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VOLUME 6, ISSUE 1 

 2023 

 

RESEARCH ARTICLE 

Smith JD, Guerra G, Symons TB, Kwon EH, Yoon EJ. Comparison of body composition methods for estimating body fat percentage in lower limb prosthesis 

users. Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, Issue 1, No.2. https://doi.org/10.33137/cpoj.v6i1.41605 

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1 

Smith JD, Guerra G, Symons TB, Kwon EH, Yoon EJ. Comparison of body composition methods for estimating body fat percentage in lower limb prosthesis users. 
Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, Issue 1, No.2. https://doi.org/10.33137/cpoj.v6i1.41605 

 

 

RESEARCH ARTICLE 

 

COMPARISON OF BODY COMPOSITION METHODS FOR ESTIMATING BODY FAT 

PERCENTAGE IN LOWER LIMB PROSTHESIS USERS 

Smith JD1, Guerra G2 *, Symons TB1, Kwon EH1, Yoon EJ2, 3 
 
1 Department of Counseling, Health and Kinesiology, College of Education and Human Development, Texas A&M University- San Antonio, San Antonio, Texas, 

   USA. 
2 Department of Exercise and Sport Science, St. Mary’s University, San Antonio, Texas, USA. 
3 Laboratory of Animal Physiology and Medicine, Department of Biology Education, Korea National University of Education, Chungbuk, Republic of Korea. 

 
  
 

 

 

 

  

 

 

 

 

 

 

 

 
 

INTRODUCTION   

In the United States over forty percent of individuals are 

considered obese.1 Persons with a higher percentage of 

body fat are at greater risk of negative cardiometabolic 

health.2,3 Likewise, higher body mass index (BMI) may 

increase susceptibility to coronary heart disease and type 2 

diabetes,4–6 and increase medical expenses.7,8 There is 

also evidence that individuals who are obese may suffer 

from lowered wages and education.9 Prevalence of obesity 

may be  higher  in persons with lower limb amputation (LLA) 

than in able-bodied persons,10–12 with higher BMI typically 

seen at higher amputation levels (i.e. trans-femoral).13,14 For 

those having received dysvascular-related amputations, 

loss of adequate blood flow to the peripheries, negatively 

alters limb musculature and fat mass.15,16 Most people 

receive amputation as a result of dysvascular disease and 

it is these individuals that are often overweight with a BMI 

≥ 25 kg/m2 or even obese with a BMI ≥ 30 kg/m2.17,18 

Although BMI is simple to calculate, body fat percentage 

(BF%) provides a better indicator of health risk.19 A closer 

analysis of limb composition in people with amputation has 

found greater muscle atrophy and fat mass (FM) in the 

amputated limb.20 Obesity is associated with dysvascular 

disease, which accounts for a majority of lower extremity 

amputations in the United States, thus, valid body 

composition assessment is essential.  

 
OPEN  ACCESS 

ABSTRACT 

BACKGROUND: There is a dearth of literature evaluating the accuracy of Air Displacement 

Plethysmography (ADP) compared to Dual-energy X-ray Absorptiometry (DXA) for assessing body 

composition in individuals with lower limb amputations. Validity of ADP in persons with lower limb 

amputations must be established.  

OBJECTIVE: The objective of this study was to compare body composition in persons with lower limb 

amputations using the BOD POD® and DXA. 

METHODOLOGY: Body composition was performed on eleven lower limb prosthesis users (age 

53.2±14.3 years, weight 81.9±22.3kg) using ADP and DXA with and without prosthesis. 

FINDINGS: Repeated measures ANOVA indicated no significant difference in body composition among 

and between trials, F(3,8)= 3.36, p= 0.075. There were no significant differences in Body Fat (BF) 

percentage with and without prostheses on the BOD POD (28.5±15.7% and 33.7±12.1%, respectively) 

nor the DXA (32.9±10.6% and 32.0±9.9%, respectively). Association between the BOD POD and DXA 

were greatest when prostheses were not worn compared to when they were worn. Bland-Altman plots 

indicate agreement between BOD POD® and DXA was greatest while wearing the prosthesis. 

