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Lancet. 2015 Jul 18;386(9990):266-73. doi: 10.1016/S0140-6736(14)62000-6. Epub 2015 May 13.


Collaborators (367)

Yusuf S, Rangarajan S, Teo KK, Chow CK, O'Donnell M, Mente A, Leong D, Smyth A, Joseph P, Islam S, Zhang M, Hu W, Wong G, Dayal L, Casanova A, Dehghan M, DeJesus J, Lewis G, Mackie P, Chin SL, Farago L, Kay I, Agapay D, Solano R, Ramacham S, Kandy N, Rimac J, Trottier S, ElSheikh W, Mustaha M, Tongana T, Aoucheva N, Swallow J, Ramezani E, Aliberti A, Lindeman J, McQueen M, Hall K, Keys J, Wang X, Keneth J, Devanath A, Diaz R, Orlandini A, Linetsky B, Toscanelli S, Casaccia G, Maini Cuneo JM, Rahman O, Yusuf R, Azad AK, Rabbani KA, Cherry HM, Mannan A, Hassan I, Talukdar AT, Tooheen RB, Khan MU, Sintaha M, Choudhury T, Haque R, Parvin S, Avezum A, Oliveira GB, Marcilio CS, Mattos AC, Teo K, Yusuf S, Dejesus J, Agapay D, Tongana T, Solano R, Kay I, Trottier S, Rimac J, Elsheikh W, Heldman L, Ramezani E, Dagenais G, Poirier P, Turbide G, Auger D, LeBlanc De Bluts A, Proulx MC, Cayer M, Bonneville N, Lear S, Gasevic D, Corber E, de Jong V, Vukmirovich I, Wielgosz A, Fodor G, Pipe A, Shane A, Lanas F, Seron P, Martinez S, Valdebenito A, Oliveros M, Li W, Liu L, Chen C, Wang X, Zhao W, Zhang H, Jia X, Hu B, Sun Y, Bo J, Zhao X, Chang X, Chen T, Chen H, Chang X, Deng Q, Cheng X, Deng Q, He X, Hu B, Jia X, Li J, Li J, Liu X, Ren B, Sun Y, Wang W, Wang Y, Yang J, Zhai Y, Zhang H, Zhao X, Zhu M, Lu F, Wu J, Li Y, Hou Y, Zhang L, Guo B, Liao X, Zhang S, Bian R, Tian X, Li D, Chen D, Wu J, Xiao Y, Liu T, Zhang P, Dong C, Li N, Ma X, Yang Y, Lei R, Fu M, He J, Liu Y, Xing X, Zhou Q, Lopez-Jaramillo P, Camacho Lopez PA, Garcia R, Jurado LJ, Gómez-Arbeláez D, Arguello JF, Dueñas R, Silva S, Pradilla LP, Ramirez F, Molina DI, Cure-Cure C, Perez M, Hernandez E, Arcos E, Fernandez S, Narvaez C, Paez J, Sotomayor A, Garcia H, Sanchez G, David T, Rico A, Mony P, Vaz M, Bharathi AV, Swaminathan S, Shankar K, Kurpad AV, Jayachitra KG, Kumar N, Hospital HA, Mohan V, Deepa M, Parthiban K, Anitha M, Hemavathy S, Rahulashankiruthiyayan T, Anitha D, Sridevi K, Gupta R, Panwar RB, Mohan I, Rastogi P, Rastogi S, Bhargava R, Kumar R, Thakur JS, Patro B, Lakshmi PV, Mahajan R, Chaudary P, Raman Kutty V, Vijayakumar K, Ajayan K, Rajasree G, Renjini AR, Deepu A, Sandhya B, Asha S, Soumya HS, Kelishadi R, Bahonar A, Mohammadifard N, Heidari H, Yusoff K, Ismail TS, Ng KK, Devi A, Nasir NM, Yasin MM, Miskan M, Rahman EA, Arsad MK, Ariffin F, Razak SA, Majid FA, Bakar NA, Yacob MY, Zainon N, Salleh R, Ramli MK, Halim NA, Norlizan SR, Ghazali NM, Arshad MN, Razali R, Ali S, Othman HR, Hafar CW, Pit A, Danuri N, Basir F, Zahari SN, Abdullah H, Arippin MA, Zakaria NA, Noorhassim I, Hasni MJ, Azmi MT, Zaleha MI, Hazdi KY, Rizam AR, Sazman W, Azman A, Iqbal R, Afridi A, Khawaja R, Raza A, Kazmi K, Zatonski W, Szuba A, Zatonska K, Ilow R, Ferus M, Regulska-Ilow B, Różańska D, Wolyniec M, Kruger A, Voster HH, Schutte AE, Wentzel-Viljoen E, Eloff FC, de Ridder H, Moss H, Potgieter J, Roux AA, Watson M, de Wet G, Olckers A, Jerling JC, Pieters M, Hoekstra T, Puoane T, Igumbor E, Tsolekile L, Sanders D, Naidoo P, Steyn N, Peer N, Mayosi B, Rayner B, Lambert V, Levitt N, Kolbe-Alexander T, Ntyintyane L, Hughes G, Swart R, Fourie J, Muzigaba M, Xapa S, Gobile N, Ndayi K, Jwili B, Ndibaza K, Egbujie B, Rosengren A, Bengtsson Boström K, Lindblad U, Langkilde P, Gustavsson A, Andreasson M, Snällman M, Wirdemann L, Pettersson K, Moberg E, Oguz A, Akalin AA, Calik KB, Imeryuz N, Temizhan A, Alphan E, Gunes E, Sur H, Karsidag K, Gulec S, Altuntas Y, Yusufali AM, Almahmeed W, Swidan H, Darwish EA, Hashemi AR, Al-Khaja N, Muscat-Baron JM, Ahmed SH, Mamdouh TM, Darwish WM, Abdelmotagali MH, Omer Awed SA, Movahedi GA, Hussain F, Al Shaibani H, Gharabou RI, Youssef DF, Nawati AZ, Abu Salah ZA, Abdalla RF, Al Shuwaihi SM, Al Omairi MA, Cadigal OD, Alejandrino RS, Chifamba J, Gwaunza L, Terera G, Mahachi C, Murambiwa P, Machiweni T, Mapanga R.

Author information

Population Health Research Institute, McMaster University, Hamilton, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada. Electronic address:
Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
Fundacion Oftalmologica de Santander and Medical School, Universidad de Santander, Colombia.
Dante Pazzanese Institute of Cardiology, São Paulo University, Brazil.
ECLA Foundation, Instituto Cardiovascular de Rosario, Rosario, Argentina.
Universidad de La Frontera, Temuco, Chile.
Dubai Health Authority, Dubai, United Arab Emirates.
Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
Independent University, Dhaka, Bangladesh.
St. John's Medical College, St. John's Research Institute, Bangalore, India.
Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan.
Fortis Escorts Hospital, Jaipur, India.
Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada.
Department of Internal Medicine, Istanbul Medeniyet University, Istanbul, Turkey.
Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia; UCSI University, Cheras, Kuala Kumpur, Malaysia.
Department of Social Medicine, Medical University of Wrocław, Wrocław, Poland.
University of Zimbabwe, Harare, Zimbabwe.
Madras Diabetes Research Foundation, Chennai, India.
State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.



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.


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.


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.


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.



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