Clinical Nutrition ESPEN 19 (2017) 54e58

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Clinical Nutrition ESPEN

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Original article

Handgrip strength: Reference values and its relationship with

bioimpedance and anthropometric variables
Wendy Daniella Rodríguez-García a, b, Luis García-Castan ~ eda a, b, Arturo Orea-Tejeda c,
Víctor Mendoza-Nún lez-Islas c, Cira Santilla
~ ez b, Dulce Gabriela Gonza n-Díaz a,
a, *
Lilia Castillo-Martínez
a
Clinical Nutrition Department, Instituto Nacional de Ciencias M n Salvador Zubira
edicas y Nutricio n, Mexico
b
Gerontology and Research Unit, FES-Zaragoza, Universidad Nacional Auto noma de M exico, Mexico
c
Heart Failure and Respiratory Distress Clinic, Cardiology Department, Instituto Nacional de Enfermedades Respiratorias “Ismael Cosío Villegas”, Mexico

a r t i c l e i n f o s u m m a r y

Article history: Background & aims: Handgrip strength by dynamometry is an anthropometric measurement used to
Received 8 November 2016 estimate muscle function in healthy adults, predict functional limitations, disabilities and survival in
Accepted 20 January 2017 older people. Low handgrip strength is considered a better predictor of clinical outcomes than low
muscle mass when it is measured in standard conditions and compared with reference populations. It is
Keywords: well known that age, sex and height are the most important factors correlated with handgrip strength.
Handgrip strength
The aim of this study was to establish reference values for handgrip strength in Mexican adults for both
Reference values
genders and identify its relationship with anthropometric factors.
Mexico
Methods: Cross-sectional study with 902 apparently healthy adults (478 women and 424 men) older
than 20 years old from Mexico City. Personal data, dietary information and anthropometry were
assessed. Handgrip strength was measured in dominant hand with a Smedley Hand Dynamometer
(Stoelting, Wood Dale, UK).
Results: Mexican population presented the maximum strength at 30 years of age decreasing continuously
further on (p < 0.001). Handgrip is higher in men than in women for all age ranges. The correlation between
height and handgrip strength was stronger (r ¼ 0.757, p < 0.001) compared with the observed correlation
between handgrip strength and diet (r ¼ 0.397, p < 0.001). In contrast, occupation showed no correlation
(r ¼ 0.057, p ¼ 0.123). We present reference values of handgrip strength for each gender and age categories.
Also, we proposed tables with the index of handgrip strength adjusted by the squared of height.
Conclusions: Height is the anthropometric factor with higher correlation to handgrip strength. Factors
such as nutrition and occupation had a weak correlation with handgrip. Use of these reference values
stratified by age and sex will allow us to have an assessing tool to evaluate muscle functionality in
Mexican people with characteristics similar to this study.
© 2017 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights
reserved.

1. Introduction The relevance of measuring the HGS has increased in recent

years, due to its clinical and epidemiological applications as part of
Handgrip strength (HGS), used to estimate the total muscular the diagnosis of sarcopenia proposed by the European Working
force, measures the ability that hand muscles have to generate Group (EWGSOP) [2], or as nutritional status marker and because of
tension (force) through a handshake [1]. its relationship with morbidity and mortality [3].
Measurements commonly made to determine nutritional status
of teenagers, people of medium age and elderly, both healthy and
ill, are mainly based on the measurement of weight, height, skin
* Corresponding author.
E-mail addresses: wen_030@yahoo.com.mx (W.D. Rodríguez-García), luisro.
folds and different perimeters, these measurements are charac-
casta@gmail.com (L. García-Castan ~ eda), artorea@gmail.com (A. Orea-Tejeda), terized because they are simple and low cost. However, it is
mendovic@servidor.unam.mx (V. Mendoza-Nún ~ ez), gzz.dulce@gmail.com important to include in the clinical and nutritional evaluation
(D.G. Gonzalez-Islas), cirsadi16@gmail.com (C. Santill
an-Díaz), caml1225@yahoo. methods that determine the functionality of different organs and
com (L. Castillo-Martínez).

