation. The authors k<strong>in</strong>dly acknowledge and thankthe participants for their participation <strong>in</strong> this study, their representatives for given permission tothis, Ms J. Kramer and the caregivers of ‘De Br<strong>in</strong>k’ for assistance <strong>with</strong> the measurements.34 | Chapter 2
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38 Multilevel Models Project (2004)
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