Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Article
  • Published:

Beyond body mass index: the role of muscle strength in reducing mortality risk in older adults with severe obesity – multi-country cohort study

European Journal of Clinical Nutrition volume 79, pages 787–792 (2025)Cite this article

Subjects

Abstract

Background/Objective

Since muscle strength is modifiable and handgrip strength is a reliable biomarker for strength and mortality, exploring its association with mortality in individuals with severe obesity could help identify protective thresholds. We aimed to examine the dose-response association between handgrip strength and mortality in adults with severe obesity.

Subjects/Methods

We retrieved data from the Survey of Health, Ageing and Retirement in Europe (SHARE). Handgrip strength was measured in participants with a body mass index (BMI) higher than 40 kg/m2. We used time-varying Cox proportional hazards regression to assess the association between handgrip strength and all-cause mortality risk. To account for potential non-linearity, we employed restricted cubic splines. We examined a total of 2229 adults (67.9% women; BMI of 43.8 kg/m2).

Results

We found an association between handgrip strength and mortality, showing a minimal and optimal dose for a reduced risk with 31 kg (HR 0.97, 95% CI, 0.96–0.99) and 36 kg (HR 0.90, 95% CI, 0.81–0.99), respectively. Additional sex-stratified analysis showed that lower than median levels of handgrip strength were gradually associated with increased risk in both men and women.

Conclusions

The association between handgrip strength and all-cause mortality in European adults with severe obesity highlights practical thresholds for risk reduction, with 31 kg as the minimum and 36 kg as the optimal strength level. In both men and women, handgrip strength below the median was linked to a gradual increase in mortality risk, emphasizing the importance of maintaining adequate muscle strength to improve health outcomes.

Access through your institution
Buy or subscribe

This is a preview of subscription content, access via your institution

Access options

Access through your institution

Buy this article

  • Purchase on SpringerLink
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Fig. 1
Fig. 2: Dose-response association (Adjusted hazard ratios and associated 95% confidence interval band) between handgrip strength (Kg) and all-cause mortality.
Fig. 3: Dose-response association (Adjusted hazard ratios and associated 95% confidence interval band) between handgrip strength (Kg) and all-cause mortality in men.
Fig. 4: Dose-response association (Adjusted hazard ratios and associated 95% confidence interval band) between handgrip strength (Kg) and all-cause mortality in women.

Similar content being viewed by others

Data availability

Data described in the manuscript can be accessed through an application to the SHARE database. Code book and analytic code will be made publicly and freely available upon reasonable request to the corresponding author.

References

  1. Bray GA, Heisel WE, Afshin A, Jensen MD, Dietz WH, Long M, et al. The science of obesity management: an endocrine society scientific statement. Endocr Rev. 2018;39:79–132.

    Article  PubMed  PubMed Central  Google Scholar 

  2. NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in underweight and obesity from 1990 to 2022: a pooled analysis of 3663 population-representative studies with 222 million children, adolescents, and adults. Lancet Lond Engl. 2024;403:1027–50.

    Article  Google Scholar 

  3. Xu H, Cupples LA, Stokes A, Liu CT. Association of obesity with mortality over 24 years of weight history: findings from the Framingham Heart Study. JAMA Netw Open. 2018;1:e184587.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Mokdad AH, Ford ES, Bowman BA, Dietz WH, Vinicor F, Bales VS, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA. 2003;289:76–9.

    Article  PubMed  Google Scholar 

  5. Prado CMM, Wells JCK, Smith SR, Stephan BCM, Siervo M. Sarcopenic obesity: a Critical appraisal of the current evidence. Clin Nutr Edinb Scotl. 2012;31:583–601.

    CAS  Google Scholar 

  6. Carbone S, Billingsley HE, Rodriguez-Miguelez P, Kirkman DL, Garten R, Lee Franco R, et al. Lean mass abnormalities in heart failure: the role of sarcopenia, sarcopenic obesity, and cachexia. Curr Probl Cardiol. 2020;45:100417.

