Research Article| Volume 58, ISSUE 6, P757-765, June 2020

Grip Strength Cut Points for Diabetes Risk Among Apparently Healthy U.S. Adults


      Early detection screening tools are needed to aid in preventing vascular complications associated with type 2 diabetes. As low muscular strength is linked to increased diabetes risk, the purpose of this study is to establish muscular strength cut points for determining diabetes risk using a large, nationally representative U.S. sample.


      Using the 2011–2012 and 2013–2014 National Health and Nutrition Examination Survey data, 5,108 participants aged 20–80 years (68.6% aged 20–50 years; young male participants, n=1,813, mean age=33.43 years; young female participants, n=1,692, mean age=33.39 years; older male participants, n=813, mean age=59.92 years; older female participants, n=790, mean age=60.45 years) and free of common diabetes comorbidities were included. Muscular strength was assessed using a handgrip dynamometer and normalized by adjusting for body weight. A logistic regression for survey data controlling for covariates was used to determine normalized grip strength cut points. Diabetes risk was determined using American Diabetes Association diagnostic criteria. Analyses were conducted in the summer of 2019.


      Normalized grip strength significantly predicted diabetes (p=0.0332), and the cut points for detecting diabetes risk included 0.78 (young male participants), 0.57 (young female participants), 0.68 (older male participants), and 0.49 (older female participants). The risk percentages for diabetes and estimated rates reported for all subgroups were comparable, and the risk percentages included 6.84 (95% CI=5.32, 8.36; younger male participants), 7.49 (95% CI=5.87, 9.10; younger female participants), 5.76 (95% CI=2.34, 9.19, older male participants), and 4.27 (95% CI=2.44, 6.10; older female participants).