http://dx.doi.org/10.1016/j.clnesp.2017.01.010
2405-4577/© 2017 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.
 W.D. Rodríguez-García et al. / Clinical Nutrition ESPEN 19 (2017) 54e58
systems in relation to its nutritional integrity with accessible
equipment and easy handling [4].
In clinical area, HGS in the elderly, has been used as a predictor
of functional limitations, disabilities and survival [5e10], it is also
very useful in orthopedic and surgical management [1,11,12], as an
important part of the assessment of the nutritional status in pa-
tients with impaired muscular reserve such as those with diabetes
mellitus [13], renal failure [14,15], coronary heart disease [16,17],
and COPD [6]. In addition, it has been used as a predictor of post-
surgical complications [18].
HGS has been associated with different anthropometric factors,
it is well-founded that men have 50e70% more strength compared
to women at any age, and that the decrease of the same is one of the
most important changes occurring in elderly subjects [12,19e22].
Other variables correlated with HGS mainly in Caucasian popula-
tion were described: height (r2 ¼ 0.713, p < 0.001) [23], weight
(r ¼ 0.247, p < 0.001) and arm circumference (r ¼ 0.375, p < 0.001)
[12].
There are several studies [11,12,20], few in Latin-American
population [21], that present reference values of HGS, however
the techniques to measure HGS and the equipment they use are
different.
There are no HGS reference values for Mexican population,
that is because the objective of this study is to propose tables with
reference values (stratified by gender, age and height) and to
determine the association of anthropometric and body composition
variables, occupation and diet with HGS.
2. Material and methods
A total of 972 adults from Mexico City were enrolled in the
study. All subjects were volunteers, apparently healthy by self-
report and born in Mexico. Excluded participants were high per-
formance athletes and pregnant women; also those with any
traumatic event in upper extremities or presence of pain while
squeezing; hospitalizations in the last six months; positive history
of inflammatory or neurologic diseases. This work was supported
by General Directorate of Faculty Affairs, Universidad Nacional
Autonoma de Mexico (DGAPA, UNAM) and performed in the sub-
way of Mexico City (from February to April 2012), each participant
was informed about the purpose of the study and confirmed con-
sent by participating actively.
The survey and the measurements were performed in a
consulting room of a station of Metro public transport system,
which is a commuting transportation system used by a large
percentage of the population living in this City (One billion 410
million 121 thousand 151 users in 2010) therefore, it was
considered an adequate place for the sample. The sample size was
calculated based on the hypothesis of normality of the HGS vari-
able stratified by age (decades) and gender. It was required to
cover the number of people for 5 age ranges, stratified by gender,
and pooled into HGS terciles, obtaining a sample size of 750
people.
The questionnaire gathered demographic and dietary informa-
tion, also anthropometric measurements (weight, height, and
forearm circumference), body composition and HGS by
dynamometry.
2.1. Anthropometry
Anthropometric measurements were performed according to
the reference manual for anthropometric standardization [24]. For
weight, all subjects were barefoot, avoiding extra weight from
55
money, wallets, and phones. Forearm circumference was measured
at the midpoint of the right arm. Body mass index (BMI) was
calculated by dividing the total body weight (kg) by the squared
height (m).
2.2. Body composition
Body composition was measured with whole-body bioelectrical
impedance using four-pole mono-frequency equipment (50-kHz,
Quantum X, RJL System) using the standard technique: the person
in supine position with arms separated from trunk by about 30
and legs separated by about 45 free of drafts and portable electric
heaters. The area was cleaned with alcohol and the electrodes were
placed on the hand and unilateral foot, finally we register the
resistance and reactance [25].
To determine the proportions of fat free mass (FFM) and fat mass
(FM), validated predictive equations for Mexican population
were employed (MLG (kg) ¼ 0.7374 * (height cm2/R) þ 0.1763 *
(weight)  0.1773 * (age) þ 0.1198 * (Xc)  2.4658) and the per-
centages of FFM and FM were recorded [26].
2.3. Handgrip strength
Handgrip strength was measured with a mechanical Smedley
Hand Dynamometer (Stoelting, Wood Dale, UK) adjustable to the
width of the hand. Subjects were placed standing with arms out-
stretched parallel to the trunk then took the dynamometer and
applied maximum strength with each hand without support. The
measurement was repeated three times alternately in dominant
hand with separation of 1 min to avoid fatigue. The maximum value
was recorded in kg.
2.4. Dietary intake
Diet was assessed using 24 hour recall, total nutrient intake
(macronutrient and micronutrient) was analyzed using Food Pro-
cessor software®, 4747 Skyline Rd Suite 100, Salem, OR 97306 D
[27].
2.5. Statistical analysis
The normal distribution for the variables studied was tested by
KolmogoroveSmirnov. For the descriptive analysis, the variables
with normal distribution are reported in mean ± Standard Devia-
tion (SD) and those non-normally distributed, as median and
interquartile intervals. The categorical variables were presented as
absolute and relative frequencies. The c2-test was used for com-
parisons between categorical variables, and for continuous vari-
ables the unpaired t-test or U ManneWhitney was used as
appropriate, according with normal or non-normal distribution.
Variations of HGS for each age range and gender were tested by
 post-hoc contrast. Levene test was
one-way ANOVA with Scheffe
used to analyze equality of variances.
The distribution of HGS terciles stratified by gender and age
ranges was reported. The HGS/height index was calculated. The
Pearson's or Spearman's correlation coefficient was calculated to
verify the correlations between HGS with demographic and nutri-
tion variables (anthropometric, body composition, diet, occupation
and physical activity) according with normal or non-normal
distributed values. Finally, a multiple linear regression analysis
was performed with the variables that in the bivariate analysis had
a value of p < 0.2. Data were analyzed using the SPSS program
version 21.0.
56 W.D. Rodríguez-García et al. / Clinical Nutrition ESPEN 19 (2017) 54e58

