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Reference values of handgrip dynamometry of

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Clinical Nutrition (2008) 27, 601e607

available at www.sciencedirect.com

http://intl.elsevierhealth.com/journals/clnu

ORIGINAL ARTICLE

Reference values of handgrip dynamometry of

healthy adults: A population-based study
Michael Maia Schlussel a, Luiz Antonio dos Anjos b,c,*,
Maurcio Teixeira Leite de Vasconcellos d, Gilberto Kac a

a
Programa de Pos-Graduacao em Nutricao, Instituto de Nutricao, Universidade Federal do Rio de Janeiro,
Rio de Janeiro, Brazil
b
Laboratorio de Avaliacao Nutricional e Funcional, Departamento de Nutricao Social,
Universidade Federal Fluminense, Niteroi, Rio de Janeiro, Brazil
c
Escola Nacional de Saude Publica Sergio Arouca, Fundacao Oswaldo Cruz, Rio de Janeiro, Brazil
d
Escola Nacional de Ciencias Estatsticas, Fundacao Instituto Brasileiro de Geografia e Estatstica,
Rio de Janeiro, Brazil

Received 28 September 2007; accepted 14 April 2008

KEYWORDS Summary
Hand strength; Background & aims: Although maximal voluntary handgrip strength (HGS) is considered a reliable
Urban population; tool in nutritional assessment there are few reference data available. This paper presents ref-
Nutrition assessment; erence values for handgrip strength of healthy adults (age 20 years) from a household survey.
Reference values; Methods: Data were obtained from a representative sample of adults (1122 males and 1928
Muscle strength females) living in Niteroi, Rio de Janeiro, Brazil. HGS was measured three times with a Jamar me-
dynamometer; chanical dynamometer in both hands and the highest value used in the analysis. The percentile
Nutrition surveys distribution of HGS was calculated according to sex and age categories.
Results: Mean values of right and left HGS were 42.8 and 40.9 kg for males, and 25.3 and 24.0 kg
for females, respectively. HGS increased with age and significantly decreased after 40 and
50 year-olds for women and men, respectively. Body mass index (BMI) was associated with
HGS in both sexes but only underweight male subjects had significantly lower HGS values.
Conclusions: The highest HGS values are observed at the 4th decade of life with significant
declines thereafter. HGS is significantly associated with BMI. The reference values of HGS may
be useful in assessing the nutritional status of similar adult urban population.
2008 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights
reserved.

* Corresponding author. Departamento de Nutricao Social, Universidade Federal Fluminense, Caixa Postal 100231, 24020-971 Niteroi,
Rio de Janeiro, Brazil. Tel.: 55 21 2629 9856; fax: 55 21 2629 9847.
E-mail addresses: michaelmaia@gmail.com (M.M. Schlussel), anjos@ensp.fiocruz.br (L.A. dos Anjos), mtlv@ibge.gov.br (M.T.L. de
Vasconcellos), kacetal@gmail.com (G. Kac).

