Elsevier

The Lancet

Volume 386, Issue 9990, 18–24 July 2015, Pages 266-273
The Lancet

Articles
Prognostic value of grip strength: findings from the Prospective Urban Rural Epidemiology (PURE) study

https://doi.org/10.1016/S0140-6736(14)62000-6Get rights and content

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).

Section snippets

introduction

Physical fitness is an important predictor of mortality and morbidity.1, 2 Physical fitness consists of cardiorespiratory fitness and muscular fitness. Both muscular endurance and muscle strength are indicators of muscular fitness. Reduced muscle strength, as measured by grip strength, has been associated with an increased risk of mortality in many studies.2, 3, 4, 5, 6, 7, 8, 9, 10, 11 However, the mechanism by which low muscle strength might predispose to death is uncertain. Grip strength

Study Design and participants

The design of the PURE study has been described previously.12 In brief, we selected countries to achieve substantial socioeconomic heterogeneity. For reasons of feasibility, we did not undertake proportionate sampling of all countries worldwide, or of regions within countries. At the start of the study, we classified selected countries according to the World Bank scheme as high-income (Canada, Sweden, and United Arab Emirates), upper middle-income (Argentina, Brazil, Chile, Malaysia, Poland,

Results

Participant characteristics were stratified by sex and grip-strength tertile (table 1). Baseline grip strength and vital status were recorded for 139 691 participants. Increased grip strength was associated with young age, male sex, high level of education, employment, high level of physical activity, high dietary calorie intake, of which a high proportion came from protein, and with increasing height, weight, and upper arm circumference. Previous use of alcohol or tobacco was associated with

Discussion

In people of diverse economic and sociocultural backgrounds, grip strength is a strong predictor of cardiovascular mortality and a moderately strong predictor of incident cardiovascular disease. Grip strength is also predictive for non-cardiovascular mortality, but is not predictive of incident non-cardiovascular disease. Low grip strength is associated with higher case-fatality rates in people who develop cardiovascular or non-cardiovascular disease. These findings suggest that muscle strength

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