    Article  PubMed  Google Scholar 

  7. Carbone S, Lavie CJ, Arena R. Obesity and heart failure: focus on the obesity paradox. Mayo Clin Proc. 2017;92:266–79.

    Article  PubMed  Google Scholar 

  8. Ventura HO, Carbone S, Lavie CJ. Muscling up to improve heart failure prognosis. Eur J Heart Fail. 2018;20:1588–90.

    Article  PubMed  Google Scholar 

  9. Upadhya B, Haykowsky MJ, Eggebeen J, Kitzman DW. Sarcopenic obesity and the pathogenesis of exercise intolerance in heart failure with preserved ejection fraction. Curr Heart Fail Rep. 2015;12:205–14.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  10. Emami A, Saitoh M, Valentova M, Sandek A, Evertz R, Ebner N, et al. Comparison of sarcopenia and cachexia in men with chronic heart failure: results from the Studies Investigating Co-morbidities Aggravating Heart Failure (SICA-HF). Eur J Heart Fail. 2018;20:1580–7.

    Article  PubMed  CAS  Google Scholar 

  11. Williams PT. Dose-response relationship of physical activity to premature and total all-cause and cardiovascular disease mortality in walkers. PLoS ONE. 2013;8:e78777.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Manson JE, Greenland P, LaCroix AZ, Stefanick ML, Mouton CP, Oberman A, et al. Walking compared with vigorous exercise for the prevention of cardiovascular events in women. N Engl J Med. 2002;347:716–25.

    Article  PubMed  Google Scholar 

  13. Armstrong MEG, Green J, Reeves GK, Beral V, Cairns BJ, Million Women Study Collaborators. Frequent physical activity may not reduce vascular disease risk as much as moderate activity: large prospective study of women in the United Kingdom. Circulation. 2015;131:721–9.

    Article  PubMed  CAS  Google Scholar 

  14. Koolhaas CM, Dhana K, Schoufour JD, Ikram MA, Kavousi M, Franco OH. Impact of physical activity on the association of overweight and obesity with cardiovascular disease: the Rotterdam Study. Eur J Prev Cardiol. 2017;24:934–41.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Fogelholm M. Physical activity, fitness and fatness: relations to mortality, morbidity and disease risk factors. A systematic review. Obes Rev J Int Assoc Study Obes. 2010;11:202–21.

    Article  CAS  Google Scholar 

  16. Tomlinson DJ, Erskine RM, Morse CI, Winwood K, Onambélé-Pearson G. The impact of obesity on skeletal muscle strength and structure through adolescence to old age. Biogerontology. 2016;17:467–83.

    Article  PubMed  CAS  Google Scholar 

  17. ten Hoor GA, Plasqui G, Schols AMWJ, Kok G. A benefit of being heavier is being strong: a cross-sectional study in young adults. Sports Med Open. 2018;4:12.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Bohannon RW. Grip strength: an indispensable biomarker for older adults. Clin Inter Aging. 2019;14:1681–91.

    Article  CAS  Google Scholar 

  19. López-Bueno R, Andersen LL, Koyanagi A, Núñez-Cortés R, Calatayud J, Casaña J, et al. Thresholds of handgrip strength for all-cause, cancer, and cardiovascular mortality: a systematic review with dose-response meta-analysis. Ageing Res Rev. 2022;82:101778.

    Article  PubMed  Google Scholar 

  20. Bhaskaran K, dos-Santos-Silva I, Leon DA, Douglas IJ, Smeeth L. Association of BMI with overall and cause-specific mortality: a population-based cohort study of 3·6 million adults in the UK. Lancet Diabetes Endocrinol. 2018;6:944–53.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Bauer S, Reiter L, Weijs PJM, Schoufour JD, Boirie Y, Topinková E, et al. Adherence to resistance training and hypocaloric diet among persons near retirement age — a secondary data analysis of three randomized controlled trials. J Nutr Health Aging. 2024;28:100344.