3. Results literature there is evidence on the relationship between the HGS

From 972 we excluded 70 because they were under 20 years old
or were unable to perform the HGS measurement. So the charac-
teristics of 902 adults (478 women and 424 men) that were
included at the present study are depicted in Table 1. BMI, protein,
carbohydrates, sugar and lipids intake were not statistically
different between men and women. Compared with women, men
showed higher values of body weight, arm circumference, fat mass
(%), FFM, phase angle, HGS (right and left hand), total energy (kcal),
PFA and cholesterol intake.
HGS values were sequentially lower from the youngest
(20e29 y) towards the older age groups. No significant differences
were observed in the values of HGS between groups 20e29 y vs
30e39 y, for both genders. Women showed higher HGS values
comparing groups 20e29 y and 30e39 y vs the last three age
groups (50e59, 60e69 and >70 y); the 40e49 y group presented
higher HGS compared with the 60e69 and >70 y groups (Table 2).
In male individuals the HGS values were not different comparing
the first four age groups (20e29, 30e39, 40e49 and 50e59 y)
(Table 2).
The mean with deviation standard and medians and percentiles
(25 e75 ) of reference values and index of dominant HGS
are presented and divided by decades for each gender (Tables 2
and 3).
Additionally, Table 4, shows the correlations between HGS with
its associated factors, finding a negative correlation between HGS
and age (r ¼ 0.346, p < 0.001) and a positive correlation with
height (r ¼ 0.757, p < 0.001).
Finally, a multiple linear regression analysis was made, where
the variables associated with handgrip strength in this population
were gender, age, height, resistance, phase angle (R2
corrected ¼ 0.76 for dominant hand) (Table 5).
4. Discussion
Measuring HGS by dynamometry is a simple tool that has been
implemented as part of the evaluation of the nutritional status, in
with age and gender, however, this evidence corresponds to foreign
population that is not comparable to the Mexican population.
This study confirms that the principal factors correlated with
HGS are sex, height, and FFM and shows that diet and occupation
have no correlations with HGS.
It is well established that gender is the main factor influencing
HG between men and women, studies previously reported higher
HGS up to 70% in men compared to women; this study is not the
exception, we found this relationship, but in lower percentage,
36e37% of more strength in men than in women for all age ranges.
The correlation found between HGS and age (r ¼ 0.346,
p < 0.001) is similar to studies reported in the literature for British
population (r ¼ 0.43, p < 0.001) [28]. The peak of maximum
handgrip strength for Mexican population was presented at 30
years of age, likewise it has been reported in Brazilian and Greek
populations, starting to decrease at 40 years of age in women
accentuating this loss at 50 years of age, which can be explained
due to hormonal changes [22]. Annual strength losses were 2.51% in
men and 7.45% in women indicating great differences compared to
other populations that reported only an annual loss of 1.1% [6].
Height was the variable that best correlated with HGS (r ¼ 0.757,
p < 0.001), this correlation was higher in our population, compared
to those found in adult British population >39 years old (r ¼ 0.67,
p < 0.01) [29] and >65 years of age (r ¼ 0.31 p < 0.001) [27], for
adults between 25 and 44 years of age (r ¼ 0.713, p < 0.001) [23]
and for Greek population (r ¼ 0.553 p < 0.001) [1].
Other anthropometric factors are also correlated with HGS as:
arm circumference (r ¼ 0.278, p < 0.001), FFM (r ¼ 0.627, p < 0.001),
resistance (r ¼ 0.497, p < 0.001) and phase angle (r ¼ 0.587,
p < 0.001).
Although in most of the studies proposed to include the type of
occupation as a variable which could modify HGS [11,21,30] and
that some studies have found association between different types
of occupation [28,31], in this study no statistically significant rela-
tionship was found with HGS (r ¼ 0.057, p ¼ 0.123), these results are
consistent with those reported by Budziareck et al and Günther
et al. (2008) [12,19].