0261-5614/$ - see front matter 2008 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
doi:10.1016/j.clnu.2008.04.004
602
Introduction
Nutritional balance is essential in the prevention and
treatment of diseases. Many complications can be avoided
or attenuated by monitoring the nutritional status and thus
preventing nutritional deficiencies. Clinical history and
physical examination, including anthropometry, remain
the primary methods in nutritional assessment but they
are not enough for a complete evaluation. Laboratory
parameters have some limitations and many of the modern
equipments used in these procedures are very expensive
and not always available in clinical settings.1 Thus, clini-
cians should always try to combine different nutritional
assessment methods in an attempt to make faster and
more accurate diagnosis so that slight modifications can
be detected early.
Skeletal muscle function is regarded as a useful indicator
of malnutrition.2e4 Besides, functional recovery occurs rap-
idly in response to the initiation of nutritional support in
contrast to anthropometric measures which may only mod-
ify after weeks. Therefore, functional tests may be the
most sensitive and relevant indicator of nutritional status
alterations due to nutritional support in the short term.5,6
Handgrip strength (HGS), a measure of maximum volun-
tary force of the hand, has been described as the simplest
method in assessing muscle function.7 Furthermore, this
technique has been demonstrated to be a reliable screening
tool in the assessment of nutritional risk in hospital admis-
sion4,8,9 as well as a useful indicator of nutritional status in
the non-hospitalized population, particularly in identifying
individuals with chronic malnutrition.10 Moreover, data
from the literature tend to support the fact that HGS may
be a good predictor of body cell mass depletion, functional
decrease during hospitalization, post-surgery complications
and mortality.7,11e22
Over the last few years there has been growing interest
in research involving HGS use and application in nutritional
assessment.20 However, there is limited information on HGS
of healthy subjects. Some studies have proposed normative
HGS values but the samples of healthy subjects were
small.23e26 Therefore, the objective of the present study
was to establish reference data of HGS in a representative
sample of adults from a municipality of Brazil.
Methods
The data presented here is derived from the Nutrition,
Physical Activity and Health Survey (PNAFS), a household
survey carried out in a representative sample of adults from
the city of Niteroi, State of Rio de Janeiro, Brazil. Niteroi is
a municipality of 129 km2 located in the Southeast region of
Brazil (22 530 0000 S; 43 060 1300 W) with a total population of
459,451 inhabitants (2000 Census data). The Institutional
Review Board of the Sergio Arouca National School of
Public Health, Oswaldo Cruz Foundation, approved all the
research procedures.
Sample
The PNAFS was conducted from January to December 2003
based on a three-stage probabilistic sample: census
M.M. Schlussel et al.
enumeration area (CEA), permanent private household
(PPH) and adults (20 years). This sample was designed
for the major project with the objective of studying the
physical activity level in a subpopulation characterized by
healthy adults. For the present work, however, only PPH
sample was considered.
In the first stage, 110 CEAs in Niteroi were systematically
selected with probability proportional to the number of
PPHs observed in the 2000 Brazilian Population Census.
Prior to selection, the CEAs were ordered by the mean of
the head-of-households nominal monthly income, a pro-
cedure that implicitly stratified the CEA by mean income
and ensured the selection of CEAs from all income levels. In
order to have 16 interviewed PPHs in each of the 110 CEAs
the inverse sampling technique was applied leading to
a sample size of 1760 (110  16) households. This method
was proposed by Haldane27 and consists of sequentially
visiting the households until the fixed number of interviews
is reached (16 in this case).
The PPHs to be visited were randomly determined based
on the CEA listing from the 2000 Brazilian Population
Census. For this, 50 PPHs ordinal numbers from each
selected CEA list were selected with equal probability.
The households were then visited in the pre-established
selection order. The results of each visit were recorded in
an appropriate data collection instrument and the visits
ended when the 16th interview had been obtained in the
given CEA.
There were 12 non-responses. In the 1748 interviewed
PPHs, 5745 subjects lived of which 4180 were adults.28
Several visits to the interviewed PPHs were done in order
to locate and measure as many adults as possible. After
eliminating the subjects who were not available for mea-
surements (n Z 919) or explicitly declined to participate
(n Z 123) and those whose measurements were not valid
(n Z 106) the final sample comprised 1122 males and
1928 females for whom there were valid measures of HGS
of both hands.
The non-response and loss of HGS information were
corrected during sample weighting procedure.26 The sam-
ple design weights (calculated as the product of the inverse
of each stage inclusion probability) were then calibrated in
order to estimate the correct distribution of the population
by age and sex28 such that the observed sub-sample was
representative of the 324,427 (145,642 men and 178,785
women) adults residing in Niteroi.
Data collection
A preliminary visit to each selected household was made to:
a) explain the objectives of the survey and the data
collection protocol; b) ask for permission to develop the
survey; and c) set the date and hour to begin data
collection. On the day of the interview, the head-of-
household signed the informed consent form and answered
a standardized questionnaire prepared to collect both
coded information on the survey area and household as
well as individual and family data.
Anthropometric data of all available subjects were
collected. Body mass was measured with the subjects
wearing light clothes and no shoes, and recorded to the
Reference values of handgrip strength 603

