nature publishing group
Although obesity is recognized as a global public health
problem, the extent of obesity is a matter of contention, due
largely to a lack of consensus regarding definition. Clinically,
obesity is defined as a condition characterized by excessive
body fat to the extent that it is harmful to well being and health
(1). Currently, the operational definition of obesity is based
on BMI. According to the World Health Organization crite-
ria, any individual whose BMI ≥30 kg/m2 is considered obese
(2). Although BMI is widely used in the diagnosis of obesity, it
has been criticized because it does not distinguish between fat
mass (FM), muscle mass, bone and vital organs (3–8).
It has been argued that a better classification of obesity should
be based on percent body fat (PBF), in which any woman
whose PBF >35% and any man whose PBF >25% is considered
obese (9). Using the relationship between BMI and PBF, it has
been suggested that in Asian populations, a BMI ≥25 should be
classified as obese (10), because a BMI of 25 kg/m2 is assumed
to correspond to about 25 and 35% body fat for Asian men
and women, respectively (9). This classification is based on
the assumption that for a given BMI, Asians have greater PBF
than whites (11,12). However, a close examination of the data
on which this assumption is based on (12) reveals little differ-
ence in PBF between Chinese in New York and white women.
In this article, we examine the validity of this assumption by
comparing PBF between white American women of European
ancestry and Vietnamese women living in Vietnam.
Methods and Procedures
study design and participants
This study was designed as a comparative observational investigation
that involved two populations, one in Ho Chi Minh City (Vietnam) and
one San Diego (United States). Study design and details of data collec-
tion have been described elsewhere (13,14).
The Vietnamese study was part of a cross-sectional study designed to
examine the effect of veganism on bone health. We randomly selected 20
temples and monasteries in Ho Chi Minh City, and then sent a letter of
invitation to all nuns aged ≥50 to participate in the study. In the next step,
we randomly sampled households around each temple or monastery,
and a similar letter of invitation was sent out to female members of the
Similarity in Percent Body Fat Between
White and Vietnamese Women: Implication
for a Universal Definition of Obesity
Lan T. Ho-Pham1, Thai Q. Vu1, Nguyen D. Nguyen2, Elizabeth Barrett-Connor3 and Tuan V. Nguyen2,4
It has been widely assumed that for a given BMI, Asians have higher percent body fat (PBF) than whites, and that
the BMI threshold for defining obesity in Asians should be lower than the threshold for whites. This study sought to
test this assumption by comparing the PBF between US white and Vietnamese women. The study was designed
as a comparative cross-sectional investigation. In the first study, 210 Vietnamese women ages between 50 and 85
were randomly selected from various districts in Ho Chi Minh City (Vietnam). In the second study, 419 women of the
same age range were randomly selected from the Rancho Bernardo Study (San Diego, CA). In both studies, lean
mass (LM) and fat mass (FM) were measured by dual-energy X-ray absorptiometry (DXA) (QDR 4500; Hologic). PBF
was derived as FM over body weight. Compared with Vietnamese women, white women had much more FM (24.8 ±
8.1 kg vs. 18.8 ± 4.9 kg; P < 0.0001) and greater PBF (36.4 ± 6.5% vs. 35.0 ± 6.2%; P = 0.012). However, there was no
significant difference in PBF between the two groups after matching for BMI (35.1 ± 6.2% vs. 35.0 ± 5.7%; P = 0.87)
or for age and BMI (35.6 ± 5.1% vs. 35.8 ± 5.9%; P = 0.79). Using the criteria of BMI ≥30, 19% of US white women and
5% of Vietnamese women were classified as obese. Approximately 54% of US white women and 53% of Vietnamese
women had their PBF >35% (P = 0.80). Although white women had greater BMI, body weight, and FM than Vietnamese
women, their PBF was virtually identical. Further research is required to derive a more appropriate BMI threshold for
defining obesity for Asian women.