CONCLUSION: This study is a first to compare total body fat percent between the BOD POD® and DXA 

in lower limb prosthesis users. BOD POD® report valid indices of BF%. Future work will utilize the BOD 

POD® in intervention studies for monitoring body composition changes across the continuum of 

rehabilitation.  

ARTICLE INFO 

Received: August 28, 2023 

Accepted: October 23, 2023     

Published: November 10, 2023 

CITATION 

Smith JD, Guerra G, Symons TB, 

Kwon EH, Yoon EJ. Comparison of 

body composition methods for 

estimating body fat percentage in 

lower limb prosthesis users. 

Canadian Prosthetics & Orthotics 

Journal. 2023; Volume 6, Issue 1, 

No.2. 

https://doi.org/10.33137/cpoj.v6i1.4

1605 

KEYWORDS 

Body Composition, Prosthesis, 

DXA, ADP, Air Displacement 

Plethysmography, Dual-Energy X-

Ray Absorptiometry, Body Fat, 

Amputation  

 

* CORRESPONDING AUTHOR: 

Gary Guerra, PhD    
Department of Exercise and Sport Science, St. Mary’s University, San 
Antonio, Texas, USA. 

Email: gguerra5@stmarytx.edu 

ORCID ID: https://orcid.org/0000-0002-0161-4616 

Journal Homepage: https://jps.library.utoronto.ca/index.php/cpoj/index 

Volume 6, Issue 1, Article No.2. 2023 

 

 

https://doi.org/10.33137/cpoj.v6i1.41605
https://doi.org/10.33137/cpoj.v6i1.41605
https://doi.org/10.33137/cpoj.v6i1.41605
mailto:gguerra5@stmarytx.edu
https://orcid.org/0000-0002-0161-4616
https://jps.library.utoronto.ca/index.php/cpoj/index


 

2 

Smith JD, Guerra G, Symons TB, Kwon EH, Yoon EJ. Comparison of body composition methods for estimating body fat percentage in lower limb prosthesis users. 
Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, Issue 1, No.2. https://doi.org/10.33137/cpoj.v6i1.41605 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X BODY COMPOSITION METHODS FOR ESTIMATING BODY FAT PERCENTAGE 
Smith et al., 2023 

A variety of commercial and research grade tools exist for 

measuring body composition.21  Bioelectrical Impedance 

Analysis (BIA) is inexpensive, portable and non-invasive.22 

Despite BIA being validated and used in research,23–25 error 

of 9.79% has been seen when compared to Dual-energy X-

ray Absorptiometry (DXA).26 The DXA offers precise 

estimates of body Fat Free Mass (FFM),27 but its high cost 

and radiation exposure makes routine use prohibitive. Air 

Displacement Plethysmography (ADP) is not as costly as 

DXA and requires limited training to administer.25  

There is a dearth of literature comparing total BF% from 

ADP to DXA in persons with lower limb amputations. Those 

that have explored validation have found that ADP can 

overestimate BF% in thinner individuals and underestimate 

BF% in heavier persons.28 For body composition 

assessment to become a routine outcome measurement, 

time and resources must be considered.29 ADP may be 

widely utilized, however, its validity in persons with lower 

limb amputations must still be established. The purpose of 

this study was to evaluate body composition as measured 

by ADP when compared to DXA in persons with lower limb 

amputations. 

Since there are a lack of studies that compare percent body 

fat of those with lower limb amputations using ADP and 

DXA, 1) it was hypothesized there would be no significant 

difference in percent body fat between ADP and DXA and 

2) it was also hypothesized there would be no significant 

difference in percent body fat when wearing and not wearing 

prosthesis. 