Table 1
Body composition and diet characteristics of Mexican subjects.

Variable Women, n ¼ 478 Men, n ¼ 424 (p)*

Age (years) 50 ± 17 46 ± 17 0.005

Body weight (kg) 64.3 ± 11 75.7 ± 12 <0.001
Height (cm) 152.7 ± 6.7 166.8 ± 6.8 <0.001
BMI (kg/m2) 27.5 ± 4.3 27.1 ± 3.8 0.16
Arm circumference (cm) 29.3 ± 3.4 30.4 ± 3.1 <0.001
Fat free mass (%) 58 ± 7.6 69 ± 7.7 <0.001
Fat mass (%) 42 ± 7.7 31 ± 7.7 <0.001
Resistance (ohms) 576 ± 69.4 488 ± 55 <0.001
Reactance (ohms) 57 ± 8 55 ± 7.7 0.009
Phase angle ( ) 5.6 ± 0.64 6.50 ± 0.82 <0.001
Right handgrip strength (kg) 25.4 ± 5 41 ± 7 <0.001
Left handgrip strength (kg) 24 ± 5 39 ± 7 <0.001
Diet (kcal) 1641 ± 529 2240 ± 806 <0.001
Diet (kcal/kg) 25.3 (20.0e31.3) 29.2 (22.1e36.2) <0.001
Protein intake (% kcal) 16.9 (13.7e19.7) 15.9 (13.4e19.5) 0.19
Carbohydrates intake (% kcal) 54.0 ± 10.6 54.2 ± 10.5 0.78
Sugar intake (% kcal/día) 20.3 ± 9.9 20.0 ± 9.1 0.69
Fat intake (% kcal/día) 28.8 ± 9.9 28.9 ± 8.7 0.873
PFA intake (g) 7.6 (4.8e11.7) 10.02 (6.8e16.4) <0.001
Cholesterol intake (mg) 210.3 (134.2e330.4) 279.3 (183.7e496.6) <0.001
Occupation
Non manual (%) 262 (74.2%) 267 (71.2%) 0.40
 
Values are expressed as mean ± standard deviation; median (25 e75 ) or numbers (%) when appropriate.
*p based on t-student or U ManneWhitney.
BMI, body mass index; PFA, polyunsaturated fatty acids.
 W.D. Rodríguez-García et al. / Clinical Nutrition ESPEN 19 (2017) 54e58 57

Table 2
Reference values of handgrip strength of dominant hand by age and sex.

Age (y) Women Men

n Mean ± SD Median (25e75 ) n Mean ± SD Median (25e75 )

20e29 86 28 ± 4** 28 (25e31) 89 44 ± 8** 44 (38e49)

30e39 66 28 ± 4** 29 (25e31) 72 44 ± 8** 44 (37e49)
40e49 75 27 ± 5** 27 (23e31) 67 43 ± 6** 42 (38e46)
50e59 75 25 ± 4** 25 (23e28) 74 42 ± 5** 41 (37e46)
60e69 107 22 ± 5 23 (19e26) 78 38 ± 5 38 (35e41)
>70 67 22 ± 4 21 (19e25) 43 33 ± 5 34 (29e37)

Values are expressed as mean ± standard deviation; median (25e75 ).

**p < 0.001: group 20e29 vs 50e59, 60e69 and >70, group 30e39 vs 50e59, 60e69 and >70. 40e49 vs 60e69 and >70 in women. In men 20e29 vs 60e69 and >70, 30e39 vs
60e69 and >70. 40e49 vs 60e69 and >70, 50e59 vs 60e69 and >70.