    Article  PubMed  CAS  Google Scholar 

  22. Bergmann M, Wagner M, Börsch-Supan A. SHARE Wave 9 methodology: from the SHARE Corona Survey 2 to the SHARE Main Wave 9 Interview [Internet]. 2024. https://share-eric.eu/fileadmin/user_upload/Methodology_Volumes/SHARE_Methodenband_WEB_Wave9.pdf

  23. Börsch-Supan A, Brandt M, Hunkler C, Kneip T, Korbmacher J, Malter F, et al. Data resource profile: the survey of health, ageing and retirement in Europe (SHARE). Int J Epidemiol. 2013;42:992–1001.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Andersen LL, Calatayud J, Núñez-Cortés R, Polo-López A, López-Bueno R. Facilitators and barriers for working beyond statutory pension age: A prospective cohort study across 26 European countries. Scand J Work Environ Health. 2024. https://doi.org/10.5271/sjweh.4189

  25. López-Bueno R, Andersen LL, Calatayud J, Casaña J, Grabovac I, Oberndorfer M, et al. Associations of handgrip strength with all-cause and cancer mortality in older adults: a prospective cohort study in 28 countries. Age Ageing. 2022;51:afac117.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Flegal KM, Kit BK, Orpana H, Graubard BI. Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. JAMA. 2013;309:71–82.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  27. Hu G, Tuomilehto J, Silventoinen K, Barengo N, Jousilahti P. Joint effects of physical activity, body mass index, waist circumference and waist-to-hip ratio with the risk of cardiovascular disease among middle-aged Finnish men and women. Eur Heart J. 2004;25:2212–9.

    Article  PubMed  Google Scholar 

  28. Qi KJ, Li Q, Lu GL, Zhang MJ, Zhang MZ, Yan JM, et al. The combined effect of handgrip strength and obesity phenotype on the risk of stroke in Chinese middle-aged and elderly: A cohort study. Arch Gerontol Geriatr. 2024;124:105481.

    Article  PubMed  Google Scholar 

  29. Wei L, Wang B, Wang Y. Low handgrip strength with asymmetry is associated with elevated all-cause mortality risk in older Chinese adults with abdominal obesity. PLoS ONE. 2024;19:e0306982.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  30. da Silva Alexandre T, Scholes S, Ferreira Santos JL, de Oliveira Duarte YA, de Oliveira C. Dynapenic abdominal obesity increases mortality risk among English and Brazilian older adults: a 10-year follow-up of the ELSA and SABE studies. J Nutr Health Aging. 2018;22:138–44.

    Article  PubMed  Google Scholar 

  31. He N, Zhang Y, Zhang L, Zhang S, Ye H. Relationship between sarcopenia and cardiovascular diseases in the elderly: an overview. Front Cardiovasc Med. 2021;8:743710.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  32. Sacheck JM, Kuder JF, Economos CD. Physical fitness, adiposity, and metabolic risk factors in young college students. Med Sci Sports Exerc. 2010;42:1039–44.

    Article  PubMed  CAS  Google Scholar 

  33. Garcia-Hermoso A, Tordecilla-Sanders A, Correa-Bautista JE, Peterson MD, Izquierdo M, Prieto-Benavides D, et al. Handgrip strength attenuates the adverse effects of overweight on cardiometabolic risk factors among collegiate students but not in individuals with higher fat levels. Sci Rep. 2019;9:6986.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Aadahl M, Beyer N, Linneberg A, Thuesen BH, Jørgensen T. Grip strength and lower limb extension power in 19-72-year-old Danish men and women: the Health2006 study. BMJ Open. 2011;1:e000192.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Kuh D, Bassey EJ, Butterworth S, Hardy R, Wadsworth MEJ, Musculoskeletal Study Team. Grip strength, postural control, and functional leg power in a representative cohort of British men and women: associations with physical activity, health status, and socioeconomic conditions. J Gerontol A Biol Sci Med Sci. 2005;60:224–31.