      Normalized grip strength using the cut points proposed in this paper may be a useful screening tool for diabetes risk in apparently healthy, normotensive adults.
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        • Bertoni AG
        • Krop JS
        • Anderson GF
        • Brancati FL
        Diabetes-related morbidity and mortality in a national sample of U.S. elders.
        Diabetes Care. 2002; 25: 471-475
        • Garcia MJ
        • McNamara PM
        • Gordon T
        • Kannel WB
        Morbidity and mortality in diabetics in the Framingham population. Sixteen year follow-up study.
        Diabetes. 1974; 23: 105-111
        • Dall TM
        • Yang W
        • Gillespie K
        • et al.
        The economic burden of elevated blood glucose levels in 2017: diagnosed and undiagnosed diabetes, gestational diabetes mellitus, and prediabetes.
        Diabetes Care. 2019; 42: 1661-1668
        • Liew G
        • Michaelides M
        • Bunce C
        A comparison of the causes of blindness certifications in England and Wales in working age adults (16-64 years), 1999-2000 with 2009-2010.
        BMJ Open. 2014; 4e004015
        • Marshall SM
        • Flyvbjerg A.
        Prevention and early detection of vascular complications of diabetes.
        BMJ. 2006; 333: 475-480
        • Katzmarzyk PT
        • Craig CL
        • Gauvin L
        Adiposity, physical fitness and incident diabetes: the physical activity longitudinal study.
        Diabetologia. 2007; 50: 538-544
        • Lynch J
        • Helmrich SP
        • Lakka TA
        • et al.
        Moderately intense physical activities and high levels of cardiorespiratory fitness reduce the risk of non-insulin-dependent diabetes mellitus in middle-aged men.
        Arch Intern Med. 1996; 156: 1307-1314
        • Wei M
        • Gibbons LW
        • Mitchell TL
        • Kampert JB
        • Lee CD
        • Blair SN
        The association between cardiorespiratory fitness and impaired fasting glucose and type 2 diabetes mellitus in men.
        Ann Intern Med. 1999; 130: 89-96
        • Mays RJ
        • Boér NF
        • Mealey LM
        • Kim KH
        • Goss FL
        A comparison of practical assessment methods to determine treadmill, cycle, and elliptical ergometer VO2 peak.
        J Strength Cond Res. 2010; 24: 1325-1331
        • Artero EG
        • Lee DC
        • Lavie CJ
        • et al.
        Effects of muscular strength on cardiovascular risk factors and prognosis.
        J Cardiopulm Rehabil Prev. 2012; 32: 351-358
        • Lee WJ
        • Peng LN
        • Chiou ST
        • Chen LK
        Relative handgrip strength is a simple indicator of cardiometabolic risk among middle-aged and older people: a nationwide population-based study in Taiwan.
        PLoS One. 2016; 11e0160876
        • Park SW
        • Goodpaster BH
        • Strotmeyer ES
        • et al.
        Decreased muscle strength and quality in older adults with type 2 diabetes: the health, aging, and body composition study.
        Diabetes. 2006; 55: 1813-1818
        • Li JJ
        • Wittert GA
        • Vincent A
        • et al.
        Muscle grip strength predicts incident type 2 diabetes: population-based cohort study.
        Metabolism. 2016; 65: 883-892
        • Leong DP
        • Teo KK
        • Rangarajan S
        • et al.
        Prognostic value of grip strength: findings from the Prospective Urban Rural Epidemiology (PURE) study.
        Lancet. 2015; 386: 266-273
        • Lawman HG
        • Troiano RP
        • Perna FM
        • Wang CY
        • Fryar CD
        • Ogden CL
        Associations of relative handgrip strength and cardiovascular disease biomarkers in U.S. adults, 2011-2012.
        Am J Prev Med. 2016; 50: 677-683
        • Peterson MD
        • Saltarelli WA
        • Visich PS
        • Gordon PM
        Strength capacity and cardiometabolic risk clustering in adolescents.
        Pediatrics. 2014; 133: e896-e903
        • Richards L
        • Palmiter-Thomas P
        Grip strength measurement: a critical review of tools, methods, and clinical utility.
        Crit Rev Phys Rehabil Med. 1996; 8: 87-109
        • Auyeung TW
        • Lee JS
        • Leung J
        • Kwok T
        • Woo J
        The selection of a screening test for frailty identification in community-dwelling older adults.
        J Nutr Health Aging. 2014; 18: 199-203
        • McGrath RP
        • Vincent BM
        • Snih SA
        • et al.
        The association between handgrip strength and diabetes on activities of daily living disability in older Mexican Americans.
        J Aging Health. 2018; 30: 1305-1318
        • Garcia-Hermoso A
        • Tordecilla-Sanders A
        • Correa-Bautista JE
        • et al.
        Muscle strength cut-offs for the detection of metabolic syndrome in a nonrepresentative sample of collegiate students from Colombia.
        J Sport Health Sci. In press. Online September 11, 2018;
        • Peterson MD
        • Zhang P
        • Choksi P
        • Markides KS
        • Al Snih S
        Muscle weakness thresholds for prediction of diabetes in adults.
        Sports Med. 2016; 46: 619-628
        • Sénéchal M
        • McGavock JM
        • Church TS
        • et al.
        Cut points of muscle strength associated with metabolic syndrome in men.
        Med Sci Sports Exerc. 2014; 46: 1475-1481
        • Peterson MD
        • McGrath R
        • Zhang P
        • Markides KS
        • Al Snih SA
        • Wong R
        Muscle weakness is associated with diabetes in older Mexicans: the Mexican Health and Aging Study.
        J Am Med Dir Assoc. 2016; 17: 933-938
        • Johnson CL
        • Dohrmann SM
        • Burt VL
        • Mohadjer LK
        National Health and Nutrition Examination Survey: sample design, 2011-2014.
        Vital Health Stat. 2014; 162: 1-33
      1. National Health and Nutrition Examination Survey: questionnaires, datasets, and related documentation. Centers for Disease Control and Prevention. Updated 2018. Accessed January 21, 2020.