METHODOLOGY 

Participants 

This study was approved by the Texas A&M University San 

Antonio Institutional Review Board (Log#2020-69) and all 

participants signed an informed consent form before study 

commencement. Eleven persons with limb amputations 

participated in this study (Table 1) and were recruited in San 

Antonio, TX through local support groups and clinics. The 

selection criteria included any person with a lower limb 

amputation who could ambulate on a prosthesis with or 

without an assisted device, and excluded those who might 

be pregnant. This sample size reflects that of other studies 

utilizing DXA as a measure of body composition.30–33 All 

participants were asked to not eat a heavy meal four hours 

prior to testing, abstain from exercise, and maintain 

appropriate hydration prior to data collection. Height was 

measured while wearing prostheses and no shoes to the 

nearest 0.1 cm using a stadiometer (Seca 213, Hamburg, 

Germany). Body mass was measured to the nearest 0.1kg 

using a digital scale (BOD POD®, COSMED, USA Inc., 

Concord, CA, USA). Body mass index was determined by 

weight divided by stature squared (kg/m2). Assessments 

were performed by trained professionals with university 

employment and all measurements were carried out 

according to manufacturer instructions. 

Measurements  

Participants reported on two separate days and prior to 

measurement, were asked to empty their bladder. The ADP 

body volume measurement was conducted using a BOD 

POD® (COSMED USA Inc., Concord, CA, USA). A warm-

up, calibration and weight scale calibration were performed 

before testing according to the manufacturer guidelines. 

Participants removed all jewelry and wore tight-fitting 

garments (swimsuits, yoga pants, etc.) and swim cap to 

reduce air trapped in clothing and hair. Body mass was 

measured using the BOD POD® scale and volume 

determined twice. Participants sat quietly and breathed 

normally while seated in the BOD POD®. The measurement 

procedure was repeated once again after doffing the 

prosthesis. The COSMED software’s Siri equation was 

chosen for measurements of BF%.34,35 Whole body DXA 

measurement occurred immediately after the BOD POD® 

measurement using a Lunar Prodigy (GE Medical Systems, 

Chicago, IL). Before measurement, the DXA was calibrated 

according to manufacturer guidelines. Participants wore the 

same minimal tight-fitting clothing worn during BOD POD® 

measurements and the same investigator performed and 

analyzed each scan. Participants were asked to lay supine 

with limbs oriented by their sides, once with the prosthesis 

and once again without wearing prosthesis. This procedure 

took 20-30 minutes and once complete, participants were 

scheduled for their second session, which took place 

approximately one week later. 

Statistical analysis 

Analysis was performed using SPSS version 27 (IBM Corp, 

Armonk, NY). A repeated measures ANOVA was performed 

to explore differences in body composition among and 

between the trials, a method commonly used to make these 

types of comparisons (CITE).36–40 Bland and Altman plots 

were created to assess the agreement between the two 

body composition methods. Pearson’s Product Moment 

correlations were performed to determine relationships 

between the two methods, with 0.20-0.39 being weak, 0.40-

0.59 being moderate, 0.60-0.79 being strong, and >0.80 

being very strong.41 Cronbach’s Alpha was used as a 

measure of internal consistency with 0.90 or greater 

considered high agreement; 0.80 to 0.89, moderate 

agreement; and 0.79 or lower, low agreement42 Alpha of 

0.05 was used for all statistical testing.  

RESULTS 

Table 1 provides participant demographics and prosthesis 

type. Results of repeated measures ANOVA on body 

composition among and between trials were not significant, 

F(3,8)= 3.36, p= 0.075. While there was a trend for BF% 

measured by the BOD POD to be lowest with the prosthesis 

https://doi.org/10.33137/cpoj.v6i1.41605


 

3 

Smith JD, Guerra G, Symons TB, Kwon EH, Yoon EJ. Comparison of body composition methods for estimating body fat percentage in lower limb prosthesis users. 
Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, Issue 1, No.2. https://doi.org/10.33137/cpoj.v6i1.41605 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X BODY COMPOSITION METHODS FOR ESTIMATING BODY FAT PERCENTAGE 
Smith et al., 2023 

(28.5±15.7%) and highest without it (33.7±12.1%), 

measurements by the DXA for both with (32.9±10.6%) and 

without (32.0±9.9%) fell between those parameters (Figure 

1), none of which were significant. It is worthy to note, 

however, that the effect size for BOD POD® (Cohen’s d = 

0.71) is moderate compared to DXA (Cohen’s d = 0.32), 

which is weak.43 Bland-Altman analysis indicated mean 

difference and 95% limits of agreement (LOA) between the 

BOD POD® and DXA was greatest when wearing 

prostheses (mdiff = -4.38, 95% LOA = -27.4 - 18.7) 

compared to not wearing the prostheses (mdiff = 1.73, 95% 

LOA = -11.5 - 14.9), Figure 2. 