nearest 0.1 kg. Stature was measured twice for each indi-
Table 2 Handgrip strength (kg) stratified by age in adults
vidual29 and recorded to the nearest 0.01 m. Body mass in-
from Niteroi, Rio de Janeiro, Brazil
dex (BMI) was calculated and the subjects were classified
as: underweight [BMI < 18.5 kg/m2]; normal [18.5 kg/ Age category (years) Males Females
m2  BMI < 25 kg/m2] or overweight [BMI  25 kg/m2].30 n Mean SE n Mean SE
HGS was measured in both sides (dominant and non-
20e29 R 295 45.8 0.67 431 27.2 0.46
dominant), using Jamar mechanical dynamometers (Sam-
L 295 43.8 0.56 431 25.6 0.42
mons Preston e Korea) with precision of 0.5 kg. Subjects
30e39 R 244 46.5 0.47 397 28.0 0.39
were instructed to self adjust the dynamometer so that it
L 244 44.5 0.50 397 26.7 0.37
fit comfortably to their hand size to obtain their best per-
40e49 R 220 43.2 0.53 403 27.0 0.37
formance.31 Prior to data collection a warm up section
L 220 41.6 0.50 403 25.7 0.35
was conducted so that the subjects would get acquainted
50e59 R 166 40.8 0.70 327 24.2 0.45
with the instrument and procedures and choose the best
L 166 39.2 0.67 327 23.0 0.43
adjustment.32 Finally, subjects were instructed to grip the
60e69 R 121 36.8 0.76 198 22.1 0.40
dynamometer with maximum strength in response to a voice
L 121 34.5 0.68 198 21.0 0.41
command.33 For the measurements the subjects stood with
70 R 76 31.8 0.79 172 17.2 0.41
both arms pending sideways to the body with the dynamom-
L 76 29.4 0.75 172 16.4 0.41
eter facing outwards the body.34 Three trials were per-
formed on each side, alternately, with a rest period of at R: right; L: left; SE: standard error.
least 1 min between trials of the same hand.35 The highest
value of each side was used to represent HGS.24e26,36e38
calculated. All statistical analyses were conducted with
HGS data from individuals with any upper limb malforma-
the appropriate sample weights based on the structural in-
tion, who reported pain during the grip assessment or pre-
formation in the sample design and calibrated to the known
sented any conditions that might compromise muscular
population subgroup totals (2000 Census) using the Descript
function were discarded.
and Regress procedures of Sudaan 9.01.
The mean values obtained with the dominant hand were
only 4.9% (SE Z 0.27; 95% CI 4.35e5.41) lower than those
obtained with the non-dominant hand, both for left or Results
right-handed subjects. Thus, the reference values of HGS
presented here combine the results of left and right- Data of all variables are summarized in Table 1. Males pres-
handed subjects, without considering their side of ent higher mean values than females for all variables, ex-
preference. cept for BMI (b Z 0.21; p Z 0.34). Only 3.8% of women
and 2.1% of men were underweight and 45.7% and 51.3%
Data analyses of females and males were overweight. BMI varied from
15.6 to 51.6 kg/m2 in females and from 16.9 to 45.8 kg/m2
Initially descriptive statistics were calculated of all studied in males.
variables, including means and standard deviations of the Table 2 presents right and left HGS mean values by sex
estimator of the mean (traditionally named standard and age. Mean difference between sides is very low (1.5e
error). Regression analysis was employed in order to assess 2.5 kg in males and 0.9e1.6 kg in females). Overall, HGS
the relationship between age and nutritional status and of both sides tended to increase slowly with age, in the
HGS. It was tested whether the regression coefficients (b, 20e39 year-age-category, and to significantly decrease
defined as the vector of population regression coefficients)
were significantly different from 0 (main effects). For mul- 55
tiple comparisons the underweight and the 20e29 year-old *
Right hand grip strength (kg)