Obesity (2010) doi:10.1038/oby.2010.19
1Department of Internal Medicine, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam; 2Osteoporosis and Bone Biology Program, Garvan Institute
of Medical Research, St Vincent’s Hospital, Sydney, Australia; 3Department of Family Medicine, UCSD School of Medicine, San Diego, California, USA; 4Faculty of
Medicine, The University of New South Wales, Sydney, Australia. Correspondence: Lan T. Ho-Pham (firstname.lastname@example.org)
Received 8 September 2009; accepted 13 January 2010; advance online publication 00 Month 2010. doi:10.1038/oby.2010.19
households. None of the participants had any diseases deemed to affect
osteoporosis (such as hyperthyroidism, hyperparathyroidism, renal
failure, malabsorption syndrome, alcoholism, chronic colitis, multiple
myeloma, leukemia, and chronic arthritis) or previous use of therapies
that interfere with bone metabolism (e.g., glucocorticosteroids, heparin,
warfarin, thyroxine, and estrogen). The study was approved by the
ethics committee of the Pham Ngoc Thach University of Medicine, and
informed consent was obtained from all participants. The measurements
had taken place between March 2008 and August 2008.
The Rancho Bernardo Study is a prospective population-based study,
in which 82% of adult residents of Rancho Bernardo, a geographically
defined Southern California community, were enrolled in the study. The
participants were middle-class whites, primarily of European ancestry,
and aged ≥55 years. About 80% of surviving noninstitutionalized and
locally resident participants returned for additional evaluations about
every 4 years. The Rancho Bernardo Study was approved by the institu-
tional review board of the University of California, San Diego, CA, and
informed consent was obtained. Data for the present study were collected
between January 2000 and August 2003.
In both studies, age, weight, and standing height were measured using
the same methods. Body weight was measured by using a balance beam
scale in participants wearing indoor lightweight clothing without shoes.
Height without shoes was measured by a stadiometer with mandible
plane parallel to the floor. BMI was derived as the ratio of weight (in
kilograms) and height (in meters squared).
Body composition measurements
In both studies, lean mass (LM), FM, and bone mineral density were
measured by the dual-energy X-ray absorptiometry densitometer (DXA
QDR 4500; Hologic, Waltham, MA) with a standard adult whole body
scan mode. The Vietnam site used the Hologic software version 12.6,
whereas the US site used the software version 12.3. The DXA instru-
ments in the US and Vietnam were standardized by a Hologic-designed
whole body phantom. The phantom includes six white high-density
polyethylene rectangle, and a sheet of polyvinylchloride is bonded to
high-density polyethylene rectangle to mimic FM.
We expressed FM in two ways. First, we used the “traditional” PBF
that was derived as the ratio of FM over body weight. Second, because
body size is associated with all of these measures, we derived the FM
index (FMi) by the following formula: FMi = FM/(height)k, where height
is expressed in meters. The power constant k was derived by fitting the
linear equation of log FM against height: log (FM) = a + k × log (height).
Using the observed data from our study, we found k = 1.96. Thus, FMi =
FM/(height)2 was calculated, a ratio similar to the calculation of BMI.
Our objective was to compare PBF between American and Vietnamese
women after adjusting for age and body size. We made the compari-
son between US white and Vietnamese women in two approaches:
unmatched and matched analyses. In the first approach, we applied the
analysis of covariance model, in which PBF was the outcome, with age
and weight being covariates. In the second approach, each Vietnamese
woman was matched with a US white woman for age and BMI. We used
the “greedy matching algorithm” (as implemented in a SAS macro by
the Mayo Clinic) for matching data (15). The two groups were exactly
matched for age and BMI. The difference in PBF between the two
groups was compared by a mixed-effects analysis, without adjustment
for age and BMI. Both analyses were performed with the R language on
the Windows XP platform (16).
On average, the California white women were older than the
Vietnamese women (71.5 years vs. 62 years) and had significantly
greater weight, height, BMI, bone mineral density, LM, and FM
than Vietnamese women. Although white women had a greater
FM (24.8 ± 8.1 kg; mean ± s.d.) than Vietnamese women (18.8 ±
4.9 kg; P = 0.012), however, there was little difference in PBF
between the two groups (36.4 ± 6.5% vs. 35.0 ± 6.2%). In abso-
lute measurement, trunk fat in US white women was significantly
higher than that in Vietnamese women. However, when trunk fat
was expressed as percentage of total FM, Vietnamese women had
a greater percent trunk fat than US white women (Table 1).
