Review Article

Bioimpedance Analysis: Basic Concepts

Vidhya K Zachariah, P. S. Priyamvada
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Department of Nephrology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Abstract
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Bioimpedance analyzers uses these differences in the electrical properties of the human body to analyze the cellular and water components.
Human body acts as a semiconductor , with the various body compartments offering resistance (R) and reactance (X) to the passage of
alternating current. The X and R thus measured can be used in validated regression equations or mathematical models to provide information
on body water, fat, and fat-free mass. Depending on the number of frequencies used, the available equipments include single frequency ,
multifrequency and bioimpedance spectroscopy . The bioimpedance vector analysis is an alternative tool that uses the raw values of X and R,
corrected to height, to categorise the hydration status as well as muscle mass.

Keywords: Body composition, Phase angle, bio impedance vector analysis, bio impdeance spectroscopy

Introduction resistance to the current flow increases. Muscles, extracellular

fluid (ECF), and intracellular fluid (ICF) offer low‑resistance
Bioimpedance analysis (BIA) is a valuable bedside tool for
pathways through which the current flows. Conversely, fat
assessing various body compartments and hydration status.
offers a higher resistance to the current flow.
The human body is a semiconductor, with multiple body
compartments exhibiting different conductive properties. Resistance (Ohms) = Applied voltage drop/current (amps)
BIA uses these differences in the electrical properties of the
Reactance
human body to analyze the cellular and water components.
It is the ability to store the charge to a certain extent and
Resistance (R) and reactance (Xc) are two fundamental
dissipate it once the upper limit of storage is reached. Reactance
properties of all substances that allow the passage of an
leads to energy storage and subsequent release as an electric
electrical current. Bioimpedance (Z) is the total effective
field (capacitance) or magnetic field (inductance). Reactance
resistance to the current flow, obtained by the sum of
opposes the passage of current without dissipating the power.
resistance (R) and reactance (Xc).[1,2] BIA does not directly
The bipolar layer of the cell membranes and various tissue
measure the body composition, but uses regression equations
interfaces primarily contributes to the capacitance. The more
validated against various gold‑standard methods such as
the cell membranes, the greater will be the capacitance.
DXA, isotope dilution, and whole‑body potassium counts to
Reactance in a biological system can be represented as:
predict the different body compartments based on the measured
resistance (R) and reactance (Xc). Reactance (Ohms) =1/2× π × frequency × Capacitance (Farads)
Resistance When applied to the human body, a low‑frequency alternating
It is the opposition offered to the flow of an electrical current, current preferentially travels through the ECF, bypassing the
akin to friction encountered by a moving object. A good
conductor like a metal wire does not provide much resistance Address for correspondence: Prof. P. S. Priyamvada,
to electricity. In contrast, a semiconductor like the human Department of Nephrology, Jawaharlal Institute of Postgraduate Medical
body offers resistance and leads to energy dissipation. The Education and Research, Puducherry, India.
E‑mail: [email protected]
intra‑ and extracellular water, with the dissolved electrolytes,
is primarily responsible for conducting electric currents in the Received: 07-12-2023 Revised: 14-12-2023
human body. As the electrolyte concentration decreases, the Accepted: 16-12-2023 Published: 09-02-2024

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DOI:
10.4103/JRNM.JRNM_9_23 How to cite this article: Zachariah VK, Priyamvada PS. Bioimpedance
analysis: Basic concepts. J Renal Nutr Metab 2023;8:30-4.

