Grip Strength as a Powerful Predictor of Mortality
Grip strength is a robust and independent predictor of all-cause mortality across all age groups, with higher grip strength consistently associated with significantly lower mortality risk regardless of body mass index, chronic disease status, or how the measurement is expressed.
Evidence for Mortality Prediction
All-Cause Mortality Association
In healthy middle-aged men followed for 30 years, grip strength predicted mortality independent of BMI, with those in the lowest third of grip strength having 25-39% higher mortality risk compared to the highest third across all BMI categories 1
In a Japanese cohort of 4,912 adults aged 35-74 years followed until 1999, each 5-kg increment in grip strength was associated with an 11-13% reduction in all-cause mortality risk (RR: 0.89 for men, 0.87 for women), and this association remained significant even after more than 20 years of follow-up 2
Analysis of 9,583 US adults from NHANES 2011-2014 demonstrated that participants with grip strength in the lowest 20% had more than double the mortality risk (HR: 2.20 for men, 2.52 for women) compared to those with higher grip strength 3
Disease-Specific Mortality
- Grip strength predicts cause-specific mortality, with each 5-kg increment associated with 15% lower risk of heart disease mortality (RR: 0.85), 10% lower stroke mortality (RR: 0.90), and 15% lower pneumonia mortality (RR: 0.85) in men 2
Clinical Application in Specific Populations
Kidney Disease Patients
In hospitalized patients with kidney failure at risk of malnutrition, handgrip strength below 10 kg at discharge and below 15 kg one month after discharge were associated with increased risk of death 4
In hemodialysis patients, handgrip strength correlates with number of comorbidities and malnutrition inflammation scores, providing valuable prognostic information 4
Liver Disease Patients
In cirrhosis patients on transplant wait lists, impaired grip strength was associated with increased mortality, while CT-derived skeletal muscle index (mass alone) was not predictive 4
Functional decline in grip strength is associated with increased risk for complications requiring hospitalization or death on the wait list or delisting in cirrhosis patients 4
Low handgrip strength allows assessment of mortality risk in liver disease patients, serving as a functional biomarker alongside phase angle measured by bioelectrical impedance 4
Optimal Measurement Approach
Measurement Methods
The simplest absolute measures of grip strength (average handgrip strength or maximum grip strength) are the optimal predictors of mortality, with area under the curve of 0.712-0.714 3
Expressing grip strength relative to anthropometric variables (height, weight, BMI, fat-free mass) does not improve mortality prediction compared to absolute values 5
Grip strength normalized to height squared (HGS/HT²) performs similarly to absolute grip strength for mortality prediction 3
Clinical Implementation
ESPEN guidelines recommend assessing muscle function by handgrip strength in collaborative patients with kidney disease 4
Handgrip strength dynamometry can identify muscle weakness even before changes in body composition parameters are detected, allowing earlier nutritional interventions 4, 6
Important Clinical Caveats
Limitations to Consider
Handgrip strength should not be used in isolation because it requires patient cooperation, lacks standardized measurement protocols, needs well-calibrated dynamometers adjusted for hand size, and lacks universal reference values 4, 6
In the ICU setting, the six-point Medical Research Council (MRC) score remains the recommended tool for assessing muscle strength, though handgrip dynamometry offers a simpler alternative 4
Interpretation Considerations
The mortality association with grip strength is independent of BMI, with grip strength showing a gradient of decreasing mortality risk across all BMI categories, while BMI itself shows minimal effect on mortality within each grip strength tertile 1
Gender differences exist in interpretation, with some evidence suggesting lower predictive validity in women compared to men for certain outcomes, though mortality prediction remains robust in both sexes 2, 5
Broader Health Implications
Grip strength serves as a biomarker for overall health functionality, with strong grip strength correlating with lower risk of adverse health events, better nutritional status, reduced hospitalization rates, and lower odds of adverse events across multiple health domains 6, 7
The predictive value of grip strength extends beyond mortality to include future function, bone mineral density, fractures, cognitive impairment, depression, diabetes, multimorbidity, and quality of life 7