Using the categorical definition of obesity based on BMI
≥30 kg/m2, 19% (n = 81/419) of the white women were obese,
and obesity was significantly more common than in Vietnamese
women whose prevalence was 4.7% (n = 10/210). Nevertheless,
65% white women and 53% of Vietnamese women had PBF >35
The relationship between PBF and BMI was linear, with the
regression equation: PBF = 9.53 + 1.05 × BMI for US white
table 1 Basic characteristics of participants
(n = 419)
(n = 210)
Age (years)71.5 (8.1)61.7 (9.6)<0.0001
Weight (kg)66.7 (12.9) 53.3 (7.9) <0.0001
Height (cm)160.8 (6.1) 148.9 (5.7)<0.0001
BMI (kg/m2) 25.8 (4.8)24.1 (3.2) <0.0001
0.69 (0.12)0.63 (0.11)<0.0001
0.98 (0.19)0.76 (0.14)<0.0001
1.05 (0.13)0.89 (0.11)<0.0001
Lean mass (kg)38.6 (5.4) 32.3 (4.1)<0.0001
14.8 (1.8)14.6 (1.5) 0.0730
Fat mass (kg)24.8 (8.1)18.8 (4.9) <0.0001
Percent body fat (%)36.4 (6.5) 35.0 (6.2)0.0122
9.5 (3.1)8.5 (2.1)<0.0001
Trunk fat (kg)11.3 (4.2) 9.8 (2.7) <0.0001
Trunk fat as percent
of total fat (%)
46.9 (5.8)51.7 (5.5)<0.0001
Values are mean (s.d.). Lean mass index = lean mass/height2; fat mass index =
fat/height2 (see Methods and Procedures).
BMD, bone mineral density.
table 2 Prevalence of “obesity” in Vietnamese and american
women ages 50–85 years by various criteria
(n = 419)
(n = 210)
Percent body fat ≥35
54.2 (227)39.1 (82)
19.3 (81)4.8 (10)
Values are percent (number for each category).
an = 350, data in percent body fat were not available in 69 participants of the
US white data.
women, and PBF = 14.81 + 0.85 × BMI for Vietnamese women
(Figure 1); these two slopes did not differ significantly (P =
0.18). For a given category of BMI, there was no significant dif-
ference in PBF between white and Vietnamese women (Table 3)
(for BMI >25, white women actually had a slightly higher PBF
than Vietnamese women, but the difference was not statistically
significant). When the analysis was adjusted for age, among
those with BMI ≤25 kg/m2, Vietnamese women had a signifi-
cantly higher PBF than US white women (33.5% vs. 31.8%;
P = 0.001); however, among those whose BMI ≥25, US white
women tended to have greater PBF than Vietnamese women,
but the difference was not statistically significant (P = 0.24).
In this analysis, we performed a 1:1 matched-pair analyses,
in which each Vietnamese woman was matched by age and
BMI with an American woman. This resulted in 110 pairs as
shown in Table 4. For a given age and BMI, white women
had greater height and body weight than Vietnamese women
(Figure 2). White women also had greater bone mineral
density, FM, and LM than Vietnamese women. However, there
was no significant difference in PBF or FMi between white and
Vietnamese women (average difference in PBF: 0.20%, 95%
confidence interval: −0.94 to 1.33%; P = 0.79).
In 1994, it was reported that Chinese individuals living in
New York City had higher PBF but lower BMI than whites
(12). However, a close reading of the data in that paper reveals
that there was only a slight difference in PBF between the two
US data (n = 429)
VN data (n = 210)
Percent body fat
Figure 1 Percent body fat and BMI in US white (open circles) and
Vietnamese women (closed circles). Data are from the nonmatched
sample. VN, Vietnam.
table 3 Percent body fat stratified by BMI category
(n = 419)
(n = 210)
<2532.0 (5.4) 33.3 (6.8)0.061
25–29 38.6 (4.6) 37.2 (5.3) 0.083
>29 43.4 (3.2)40.8 (5.6) 0.183
Adjusted for age
<2531.8 (5.8)33.5 (5.4)0.001
25–29 38.5 (5.6)37.5 (5.3)0.240
>2943.3 (5.8)40.9 (5.1) 0.172
Values are mean (s.d.)