    Article  PubMed  Google Scholar 

  36. Benito PJ, López-Plaza B, Bermejo LM, Peinado AB, Cupeiro R, Butragueño J, et al. Strength plus endurance training and individualized diet reduce fat mass in overweight subjects: a randomized clinical trial. Int J Environ Res Public Health. 2020;17:2596.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  37. Cabanas-Sánchez V, Duarte Junior MA, Lavie CJ, Celis-Morales C, Rodríguez-Artalejo F, Martínez-Gómez D. Physical activity and cause-specific cardiovascular mortality among people with and without cardiovascular disease: a cohort study of 0.6 million US adults. Mayo Clin Proc. 2024;99:564–77.

    Article  PubMed  Google Scholar 

  38. Martinez-Gomez D, Rodriguez-Artalejo F, Ding D, Ekelund U, Cabanas-Sanchez V. Trends in the association between meeting the physical activity guidelines and risk of mortality in US adults. Prog Cardiovasc Dis. 2024;83:116–23.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

We acknowledge the participants for their contribution.

Author information

Authors and Affiliations

  1. Department of Physiotherapy, University of Valencia, Valencia, Spain

    Andrea Tur-Boned

  2. National Research Centre for the Working Environment, Copenhagen, Denmark

    Lars Louis Andersen

  3. Department of Physical Medicine and Nursing, University of Zaragoza, Zaragoza, Spain

    Rubén López-Bueno

  4. Department of Physical Therapy, Faculty of Medicine, University of Chile, Santiago, Chile

    Rodrigo Núñez-Cortés & Carlos Cruz-Montecinos

  5. Exercise Intervention for Health Research Group (EXINH-RG), Department of Physiotherapy, University of Valencia, Valencia, Spain

    Luis Suso-Martí, Ana Polo-López & Joaquín Calatayud

Authors
  1. Andrea Tur-Boned
    View author publications

    Search author on:PubMed Google Scholar

  2. Lars Louis Andersen
    View author publications

    Search author on:PubMed Google Scholar

  3. Rubén López-Bueno
    View author publications

    Search author on:PubMed Google Scholar

  4. Rodrigo Núñez-Cortés
    View author publications

    Search author on:PubMed Google Scholar

  5. Carlos Cruz-Montecinos
    View author publications

    Search author on:PubMed Google Scholar

  6. Luis Suso-Martí
    View author publications

    Search author on:PubMed Google Scholar

  7. Ana Polo-López
    View author publications

    Search author on:PubMed Google Scholar

  8. Joaquín Calatayud
    View author publications

    Search author on:PubMed Google Scholar

Contributions

ATB, JC, and LLA contributed to the study conception and design. Material preparation and data collection were performed by LLA. Data analysis was performed by LLA. The first draft of the manuscript was written by ATB, and all authors commented on previous versions of the manuscript. All the authors have read and approved the final manuscript.

Corresponding author

Correspondence to Rubén López-Bueno.

Ethics declarations

Competing interests

The authors declare no competing interests.

Ethical approval

The SHARE project, operating under the umbrella of the Max Planck Society since 2011, has had its research-ethical assessments reviewed and approved by the Ethics Council of the Max Planck Society, which carefully evaluated the project’s design and subprojects, including the SHARE Corona Survey and the collection of dried blood spots, ensuring compliance with ethical research principles.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Tur-Boned, A., Andersen, L.L., López-Bueno, R. et al. Beyond body mass index: the role of muscle strength in reducing mortality risk in older adults with severe obesity – multi-country cohort study. Eur J Clin Nutr 79, 787–792 (2025). https://doi.org/10.1038/s41430-025-01616-y

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue date:

  • DOI: https://doi.org/10.1038/s41430-025-01616-y

Search

Advanced search

Quick links