30 © 2024 Journal of Renal Nutrition and Metabolism | Published by Wolters Kluwer - Medknow
 Zachariah and Priyamvada: Bioimpedance analysis

cells, whereas mid‑frequencies travel through the tissues, obtained is used to estimate the total body water (TBW) by
eliciting capacitance [Figure 1]. Reactance decreases with regression equations.[3] By calculating the TBW, fat mass and
increasing the AC frequency. As frequency increases, the fat‑free mass can be obtained by application of formulas,
cell membranes lose their capacitance, so reactance falls, and based on the assumption that 73.2% of fat‑free mass is
cells offer only resistance [Figure 1]. The frequency at which composed of water (TBW = 0.732 × Fat‑free mass). SF‑BIA
the maximum reactance occurs is called critical frequency. In cannot distinguish between ECF water (ECFW) and ICF
humans, it corresponds to 50 kHz; hence, reactance is measured water (ICFW). A phase‑sensitive single‑frequency device
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in BIA at this frequency. can measure the R and Xc components that can be used to
calculate the Ph A. It should be noted that body fat output
Phase angle from BIA will be somewhat higher than the fat mass obtained
In a conductor exhibiting only resistance, the voltage and
by whole‑body densitometry; adipose tissue comprises 80%
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current waves change similarly, and both waves peak

triglycerides (TG), representing the true fat mass, 15%–18%
simultaneously (in phase). In a capacitance circuit, the current water, and a small fraction of protein. Densitometry measures
and the voltage waves peak at different time points, with the the TG, whereas BIA equations incorporate the proportion of
current wave leading the voltage wave [out of phase; Figure 2]. adipose tissue.
The phase difference can be measured from the resistance and
reactance components at a known frequency. Phase angle (Ph Multi‑frequency Bioimpedance Analysis
A) refers to the arc tangent value of the ratio of reactance
MF‑BIA uses electric currents at a few limited
versus electric resistance at a frequency of 50 kHz, where
frequencies (around 2–6) from 5 to 1000 kHz. A low‑frequency
the capacitance is maximum. Ph A can be calculated with
current of around 5 kHz passes through the ECF, and the
the formula [Xc/R] × [180/π]. For example, at 50 kHz, at a
measured resistance reflects the ECFW. A higher frequency
resistance (R) of 518 Ohms and reactance (Xc) of 63.7 Ohms,
current around 50, 100, 200, or 500 kHz passes through
the Ph A is (63.7/518) × (180/3.14) =6.99. Ph A depends on
the cell membranes, and the resistance reflects the ICFW.
cell membrane integrity and body cell mass. The more the lean
The differences in these currents can be measured, and this
tissue mass, the current has to traverse more cell membranes;
information can be used to split the TBW into ECFW and
hence, the greater the reactance and the Ph A. In states of
ICFW using regression equations. In addition to TBW, fat,
overhydration (OH) and lower lean tissue mass, the Ph A
and lean body mass, MF‑BIA gives information on ECFW and
is reduced. Usually, healthy individuals have a Ph A of 6 or
ICFW and the body cell mass [Figure 3]. The MF‑BIA can give
more. Men tend to have a higher Ph A than females due to
the output as a three‑compartment model (fat, visceral proteins,
higher tissue mass.
and body water). TBW and ECFW estimates are more precise
Impedance, resistance, reactance, and Ph A are often called compared to SF‑BIA. Newer equipment provides information
the raw BIA parameters. The rest of the BIA output is derived on bone mass, in addition to fat, visceral proteins, and body
from mathematical equations or models. water (four‑compartment models). However, BIA is not a
recognized measurement tool for bone mass.
Single‑frequency Bioimpedance Analysis
In a single frequency of 50 kHz, a low‑intensity electrical Bioimpedance Spectroscopy
current at 50 kHz is passed through the body, and the Bioimpedance spectroscopy (BIS) is a further refinement
subsequent impedance is recorded. The impedance, thus, of MF‑BIA utilizing a broad range of frequencies (50–250)

Figure 1: Passage of AC current of different frequencies through tissue

Journal of Renal Nutrition and Metabolism ¦ Volume 8 ¦ Issue 1 ¦ July-December 2023 31