table 4 summary data for white and Vietnamese women
matched by age and BMI
(n = 110)
(n = 110)
Age (years)67.1 (8.9) 67.1 (8.9)—
BMI (kg/m2) 24.8 (3.1)24.8 (3.1)—
Weight (kg)64.9 (9.4) 54.0 (8.1) <0.0001
Height (cm)161.9 (6.1)147.5 (5.7)<0.0001
0.71 (0.12)0.60 (0.11)<0.0001
1.00 (0.18) 0.71 (0.13)<0.0001
1.08 (0.13)0.85 (0.10)<0.0001
Lean mass (kg) 38.5 (4.4)32.2 (4.1)<0.0001
14.7 (1.3)14.8 (1.5) 0.4340
Fat mass (kg)23.4 (6.1)19.6 (5.2)<0.0001
Percent body fat35.6 (5.1)35.8 (5.9)0.7890
8.9 (2.2)8.9 (2.2)0.8690
Values are mean (s.d.). Lean mass index = lean mass/height2; fat mass index =
fat/height2 (see Methods and Procedures).
BMD, bone mineral density.
BMI and age-matched (n = 110 pairs)
Percent body fat
Figure 2 Percent body fat and BMI in US white (open circles) and
Vietnamese women (closed circles). Data are from the age and BMI.
groups (31.6% in Chinese women and 30.1% in white women,
P = 0.08); even after adjusting for BMI, there was virtually
no difference in PBF between the two groups among those
with BMI >28 kg/m2 (12). A subsequent study reported that
for a given level of BMI, Indonesians had higher PBF than
Dutch (17), but there was no significant difference in PBF
between Dutch in the Netherlands and Chinese in Beijing
(18). Nevertheless, it has since been assumed that Asian
women have higher PBF than white women leading to differ-
ent standards for optimal BMI levels (11). The present study’s
result challenges that assumption. We have shown here that
postmenopausal Vietnamese have equivalent or lower PBF
than US white women, either before or after adjusting for
Because Asians tend to have smaller body size than whites,
and because FM is associated with body size, any unbiased
comparison of FM between ethnicities should be adjusted
for body size. Traditionally, FM has been normalized by body
weight to yield PBF, but this normalization can be questioned
(19). The derivation of PBF is implicitly based on the assump-
tion that FM varies as a fixed proportion of body weight (20) in
the form of FM = k × weight. In other words, the assumption
states that the relation between FM and weight is linear and
passes through the origin. But in real world, this assumption is
rarely satisfied because the relation between FM and weight is
characterized by the equation FM = a + k × weight. Therefore,
dividing both sides by weight will yield PBF = a/weight + k, and
which suggests that no constant of proportionality exists. In
other words, normalization of FM by weight does not remove
the effect of body size.
In this study, we chose height, rather than weight, as a proxy
for body size, because the correlation between FM and height
(r = 0.25) is lower than the correlation between FM and weight
(r = 0.80). We derived the FMi similar to the BMI. In this study,
there was no significant difference in FMi between US white
and Vietnamese women.
This finding has important implication for the definition of
obesity in Asian populations. Based on the assumption that
Asians have higher PBF than whites for a given BMI (11,12)
and further assumption that the relation between BMI and
PBF depends on age, sex, and ethnicity (9,12,17,21), it has
been argued that the BMI cutoff value for the diagnosis of
obesity in Asians should be lower than the cut-point for whites
(22). It has been estimated that a BMI of 22.6 in women corre-
sponded to a PBF of 35% (23); however, most previous studies
have used BMI greater or equal to 25 as a criterion for defining
obesity in Asians (10) because a BMI of 25 kg/m2 is assumed to
correspond to about 25 and 35% body fat for Asian men and
women, respectively (9).
In contrast with that assumption, we found that the slope
of association between FM and BMI in the US white group
(1.05) is similar to that in Vietnamese women (slope = 0.85).
With that association, we found that a BMI of 24 kg/m2 cor-
responded to a PBF of 35% in both US white and Vietnamese
women. Therefore, it seems the call for ethnic-specific BMI
cutoff value for defining obesity is premature (24).
