Summary
Background
Reduced muscular strength, as measured by grip strength, has been associated with an increased risk of all-cause and cardiovascular mortality. Grip strength is appealing as a simple, quick, and inexpensive means of stratifying an individual's risk of cardiovascular death. However, the prognostic value of grip strength with respect to the number and range of populations and confounders is unknown. The aim of this study was to assess the independent prognostic importance of grip strength measurement in socioculturally and economically diverse countries.
Methods
The Prospective Urban-Rural Epidemiology (PURE) study is a large, longitudinal population study done in 17 countries of varying incomes and sociocultural settings. We enrolled an unbiased sample of households, which were eligible if at least one household member was aged 35–70 years and if household members intended to stay at that address for another 4 years. Participants were assessed for grip strength, measured using a Jamar dynamometer. During a median follow-up of 4·0 years (IQR 2·9–5·1), we assessed all-cause mortality, cardiovascular mortality, non-cardiovascular mortality, myocardial infarction, stroke, diabetes, cancer, pneumonia, hospital admission for pneumonia or chronic obstructive pulmonary disease (COPD), hospital admission for any respiratory disease (including COPD, asthma, tuberculosis, and pneumonia), injury due to fall, and fracture. Study outcomes were adjudicated using source documents by a local investigator, and a subset were adjudicated centrally.
Findings
Between January, 2003, and December, 2009, a total of 142 861 participants were enrolled in the PURE study, of whom 139 691 with known vital status were included in the analysis. During a median follow-up of 4·0 years (IQR 2·9–5·1), 3379 (2%) of 139 691 participants died. After adjustment, the association between grip strength and each outcome, with the exceptions of cancer and hospital admission due to respiratory illness, was similar across country-income strata. Grip strength was inversely associated with all-cause mortality (hazard ratio per 5 kg reduction in grip strength 1·16, 95% CI 1·13–1·20; p<0·0001), cardiovascular mortality (1·17, 1·11–1·24; p<0·0001), non-cardiovascular mortality (1·17, 1·12–1·21; p<0·0001), myocardial infarction (1·07, 1·02–1·11; p=0·002), and stroke (1·09, 1·05–1·15; p<0·0001). Grip strength was a stronger predictor of all-cause and cardiovascular mortality than systolic blood pressure. We found no significant association between grip strength and incident diabetes, risk of hospital admission for pneumonia or COPD, injury from fall, or fracture. In high-income countries, the risk of cancer and grip strength were positively associated (0·916, 0·880–0·953; p<0·0001), but this association was not found in middle-income and low-income countries.
Interpretation
This study suggests that measurement of grip strength is a simple, inexpensive risk-stratifying method for all-cause death, cardiovascular death, and cardiovascular disease. Further research is needed to identify determinants of muscular strength and to test whether improvement in strength reduces mortality and cardiovascular disease.
Funding
Full funding sources listed at end of paper (see Acknowledgments).
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References
- 1.
Cardiorespiratory fitness as a quantitative predictor of all-cause mortality and cardiovascular events in healthy men and women: a meta-analysis.JAMA. 2009; 301: 2024-2035
- 2.
Muscular strength in male adolescents and premature death: cohort study of one million participants.BMJ. 2012; 345: e7279
- 3.
Muscle strength and body mass index as long-term predictors of mortality in initially healthy men.J Gerontol A Biol Sci Med Sci. 2000; 55: M168-M173
- 4.
Association of handgrip strength to cardiovascular mortality in pre-diabetic and diabetic patients: a subanalysis of the ORIGIN trial.Int J Cardiol. 2014; 174: 458-461
- 5.
Association between muscular strength and mortality in men: prospective cohort study.BMJ. 2008; 337: a439
- 6.
Grip strength, body composition, and mortality.Int J Epidemiol. 2007; 36: 228-235
- 7.
Grip strength predicts cause-specific mortality in middle-aged and elderly persons.Am J Med. 2007; 120: 337-342
- 8.