Table 1: Participant characteristics mean±SD.  

 

 

 

 

 

 

 

 

 

Figure 1: There were no significant differences in percent body fat 

between BOD POD® and DXA when wearing and not wearing 

prostheses, p > 0.05. Note: Individual data points are participant 

data points for BOD POD® and DXA with and without prosthesis. 

Table 2 provides a correlation matrix depicting the 

relationships of the measures, all of which were significant 

at 0.05. The highest Pearson correlations between the BOD 

POD® and DXA were observed between devices when 

prostheses were not worn compared to when they were 

worn (Figure 3). Similarly, internal consistency was greatest 

between the two instruments while not wearing prostheses 

(Cronbach’s Alpha = 0.901) compared to wearing them 

(Cronbach’s Alpha = 0.772). 

 

 

 

 

 

 

 

Figure 2. Tighter limits of agreement exist between the BOD POD® 

and DXA when not wearing prostheses. 

 

Figure 2: Tighter limits of agreement exist between the BOD POD® 

and DXA when not wearing prostheses. Note: Solid line represents 

mean difference and dashed lines represent 95% limits of 

agreement. 

 

Table 2: Correlations of percent body fat from BOD POD® and 

DXA with and without prostheses. 

 
BOD POD® 

With 
BOD POD® 

Without 
DXA With 

BOD POD® 
Without 

0.89*   

DXA With 0.68* 0.87*  

DXA Without 0.63* 0.84* 0.97* 

Note: *p < 0.05    

 

DISCUSSION 

In this study we compared BOD POD® derived body fat 

percent estimates to DXA estimates in persons with lower 

limb prosthesis. We found that BOD POD® estimates were 

not significantly different to DXA estimates whether 

prosthesis was worn or not. The BOD POD® 

  N=11  
Amputation 

Level 
 

Age (yrs)  53.2±14.3  Below Knee 8 

Height (cm)  170.7±9.2  Above Knee 1 

Weight (kg, with 
prostheses) 
 

 84.7±21.8  
Bilateral Below 
Knee 

1 

Weight (kg, without 
prostheses) 

 81.9±22.3  Other* 1 

BMI (with prostheses)  28.9±6.1    

BMI (without 
prostheses) 

 27.8±6.2    

*Note: Other is right hip disarticulate and left below knee. 

BOD POD BOD POD DXA DXA 

With prosthesis Without prosthesis 

B
o

d
y

 F
a

t 
P

e
rc

e
n

ta
g

e
 (

%
) 

(B
O

D
 P

O
D

 -
 D

X
A

) 
(B

F
%

) 

With prosthesis 

(BOD POD + DXA)/2 (BF%) 

 

Without prosthesis 

(BOD POD + DXA)/2 (BF%) 

(B
O

D
 P

O
D

 -
 D

X
A

) 
(B

F
%

) 

https://doi.org/10.33137/cpoj.v6i1.41605


 

4 

Smith JD, Guerra G, Symons TB, Kwon EH, Yoon EJ. Comparison of body composition methods for estimating body fat percentage in lower limb prosthesis users. 
Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, Issue 1, No.2. https://doi.org/10.33137/cpoj.v6i1.41605 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X BODY COMPOSITION METHODS FOR ESTIMATING BODY FAT PERCENTAGE 
Smith et al., 2023 

underestimated body fat percentage compared to DXA 

when wearing the prosthesis by 13.1% (difference of 4.3%) 

and overestimated without the prosthesis 5% (difference of 

1.7%), respectively.  