      2. National Health and Nutrition Examination Survey: muscular strength procedures manual.
        Centers for Disease Control and Prevention, Published 2013
      3. National Health and Nutrition Examination Survey: anthropometry procedures manual.
        Centers for Disease Control and Prevention, Published 2013
      4. National Health and Nutrition Examination Survey: mobile examination center laboratory procedures manual.
        Centers for Disease Control and Prevention, Published 2013
        • Robbins JM
        • Vaccarino V
        • Zhang H
        • Kasl SV
        Socioeconomic status and diagnosed diabetes incidence.
        Diabetes Res Clin Pract. 2005; 68: 230-236
      5. Liguori G ACSM's Health-Related Physical Fitness Assessment Manual. 5th ed. Wolters Kluwer, Philadelphia, PA2018
        • American Diabetes Association
        2. Classification and diagnosis of diabetes: standards of medical care in diabetes-2018.
        Diabetes Care. 2018; 41: S13-S27
        • Peterson MD
        • Zhang P
        • Saltarelli WA
        • Visich PS
        • Gordon PM
        Low muscle strength thresholds for the detection of cardiometabolic risk in adolescents.
        Am J Prev Med. 2016; 50: 593-599
        • Mainous 3rd, AG
        • Tanner RJ
        • Anton SD
        • Jo A
        Low grip strength and prediabetes in normal-weight adults.
        J Am Board Fam Med. 2016; 29: 280-282
        • Srikanthan P
        • Karlamangla AS
        Relative muscle mass is inversely associated with insulin resistance and prediabetes: findings from the third National Health and Nutrition Examination Survey.
        J Clin Endocrinol Metab. 2011; 96: 2898-2903
        • Abe T
        • Kearns CF
        • Fukunaga T
        Sex differences in whole body skeletal muscle mass measured by magnetic resonance imaging and its distribution in young Japanese adults.
        Br J Sports Med. 2003; 37: 436-440
        • Young A
        • Stokes M
        • Crowe M
        Size and strength of the quadriceps muscles of old and young women.
        Eur J Clin Invest. 1984; 14: 282-287
        • Kalyani RR
        • Saudek CD
        • Brancati FL
        • Selvin E
        Association of diabetes, comorbidities, and A1C with functional disability in older adults: results from the National Health and Nutrition Examination Survey (NHANES), 1999-2006.
        Diabetes Care. 2010; 33: 1055-1060
        • Leenders M
        • Verdijk LB
        • van der Hoeven L
        • et al.
        Patients with type 2 diabetes show a greater decline in muscle mass, muscle strength, and functional capacity with aging.
        J Am Med Dir Assoc. 2013; 14: 585-592
        • Kalyani RR
        • Metter EJ
        • Egan J
        • Golden SH
        • Ferrucci L
        Hyperglycemia predicts persistently lower muscle strength with aging.
        Diabetes Care. 2015; 38: 82-90
        • Kelley DE
        • He J
        • Menshikova EV
        • Ritov VB
        Dysfunction of mitochondria in human skeletal muscle in type 2 diabetes.
        Diabetes. 2002; 51: 2944-2950
        • Wang X
        • Hu Z
        • Hu J
        • Du J
        • Mitch WE
        Insulin resistance accelerates muscle protein degradation: activation of the ubiquitin-proteasome pathway by defects in muscle cell signaling.
        Endocrinology. 2006; 147: 4160-4168
        • Rasmussen BB
        • Fujita S
        • Wolfe RR
        • et al.
        Insulin resistance of muscle protein metabolism in aging.
        FASEB J. 2006; 20: 768-769
        • Norris SL
        • Kansagara D
        • Bougatsos C
        • Fu R
        U.S. Preventive Services Task Force. Screening adults for type 2 diabetes: a review of the evidence for the U.S. Preventive Services Task Force.
        Ann Intern Med. 2008; 148: 855-868
        • American Diabetes Association
        Executive summary: standards of medical care in diabetes–2012.
        Diabetes Care. 2012; 35: S4-S10
        • Souissi N
        • Gauthier A
        • Sesboüé B
        • Larue J
        • Davenne D
        Effects of regular training at the same time of day on diurnal fluctuations in muscular performance.
        J Sports Sci. 2002; 20: 929-937