Strength, but not muscle mass, is associated with mortality in the health, aging and body composition study cohort.J Gerontol A Biol Sci Med Sci. 2006; 61: 72-77
- 9.
Physical-strength tests and mortality among visitors to health-promotion centers in Japan.J Clin Epidemiol. 1995; 48: 1349-1359
- 10.
Skeletal muscle strength as a predictor of all-cause mortality in healthy men.J Gerontol A Biol Sci Med Sci. 2002; 57: B359-B365
- 11.
Handgrip strength and mortality in older Mexican Americans.J Am Geriatr Soc. 2002; 50: 1250-1256
- 12.
Prospective Urban Rural Epidemiology (PURE) study: baseline characteristics of the household sample and comparative analyses with national data in 17 countries.Am Heart J. 2013; 166: 636-646
- 13.
Cardiovascular risk and events in 17 low-, middle-, and high-income countries.N Engl J Med. 2014; 371: 818-827
- 14.
International physical activity questionnaire: 12-country reliability and validity.Med Sci Sports Exerc. 2003; 35: 1381-1395
- 15.
Validation of a semi-quantitative Food Frequency Questionnaire for Argentinean adults.PLoS One. 2012; 7: e37958
- 16.
Development, reproducibility and validity of the food frequency questionnaire in the Poland arm of the Prospective Urban and Rural Epidemiological (PURE) study.J Hum Nutr Diet. 2012; 25: 225-232
- 17.
Refinement and validation of an FFQ developed to estimate macro- and micronutrient intakes in a south Indian population.Public Health Nutr. 2009; 12: 12-18
- 18.
Maximal voluntary contraction as a functional indicator of adult chronic undernutrition.Br J Nutr. 1996; 76: 9-15
- 19.
Verbal autopsy of 48 000 adult deaths attributable to medical causes in Chennai (formerly Madras), India.BMC Public Health. 2002; 2: 7
- 20.
A proportional hazards model for the subdistribution of a competing risk.J Am Stat Assoc. 1999; 94: 496-509
- 21.
A review of the measurement of grip strength in clinical and epidemiological studies: towards a standardised approach.Age Ageing. 2011; 40: 423-429
- 22.
Association of body size and muscle strength with incidence of coronary heart disease and cerebrovascular diseases: a population-based cohort study of one million Swedish men.Int J Epidemiol. 2009; 38: 110-118
- 23.
Isometric training lowers resting blood pressure and modulates autonomic control.Med Sci Sports Exerc. 2003; 35: 251-256
- 24.
Assessment of atherosclerosis: the role of flow-mediated dilatation.Eur Heart J. 2010; 31: 2854-2861
- 25.
Exercise training enhances endothelial function in young men.J Am Coll Cardiol. 1999; 33: 1379-1385
- 26.
Poor trunk flexibility is associated with arterial stiffening.Am J Physiol Heart Circ Physiol. 2009; 297: H1314-H1318
- 27.
Efficacy of progressive resistance training on balance performance in older adults: a systematic review of randomized controlled trials.Sports Med. 2008; 38: 317-343
- 28.
Reliability and relationships among handgrip strength, leg extensor strength and power, and balance in older men.Exp Gerontol. 2014; 58: 47-50
- 29.
Clinical measures of physical fitness predict insulin resistance in people at risk for diabetes.Phys Ther. 2008; 88: 1355-1364
- 30.
Muscular strength and cardiorespiratory fitness is associated with higher insulin sensitivity in children and adolescents.Int J Pediatr Obes. 2006; 1: 222-231
Article info
Publication history
Published: May 13, 2015
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- Grip strength and mortality: a biomarker of ageing?
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Grip strength is a simple but powerful predictor of future disability, morbidity, and mortality. The relation between grip strength and future mortality has been shown, not only in older people1 but also in middle-aged2 and young people.3 The evidence has been summarised in systematic reviews4 and in a meta-analysis.5 However, important questions remain, such as whether the association between grip strength and future mortality is generalisable across countries of widely varying socioeconomic circumstances and, particularly, what might explain the associations.
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