50 Underweight
* Normal
groups were used as reference. Finally, the percentile HGS 45 * * Overweight **
distribution stratified by sex and age categories was 40 *
35 **
30
Table 1 Summary of main variables of adults from 25
20
Niteroi, Rio de Janeiro, Brazil
15
Males Females 10
n Mean SE n mean SE 5
0
Age (years) 1122 43.1 0.53 1928 45.5 0.57 20-29 30-39 40-49 50-59 60-69 70 All ages
Stature (cm) 1120 171.8 0.29 1920 158.2 0.24 Age categories (years)
Body mass (kg) 1113 75.4 0.59 1917 63.3 0.46
BMI (kg/m2) 1111 25.5 0.16 1909 25.3 0.17 Figure 1 Mean right handgrip strength (kg) by nutritional
RHGS (kg) 1122 42.8 0.35 1928 25.3 0.28 status of adult males from Niteroi, Rio de Janeiro, Brazil.
LHGS (kg) 1122 40.9 0.31 1928 24.0 0.26 The asterix represents statistically significant difference from
underweight (p < 0.05). Underweight Z Body mass index
BMI: body mass index; RHGS: right handgrip strength; LHGS:
(BMI) < 18.5 kg/m2, Normal Z 18.5  BMI < 25 kg/m2, Over-
Left handgrip strength; SE: standard error.
weight Z BMI  25 kg/m2.
604 M.M. Schlussel et al.

55 underweight and normal male subjects is higher than the

one observed between normal and overweight subjects in
Right hand grip strength (kg)
50 Under weight
Normal
45
Overweight almost all age categories.
40 Table 3 presents selected percentiles of right and left
35 HGS for the adult male and female population. It is notice-
30
*
* able that the drop in HGS with age is greatest in the highest
25 ** decile, especially in males.
20 Figure 3 presents the different normative HGS (right
15 hand) mean values from the literature in comparison to
10
the values found for the adult male population of Niteroi.
5
It is evident that the values from the present study are
0
20-29 30-39 40-49 50-59 60-69 70 All ages clearly lower in all age categories except for the oldest
Age categories (years) male group in comparison to most studies.

Figure 2 Mean right handgrip strength (kg) by nutritional sta-

tus of adult females from Niteroi, Rio de Janeiro, Brazil. The
asterix represents statistically significant difference from un-
derweight (p < 0.05). Underweight Z Body mass index
(BMI) < 18.5 kg/m2, Normal Z 18.5  BMI < 25 kg/m2, Over-
weight Z BMI  25 kg/m2.
after 50 years of age for women and 40 years of age for men
(p < 0.0001).
In males, there was a clear tendency of increasing right
HGS with increasing BMI at each age category (Fig. 1) but
not as quite in females (Fig. 2). Overall, the difference be-
tween right HGS of underweight and overweight males was
significant (b Z 7.2, 95% CI 1.9e12.5; p Z 0.001) and var-
ied from 4.4 to 12.6 kg (mean 8.1 kg) according to the age
categories. These values were much lower in females
(1.5e5.2 kg, mean 3.2 kg) and it was not significant
(b Z 0.98, 95% CI 1.3e3.3; p Z 0.40) for all ages com-
bined. When BMI was used as continuous variable in the re-
gression the model was significant for both males
(b Z 0.22, 95% CI 0.36e3.2; p Z 0.0002) and females
(b Z 0.09, 95% CI 0.17e2.3; p Z 0.02). It is interesting to
notice that the difference in right HGS mean value between
Discussion
HGS is a non-invasive, simple, rapid, objective and in-
expensive procedure12 that can be used in clinical and ep-
idemiological studies. It has been recognized as a useful
tool in assessing muscle function and therefore the nutri-
tional status of the population at large and hospitalized pa-
tients in particular. This is due, in part, to the possibility of
early detection of function impairment in individuals who
present normal anthropometric values. However, the major
drawback to its full application as a nutritional assessment
tool is the lack of agreement about a cut-off point that
defines malnourishment or normality.
Despite the fact that there is no definition about an
optimal cut-off point based on solid theory concepts, the
utility of HGS as an auxiliary procedure to assess the
nutritional status in clinical practice is evident. Klidjian
et al.11 used the value equal to 85% of HGS mean values ob-
served in a healthy sample as the cut-off point to identify
the patients under risk of complications in the post surgical
period. Although its non physiologic rationale this cut-
off point was very useful and the authors concluded that
HGS was the most sensitive test to predict complications