 

 

Figure 3: Relationships of percent body fat from BOD POD® and 

DXA with and without prosthesis. Note: There was a stronger 

association in percent body fat between BOD POD® and DXA when 

not wearing prostheses (r(9) = 0.87, p = 0.001) compared to 

wearing it (r(9) = 0.68, p = 0.02) during measurements. The (9) 

represents the degrees of freedom. 

Some studies have observed divergences of –3.0% to 

1.7%,44 while others have observed 1.6% overestimates of 

BF% for BOD POD® over DXA %BF. Still, the novelty of our 

study is our finding of similar measures of BOD POD® and 

DXA in lower limb prosthesis users. The instruments 

compared in our study have been compared in the general 

population,45 persons with diabetes and obesity,46 and even 

wheelchair sport users.47 The differences observed 

between the BOD POD® and DXA may be a result of the 

BOD POD® using a Siri 2-compartment model of fat and 

lean mass to calculate body fat percentage. The Siri 

densiometry formula estimates body fat from body density. 

This formula has been shown to overestimate BF% is non-

obese active individuals,48 as well as individuals that are 

obese.49 As the body contains other tissues such as water, 

connective, and bone, distinguishing bone density is 

possible with DXA, which may help reduce variances. 

However, it is unclear at this time if specific formulas to 

assess body fat percentages in persons with lower limb 

amputations are required. The BOD POD® is a suitable 

alternative to DXA as it places low burden on the prosthesis 

user, less expensive, simple to perform, and no need for 

radiation safety measures.  

Greater agreement between the two measures as 

evidenced by tighter limits in the Bland-Altman plots 

suggest doffing the prostheses when assessing body 

composition. This is consistent with measures of internal 

consistency as calculated by Cronbach’s Alpha. 

Furthermore, while the relationship between BF% when 

wearing the prostheses was moderately strong, doffing the 

prostheses produced the strongest relationship between the 

two measures. Given this information, and since there was 

a ~2% difference in BF% between BOD POD® and DXA, it 

may be more clinically appropriate to assess BF% without 

prostheses when using either of these instruments.  

The BOD POD® itself may be subject to measurement error 

related to isothermal air used to determine raw body volume 

(BVr). An incorrect raw body volume might underestimate 

body volume (BV) which in turn may overestimate body 

density (BD) leading to an underestimated and imprecise 

BF%. Isothermal air trapped in clothing produces error,50 

and may underestimate BF% in normal and overweight 

persons when loose fit clothing is compared with swimsuits 

or no clothing.51 As such, the present study suggests 

removal of the prosthesis during body composition 

assessment.  

Although we did not investigate the ability of the BOD POD® 

to track body composition changes, this is a popular method 

of in weight loss research. The BOD POD® has been 

validated with DXA in several weight loss intervention 

studies with mixed results. In one study overweight 

participants were randomized to either a self-help group or 

weight loss program.52 At both pre and post measurements, 

BF% were lower in DXA than BOD POD®.52 However, two 

other studies found BOD POD® to underestimate BF% and 

overestimate fat free mass (FFM) compared to DXA.53,54 

This trend was evident in the current study, where BF% from 

the BOD POD® was lower than from the DXA while wearing 

prostheses.  

The results from this study suggest, that the BOD POD® is 

a suitable option over the more resource demanding DXA. 

Dual-energy X-ray absorptiometry might have an inability to 

discern changes in components of fat free mass 

components as this method assumes adequate hydration of 

FFM.55 However, we selected DXA as our criterion as 

opposed to hydrostatic weight as DXA considers bone 

density and is more precise in measurement than the  

Relationship of Percent Body Fat from BOD POD and DXA with Prosthesis 

Relationship of Percent Body Fat from BOD POD and DXA without Prosthesis 

https://doi.org/10.33137/cpoj.v6i1.41605


 

