title: Validity of silhouette showcards as a measure of body size and obesity in a population in the African region: A practical research tool for general-purpose surveys.
abstract: BACKGROUND
  The purpose of this study is to validate the Pulvers silhouette showcard as a measure of weight status in a population in the African region. This tool is particularly beneficial when scarce resources do not allow for direct anthropometric measurements due to limited survey time or lack of measurement technology in face-to-face general-purpose surveys or in mailed, online, or mobile device-based surveys.
  
  
  METHODS
  A cross-sectional study was conducted in the Republic of Seychelles with a sample of 1240 adults. We compared self-reported body sizes measured by Pulvers' silhouette showcards to four measurements of body size and adiposity: body mass index (BMI), body fat percent measured, waist circumference, and waist to height ratio. The accuracy of silhouettes as an obesity indicator was examined using sex-specific receiver operator curve (ROC) analysis and the reliability of this tool to detect socioeconomic gradients in obesity was compared to BMI-based measurements.
  
  
  RESULTS
  Our study supports silhouette body size showcards as a valid and reliable survey tool to measure self-reported body size and adiposity in an African population. The mean correlation coefficients of self-reported silhouettes with measured BMI were 0.80 in men and 0.81 in women (P < 0.001). The silhouette showcards also showed high accuracy for detecting obesity as per a BMI ≥ 30 (Area under curve, AUC: 0.91/0.89, SE: 0.01), which was comparable to other measured adiposity indicators: fat percent (AUC: 0.94/0.94, SE: 0.01), waist circumference (AUC: 0.95/0.94, SE: 0.01), and waist to height ratio (AUC: 0.95/0.94, SE: 0.01) amongst men and women, respectively. The use of silhouettes in detecting obesity differences among different socioeconomic groups resulted in similar magnitude, direction, and significance of association between obesity and socioeconomic status as when using measured BMI.
  
  
  CONCLUSIONS
  This study highlights the validity and reliability of silhouettes as a survey tool for measuring obesity in a population in the African region. The ease of use and cost-effectiveness of this tool makes it an attractive alternative to measured BMI in the design of non-face-to-face online- or mobile device-based surveys as well as in-person general-purpose surveys of obesity in social sciences, where limited resources do not allow for direct anthropometric measurements.
authors.affiliation: University Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland.
authors.forename: Maryam
authors.initials: M
authors.lastname: Yepes
authors.affiliation: Unit for Prevention and Control of Cardiovascular Diseases, Ministry of Health, Victoria, Republic of Seychelles.
authors.forename: Barathi
authors.initials: B
authors.lastname: Viswanathan
authors.affiliation: University Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland ; Unit for Prevention and Control of Cardiovascular Diseases, Ministry of Health, Victoria, Republic of Seychelles.
authors.forename: Pascal
authors.initials: P
authors.lastname: Bovet
authors.affiliation: Department of Economics (DEEP), Faculty of Business and Economics (HEC), University of Lausanne, Lausanne, Switzerland.
authors.forename: Jürgen
authors.initials: J
authors.lastname: Maurer
keywords: Africa; Anthropometric measure; General purpose household surveys; Obesity; Silhouette body size showcard; Social survey; Socioeconomic status