Table 3 Selected percentiles (P) of right and left handgrip strength (kg) stratified by age categories in male and female adults
from Niteroi, Rio de Janeiro, Brazil
Age category (years) Handgrip strength (kg)
Right hand Left hand
P10 P30 P50 P70 P90 P10 P30 P50 P70 P90
Males
20e29 33.9 41.3 45.1 50.6 56.3 34.0 39.4 43.6 47.8 53.7
30e39 36.6 42.2 45.8 50.0 56.9 34.7 40.4 44.1 48.3 53.5
40e49 34.3 37.5 42.5 46.7 53.6 32.4 37.1 40.9 45.3 50.9
50e59 30.2 36.2 41.4 44.3 50.1 29.6 35.0 38.9 42.8 48.3
60e69 26.5 32.9 37.0 40.8 45.5 26.4 30.8 34.4 37.5 41.9
70 22.8 27.7 32.1 35.7 40.6 21.0 26.6 28.9 31.3 36.6
Females
20e29 19.5 23.8 27.4 30.0 34.0 18.6 22.3 25.8 28.4 31.8
30e39 20.7 25.0 27.6 30.7 35.0 20.1 23.5 26.4 29.3 32.9
40e49 19.8 24.4 26.9 29.4 33.6 18.4 22.9 25.7 28.1 31.7
50e59 16.6 21.1 24.3 26.4 30.9 15.4 19.9 23.0 25.3 29.8
60e69 16.6 19.6 21.7 24.6 27.5 15.0 18.2 20.5 22.8 27.1
70 9.9 13.7 16.8 20.0 23.8 9.0 13.0 16.0 19.2 22.6
P Z percentile.
Reference values of handgrip strength
60
Male right handgrip strengrh (kg)
55
50
45
40 Mathiowetz et al. (1985)
Hrknen et al. (1993)
Caporrino et al. (1998)
35
Hanten et al. (1999)
30 Luna-Heredia et al. (2005)
Present study
25
20-29 30-39 40-49 50-59
Age category (years)
Figure 3 Comparison between strongest (dominant or right)
handgrip (kg) of males from different normative studies.
in surgical patients. This led other researchers to adopt
these procedures.12e15,20
Even though the distribution of a given measure for
a specific population does not necessarily mean the health
state of the population39 it is reasonable to assume that
HGS values in the lower end of the distribution, without
other factor influencing the subjects muscular perfor-
mance, may be indicative of some functional loss. Indeed,
a recent study carried out by Matos et al.9 showed that
patients who presented HGS values in the lowest quartiles
of the sample distribution at admission had increased risk
of being nutritionally-at-risk. This risk improvement was
noted among all quartiles and stronger as HGS decreases
(p for trend <0.001). Therefore, it is important to generate
distribution of HGS values obtained from large, preferably
population-based, samples as the first step to better under-
stand the pattern of this variable and to establish reliable
comparisons between different populations.
To our knowledge, only one study investigated HGS in
a population-based sample. The objective of that study was
to describe the relation between HGS and age and the
authors used longitudinal data from three national surveys
in the Danish population aged 46e102 years.38 Almost all
studies that propose reference values for HGS used small
and convenient samples which may not be representative
of the original populations from where the samples were
extracted.23e26,36,37,40 This might be one of the explana-
tions for the differences observed between the values of
the adult population of Niteroi in the present study and pre-
vious published data.
Force generation depends on the motivation of the
subjects. In population-based studies, particularly in
household surveys, the subjects may not realize the exact
importance of this premise and they may perform sub-
maximal efforts in their trials. On the other hand,
convenient samples, comprised of hospital staff or med-
ical students, as found in many studies, may be composed
of a more homogeneous group of subjects than the
general population with all kinds of socioeconomic and
life styles.
Force is a function of the transversal area of the
muscular group in focus and the protocol used. For
example, it has been noticed that a full extension of the