Table 3 Initially we proposed include diet, considering that an adequate

Reference values of handgrip strength index of dominant hand by age and sex.
protein intake helps muscle stimulation and HGS, nevertheless we
Age (y) Women Men found no correlations between HGS protein (r ¼ 0.017, p ¼ 0.459),
Mean ± SD Median (25e75 ) Mean ± SD Median (25e75 ) also with daily caloric intake and with kcal by kg of weight for
general population (rP ¼ 0.397, p < 0.001). In contrast, the con-
20e29 11.5 ± 1.6 11.5 (10.3e12.5) 14.9 ± 2.7 15.1 (13.0e16.7)
30e39 11.4 ± 1.9 11.5 (10e12.5) 15.2 ± 2.3 15.0 (14.0e17.1) sumption of carbohydrates and sugars was negatively correlated
40e49 11.3 ± 1.9 11.2 (9.9e12.5) 15.1 ± 2.1 15.2 (13.4e16.8) (rP ¼ 0.158, p < 0.002; rP ¼ 0.105, p < 0.043) respectively.
50e59 10.8 ± 1.5 10.9 (9.8e12.0) 14.8 ± 1.6 14.6 (13.7e16.1) Of additional value to this study, the first tables with reference
60e69 10.0 ± 2.1 10.3 (8.7e11.3) 14.1 ± 1.7 14.1 (12.8e15.3)
values were produced for Mexican population. The values we ob-
>70 10.0 ± 1.8 9.8 (8.7e11.5) 12.6 ± 1.9 12.6 (11.4e13.9)
tained are lower if compared to Brazilian populations [21], British
Values are expressed as mean ± standard deviation and median (25e75 ) of kg/m2. [28], and German [12]; are similar to those found in Spanish pop-
ulation [20] and only above of Nigerian populations [11], it is
important to mention that previous studies were carried out with
different dynamometers. These differences suggest that variations
Table 4
Correlations between handgrip strength of dominant hand with demographic and are due to, in addition to the different characteristics of each pop-
nutritional factors. ulation, the technique and equipment used in each of the studies,
this is why it is useful to have the specific reference values for our
Variable r p-Value
population.
Sex 0.786** <0.001 Finally, we considered important to adjust by its main anthro-
Age (years) 0.346** <0.001
Body weight (kg) 0.519** <0.001
pometric correlated factor, in this case height, and thus create in-
Height (cm) 0.757** <0.001 dexes for each gender and age range. This correlation coincides
BMI (kg/m2) 0.005 0.89 with the values extracted from the United Kingdom cohort (UK
Arm circumference (cm) 0.278** <0.001 Biobank, 2013) with the largest number of registered participants
Fat free mass (%) 0.627** <0.001
for HGS stratified by quinquennial and height [29]. In accordance
Fat mass (%) 0.627** <0.001
Resistance (ohms) 0.497** <0.001 with our population characteristics, the national average height
Reactance (ohms) 0.072* 0.04 reported in 2006, women are 153 cm of height, while men are
Phase angle ( ) 0.587** <0.001 165 cm of height, data consistent with this study population:
Diet (kcal/weight kg) 0.397** <0.001 women 153 ± 7 cm and men 167 ± 7 cm of height. With these
Protein intake (% kcal) 0.017 0.46
Carbohydrates intake (% kcal) 0.059 0.12
results the anthropometric differences are emphasized along with
Sugar intake (% kcal/día) 0.015 0.68 the differences in HGS, between countries like Brazil [21] (women
Fat intake (% kcal/día) 0.050 0.18 152.7 cm and men 171.8 cm), Greece [1] (women 165.0 cm and men
PFA intake (g) 0.193** <0.001 170.3 cm) or United Kingdom [28] (women 155.0 cm and men
Cholesterol intake (mg) 0.280** <0.001
167 cm). These may be because these populations have larger
Occupation 0.057 0.12
height, in addition to the different dynamometers used.
Pearson's correlation coefficient, p-value, 2 tailed probability. This study has the limitation because the sample is not repre-
sentative of Mexico City, however, it allows us to infer about the
population that commutes through the station of the collective
Table 5 transportation system Metro, this means a subset of both genders
Multiple lineal regression and associated factors with handgrip strength of domi- population of Mexico City, of different ages and from different
nant hand. economic strata ranges, this population come from all political
Variable b p 95% CI delegations in the city.
In conclusion, HGS is higher in men than in women for all age
Lower limit Upper limit
ranges. HGS is affected by age, the maximum strength for both
Intersection 23.452 <0.001 35.474 11.430 genders is at 30 years of age, starting to decrease within the next
Age 0.084 <0.001 0.112 0.056
Height 0.341 <0.001 0.284 0.398
decade. Height is the variable with higher correlation with HGS for
Resistance 0.014 <0.001 0.022 0.007 both genders. Indirect calculation of FFM and values of phase angle
Phase angle 1.887 <0.001 1.310 2.465 and resistance had a moderate correlation with HGS. Therefore,
Sex(Men) 7.385 <0.001 6.165 8.605 HGS is modified by the set of anthropometric variables and body
R2 corrected ¼ 0.76. composition in Mexican population.
58 W.D. Rodríguez-García et al. / Clinical Nutrition ESPEN 19 (2017) 54e58
Conflict of interest statement
All authors state no conflict of interest.
Acknowledgments
We want to thank Mexico City's collective transportation system
(METRO) and Nutritionists Ana Elizabeth Gutie rrez Rodríguez,
Marisela V n for their participating in the project, also
azquez Dura
to Juan Rolando Gonza lez Bla
squez Cerro for English language
edition.
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