The ultimate goal of finding an “optimal” BMI cutoff value
is to identify high-risk individuals for intervention, clini-
cal counseling, and public health policy-making. In 1993,
based on the association between BMI and the risk of diabe-
tes and cardiovascular diseases (25), a WHO (World Health
Organization) (world expert panel proposed BMI cutoff points
of >30 for obesity (26) in all ethnicities, which is similar to the
Metropolitan Life Insurance table results for whites on which
“optimal” BMI cutoff value has been based. However, mortal-
ity seems to be a better outcome for defining obesity because
mortality is a unique and precise end point that can easily be
assessed. A number of prospective studies in Asian populations
found increased risk of mortality in individuals with BMI >30,
but no increased risk of mortality among men and women with
BMI within the range of 18.5 and 25 (27). In a major study in
China that involved 68,116 men and 86,620 women ages ≥40
years, the risk of mortality in both sexes increased abruptly
among those whose BMI was ≥30 kg/m2 (28). Taken together,
these data consistently suggest that the BMI cutoff value of 30
seems appropriate for defining obesity in Asians as well. Based
on BMI ≥30 as criteria for defining obesity, in this study ~19%
US white women and ~5% Vietnamese women were obese.
The prevalence of obesity in Vietnamese women in this study
is also highly comparable to the study in the Chinese popula-
tion by Gu et al. (28), in which 4.1% of women had BMI >30.
The present study’s findings should be interpreted within the
context of potential strengths and weaknesses. The Vietnamese
were randomly drawn from the general population to ensure its
external validity, and the Rancho Bernardo cohort represented
82% of a geographically defined community. The DXA meas-
urements of FM, LM, and bone mass are accurate and reliable
measures of body composition, made by trained densitometrists
using the same model regularly calibrated DXA instruments,
which enhance the internal validity of the study. The analysis of
FM was rigorously adjusted for body size, intended to decrease
bias created by differences in body size. Although the Hologic
QDR 4500A tends to underestimate FM by about 5% (29), the
underestimation did not explain the relative difference in FM
between the US white and Vietnamese women, in that using
the adjusted equation provided by Schoeller et al. (29) showed
that the “corrected” FM in US white women was 5.6 kg higher
than that in Vietnamese women, after adjusting for age and
BMI. It should be noted that although Vietnamese are geneti-
cally similar to southern Chinese or other Southeast Asians,
their lifestyles and nutritional status likely differ, requiring
other data with similar quality measures in these populations.
Participants in the Rancho Bernardo Study were of middle to
upper socioeconomic status, and differ in many ways from
the Vietnamese women. The study design was cross-sectional;
therefore, it is not possible to assume causality about the rela-
tionship between FM and BMI.
In summary, these data suggest that although white women
have greater body weight and FM than Vietnamese women,
their PBF is similar. The data also suggest that the association
between PBF and BMI in white and Vietnamese women is
similar. Definitions of normal or optimal fat levels for defining
obesity in Asian populations still require prospective studies of
longevity or clinical outcomes.
We express our great appreciation to Phuong L.T. Nguyen, Tu T.T. Le,
Tuyet A.T. Doan, and Ngoc T. Tran for their assistance in the recruitment
of participants. N.D.N. is supported by a grant from the AMBeR alliance.
T.V.N. is supported by a fellowship from the National Health and Medical
Research Council. The Rancho Bernardo Study was funded by the National
Institutes of Health/National Institute on Aging (grants AG07181 and
AG028507) and the National Institute of Diabetes and Digestive and Kidney
Diseases (grant DK31801). Study concept and design: L.T.H.-P., T.V.N.,
E.B.-C., N.D.N.; acquisition of data: L.T.H.-P., T.Q.V., E.B.-C.; analysis and
interpretation of data: L.T.H.-P., T.V.N., N.D.N.; drafting the manuscript:
L.T.H.-P., T.V.N., E.B.-C.; statistical expertise: N.D.N., T.V.N.; critical revision
of the manuscript: L.T.H.-P., T.V.N., E.B.-C., N.D.N. There was no funding
for this study.
T.V.N. received honorarium for speaking and providing consultant services to
MSD Vietnam Ltd, Sanofi-Aventis, Novartis, and Roche. T.V.N. is supported
by a senior research fellowship from the Australian National Health and
Medical Research Council. E.B.-C. was a paid external investigator for the
raloxifene MORE and RUTH studies by Lilly Research Laboratories. N.D.N.
is supported by a grant from the AMBeR (Australian Medical Bioinformatics
Resource). Other authors declared no conflict of interest.
© 2010 The Obesity Society
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