arm allow individuals to produce greater values of HGS than
605
the ones generated with the elbow at 90 of flexion.34
Besides, HGS has been found to be higher at the standing
position.34,41 Furthermore, HGS values depend on many
other factors such as the model of dynamometer in use, in-
adequate calibration of the instruments, sample character-
istics (physical activity level, occupation of the subjects),
and probably ethnical differences.42 As this information is
not always available it becomes difficult to make more ac-
curate comparisons. Comparatively to the only other study
with a Brazilian sample, the mean values were practically
the same for all age categories.
60-69 70 Leyk et al.40 have recently shown that HGS strength was
linearly correlated with lean body mass (R2 Z 0.765) in
a large sample of 20e25-year-old men and women in Ger-
many. In the absence of more objective measurements of
body composition, BMI is frequently used in the nutritional
assessment of adults in population-based studies.43 The
medical literature documents a weak, but generally signif-
icant, correlation between BMI and HGS26,44,45 which in part
can be explained by the inability of BMI to differentiate
lean from fat mass. Nevertheless, BMI was related to HGS
in the adult (male and female) population of Niteroi simi-
larly to what has been recently described in a large sample
of adults from Teruel, Spain.46 Vaz et al.10 have shown that
subjects with underweight (BMI < 18.5 kg/m2) had signifi-
cantly lower HGS values than those with higher BMI which
was also observed in the male population of Niteroi. This
relationship was not significant in the female population
of Niteroi perhaps due to the lower prevalence of under-
weight in this population.
Similarly to all studies in the literature, males presented
higher HGS mean values than females for both hands and
over all age categories. Right and left HGS mean values, for
males, were significantly different among all age categories
after the 40 year-old category (p < 0,001). The curvilinear
relation between age and HGS is also very well-documented
in the literature23,25,26,37,38,42,47 and it was also observed in
the adult population of Niteroi.
Clinicians should always be aware of the possibility that
the differences in the assessment protocol may signifi-
cantly affect the comparisons with references. Therefore,
it is very important to choose the correct reference to
compare the results of an evaluation of HGS. The present
study found important differences in HGS across popula-
tions from different countries or ethnical origins and the
difference might be due to the sampling characteristics of
the studies.
Contributors
L.A. Anjos and M.T.L. Vasconcellos planned the research.
M.T.L. Vasconcellos designed the sample and calculated the
natural and calibrated sampling weights. L.A. Anjos and
M.M. Schlussel supervised the field data collection and were
in charge of data analyses. M.M. Schlussel and G. Kac wrote
the first draft of the paper, which was revised and approved
by the other authors.
Conflict of interest statement
None declared.
606
Acknowledgements
The Nutrition, Physical Activity, and Health Survey was
partially funded by the Brazilian National Research Council
(CNPq; grants 471172/2001-4 and 475122/2003-8) and by
the Oswaldo Cruz Foundation (PAPES III e Program to
Support Strategic Projects in Health, no. 250.139). L.A.
Anjos received a research productivity grant from CNPq
(no. 301076/89-8). M.T.L. Vasconcellos received a research
productivity grant from CNPq (no. 302992/2003-0). G. Kac
received a research productivity grant from CNPq (no.
306523/2006-0).
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