5 

Smith JD, Guerra G, Symons TB, Kwon EH, Yoon EJ. Comparison of body composition methods for estimating body fat percentage in lower limb prosthesis users. 
Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, Issue 1, No.2. https://doi.org/10.33137/cpoj.v6i1.41605 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X BODY COMPOSITION METHODS FOR ESTIMATING BODY FAT PERCENTAGE 
Smith et al., 2023 

BOD POD®.56 As such, we believe differences seen 

between BOD POD® and DXA are because of limitations of 

the BOD POD® and not necessarily our sample of 

participants. Furthermore, while some participants had to be 

assisted on the body weight scale without prostheses prior 

to BOD POD® measurements, entering the chamber itself 

was safe and not cumbersome. Some participants preferred 

to transfer themselves from a wheelchair to the chamber 

while others preferred to seat themselves in the chamber 

while wearing the prosthesis and then remove it just prior to 

measurement. 

Limitations 

Our study is not without limitations. Our study was limited 

by a smaller sample with limited number of persons with 

transfemoral and bilateral amputations. Subject selection 

may have influenced the results because of the unique 

anthropometry of participants with amputations. Moreover, 

our group of participants had a BMI of 28.1 corresponding 

to an overweight classification (25.0 to 29.9 kg/m2). This 

may limit generalizability of our findings for those with lower 

limb amputations in other BMI ranges. Still, others have 

reported BMI of 31.7 in people with dysvascular 

amputation,17 and a study of 16,259 individuals with non-

traumatic amputation found 30.4% to be non-obese, 18.2% 

obesity class 1 (BMI= 30-34.9), 17.3% obesity class 2 (BMI= 

35-39.9), and finally 34.1% with obesity class 3 (BMI≥40).57   

Although the BOD POD® is a valid and reliable technique 

when estimating total BF% compared to the DXA, there are 

distinct advantages and disadvantages of either system. 

They are both simple to administer by practitioners and easy 

to perform by patients. The BOD POD® is a less costly 

technique with no exposure to the very low radiation 

produced by the DXA. However, the DXA provides total 

values of FM, FFM and bone bass which differs from the 

BOD POD® which measures the relative concentrations in 

estimating tissue content. Regardless, the BOD POD® is 

widely acceptable for body composition testing for a range 

of patient populations. Our study suggests that it is also 

acceptable for measurement of body composition in lower 

limb prosthesis users.   

CONCLUSION 

The rise of obesity around the world has ushered in a need 

for interventions as well as way of measuring body 

composition. Assessing body weight and BMI changes 

alone is misleading and cannot measure changes in lean 

mass or fat mass. This study is a first to assess differences 

of the BOD POD® to DXA in lower limb prosthesis users. 

The results of this study indicate that when considering 

measuring BF% with BOD POD® using DXA as a criterion, 

BOD POD® reports less difference and greater agreement 

of BF% when doffing the prostheses. Future work will utilize 

the BOD POD® in intervention studies for monitoring body 

composition changes across the continuum of rehabilitation.  

ACKNOWLEDGEMENTS 

The authors would like to thank the participants and Texas A&M 

University-San Antonio. 

DECLARATION OF CONFLICTING INTERESTS 

The authors declare no financial and personal relationships with 

organizations or individuals that might have influenced their 

research.   

AUTHORS CONTRIBUTION 

• John D. Smith: original drafting, writing, data collection, 

statistical analysis. 

• Gary Guerra: conceptualization, writing, data collection, 

statistical analysis. 

• T.Brock Symons: writing, data collection, proofing. 

• Eun Hye Kwon: writing, data collection, proofing. 

• Eun Jung Yoon: writing, data collection, proofing. 

 

SOURCES OF SUPPORT 

This research was supported by the COEHD Faculty Grant 

Program. 

ETHICAL APPROVAL 

This study was approved by the Texas A&M University San Antonio 

Institutional Review Board (Log#2020-69) and all participants 

signed an informed consent form before study commencement. 

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Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, Issue 1, No.2. https://doi.org/10.33137/cpoj.v6i1.41605 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X BODY COMPOSITION METHODS FOR ESTIMATING BODY FAT PERCENTAGE 
Smith et al., 2023 

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