 Zachariah and Priyamvada: Bioimpedance analysis

for body composition analysis. Apart from the number of Overhydration index: The information on ECFW and ICFW
frequencies used, a significant difference is the mathematical obtained by BIS or MF‑BIA can be used to calculate the degree
estimation models used. [4] While single‑frequency and of OH using a mathematical equation.
multifrequency BIA use linear regression, BIS estimates the OH = 1.136* × ECFW – 0.430 × ICFW – 0.114 × body weight
body compartments by fitting a polynomial curve termed the
Cole–Cole plot. By extrapolation of the resistance‑reactance Relative OH is the ratio of OH to ECFW. A relative OH
planes, based on the Cole–Cole model, a mathematical of >15% is associated with adverse outcomes in patients on
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assessment of resistance at zero frequency (Re; representing dialysis.

extracellular resistance) and at an infinite frequency (R tot;
representing total body resistance) can be estimated. Resistance Electrode Placement for Bioimpedance Analysis
of intracellular compartment (Ri) is calculated from R tot and
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Conventionally, in BIA measurements, the human body

Re. Re is considered the best estimate of ECFW, and Ri is the is considered a single cylinder. However, the electrical
best estimate for ICFW. Subsequently, using Hanai’s mixture conductive properties of the limbs and trunk are different.
theory algorithms, the Re and Ri are translated to ECFW and The limbs with neurovascular bundles and more muscle tend
ICFW. BIS gives similar information as MF‑BIA; due to the to act as low‑resistance conduits compared to the trunk. BIA
use of multiple frequencies and different models for estimating measurements can be done for the whole body or a segment
body composition, the results are considered more accurate. using SF‑BIA, MF‑BIA, or BIS. Electrodes are placed over the
skin, and a small AC electric current is injected through current
electrodes, and voltage electrodes measure the corresponding
skin voltage and impedance signal. The number of electrodes can
be 2, 4, or 8. In eight‑polar electrode system used for segmental
analysis, two electrodes in each hand and two electrodes in each
foot are used. Tetrapolar electrode placement is the most used
method. Three approaches are commonly used in bioimpedance
instruments for electrode placement [Figure 4].
Hand‑to‑foot method
This technique was introduced by Hoofer and revised by
Nyboer and is the most common method. Measurements are
done with the patient in a supine position. The electrodes with
gel are applied onto the dorsal surfaces of the right hand and
right foot. Current electrodes are placed distally, and voltage
Figure 2: Behaviour of AC in resistance and reactance circuits electrodes are placed proximally. Distal electrodes are placed

Figure 3: Various body compar tments measured by bioimpedance analysis equipment. ECF: Extracellular fluid, ICF: Intracellular fluid,
SF‑BIA: Single‑frequency bioimpedance analysis, MF‑BIA: Multifrequency bioimpedance analysis, BIS: Bioimpedance spectroscopy

32 Journal of Renal Nutrition and Metabolism ¦ Volume 8 ¦ Issue 1 ¦ July-December 2023

 Zachariah and Priyamvada: Bioimpedance analysis

proximal to the metacarpal and metatarsal phalangeal joints and equations or advanced mathematical models for estimating the
proximal electrodes just beneath a line between the prominent body composition. This makes generalization of the results
bones of the wrist and ankle. In patients on HD, the electrodes difficult, especially when the characteristics of a given patient
are placed on the nonaccess limb. differ from the reference population from which the equations/
models are derived. Bioimpedance vector analysis (BIVA),
Foot‑to‑foot method
using raw data on R and Xc, has been proposed by Picoli et al.
In this method, measurement is done in a standing position.
as an independent tool to assess the hydration status and body
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The patient stands on four stainless steel footpad electrodes,

composition.[5] A vector is constructed with R/height on the
and in each foot, current and voltage electrodes are placed
X‑axis and Xc/height on the Y‑axis [Figure 5]. The R and Xc
anteriorly and posteriorly.
obtained at 50 kHz are used for plotting the graph. Based on
Hand‑to‑hand method data from the healthy population, assuming R and Xc follows
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Here, the patient stands with both arms stretched horizontally a normal distribution, three tolerance ellipses, corresponding
in front of the body. Measurement is done using a handheld to 50%, 75%, and 95% confidence intervals are constructed
impedance meter. around the mean R and Xc for the healthy population. It should
be noted that separate tolerance ellipses need to be constructed
Limitations of Bioimpedance Analysis for males and females.
Resistance and reactance are not interchangeable between The length of the vector corresponds to the impedance (Z).
devices or SF‑BIA and MF‑BIA. Raw values from one system The angle formed by the vector and X‑axis (Ph A adjusted for
or device cannot be imputed into another device. Different height) represents muscle mass. Hydration status changes the
manufacturers may use proprietary regression models, making length of the vector, whereas changes in body composition
comparisons across devices error‑prone. Furthermore, fat tend to be reflected by the Ph A. A shorter vector means a
distribution in different ethnic groups might be variable; hence, lower impedance due to ECFW, and a longer vector means
equations validated in the respective populations must be used dehydration. A more acute angle means less muscle mass
for analysis. The distribution of fat and fat‑free mass is based and a more obtuse angle means more muscle mass. The
on the assumption that 73% of fat‑free mass is water; however, length of the vector is preserved under these conditions.
this assumption may not hold true in patients with altered Obese individuals generally fall on the left‑hand side of the
hydration status. The regression equations are derived from 75th tolerance ellipse.
healthy populations – hence, the application might be limited Based on the position of the vector, information can be
in individuals with extreme malnutrition, obesity, extremes derived on the hydration status and body composition.
of age, and in professional bodybuilders. Even though the For example, in Figure 5, the red dot represents the vector
BIA technique is not harmful in pregnancy, none of the BIA of patients with end‑stage renal disease who presented in
equations are validated in pregnancy. BIA cannot be used in volume overload. The vector ends in the left lower quadrant
patients with electronic implants like pacemakers. Metallic
corresponding to OH, outside the tolerance ellipses. The blue
implants may interfere with the accuracy of fat measurements.
dot represents the vector of the same patient, after a few
dialysis sessions. The vector lies well within the tolerance
Bioimpedance Vector Analysis ellipses, meaning the patient is closer to euvolemia and
The major limitation of BIA is the fact that it does not measure
the body composition directly, but rather uses mathematical

a b c
Figure 4: Electrode placement for bioimpedance analysis. (a) Hand‑to‑foot
method, (b) foot‑to‑foot method, (c) Eight‑electrode method Figure 5: Bioimpedance vector

Journal of Renal Nutrition and Metabolism ¦ Volume 8 ¦ Issue 1 ¦ July-December 2023 33

 Zachariah and Priyamvada: Bioimpedance analysis

normal body composition. The green dot represents the Conflicts of interest
vector after a few more sessions. It has moved out of the There are no conflicts of interest.
ellipses, toward the dehydration range, alerting the clinician
to scale down the dry weight. References
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Conclusions bioimpedance analysis in clinical status monitoring and diagnosis of
diseases. Sensors (Basel) 2014;14:10895‑928.
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BIA is a simple and effective bedside tool for assessing 2. Moonen HP, Van Zanten AR. Bioelectric impedance analysis for body
hydration and body composition, albeit with limitations due to composition measurement and other potential clinical applications in
critical illness. Curr Opin Crit Care 2021;27:344‑53.
the derived nature of its output. BIVA analysis incorporating
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the raw BIA data is proposed as an alternative tool to overcome in helping to aid clinical decision‑making of volume assessments in
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the limitations of BIA. Even though theoretically BIS offers dialysis patients. Kidney Int 2014;86:489‑96.
more reliable data compared to MF‑BIA, the same has not 4. Kyle UG, Bosaeus I, De Lorenzo AD, Deurenberg P, Elia M, Gómez JM,
et al. Bioelectrical impedance analysis – Part I: Review of principles and
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Financial support and sponsorship body fluid variation by bioimpedance analysis: the RXc graph. Kidney
Nil. Int 1994;46:534‑9.

34 Journal of Renal Nutrition and Metabolism ¦ Volume 8 ¦ Issue 1 ¦ July-December 2023