Association Between Anaemia and Handgrip Strength: A Systematic Review and Meta-Analysis

Abstract

Introduction

Methods

Results

Study Selection:

A total of 510 records were identified through electronic database searches. Following the removal of duplicates (n=60), 450 records were screened by title and abstract. Of these, 438 studies were excluded because they did not meet the eligibility criteria. The full texts of 12 studies were retrieved and assessed, all of which met the inclusion criteria. The study selection process is detailed in Figure 1. 

Study characteristics:

The review included 12 studies with 50,045 participants and sample sizes ranging from 118 to 24,022. Studies were conducted in Australia, Indonesia, Korea, and Singapore (two each) and Brazil, Germany, Saudi Arabia, and the United States (one each). Seven studies were cross-sectional, one was a population-based cohort, three used secondary data, and one was cross-sectional longitudinal. Three studies involved 2,102 participants aged ≥65 years, six included 4,938 participants aged ≥60 years, and one in Australia included 640 women aged 18–49 years. A longitudinal study in Australia involved 1,705 men aged ≥70 years, whereas two Korean studies included 24,022 participants aged ≥30 years and 16,638 aged >19 years.

Handgrip strength measurement:

Handgrip strength (HGS) was consistently measured via validated dynamometers, although the specific devices used varied. The JAMAR hydraulic dynamometer was employed in three studies, whereas the Smedley spring-type dynamometer was used in the study by Sutandyo et al.^[12] Four studies utilized a Takei A5401 digital dynamometer (Japan). One study used an electronic dynamometer (CAMRY EH101; Almari & Simbawa^[13]), and another used  SAEHAN SH5001 hydraulic device.^[14] Two studies did not specify the make or model of the device used. Definitions of low handgrip strength vary across studies. The most commonly applied cutoff was <28 kg for men and <18 kg for women, as seen in the studies by Sutandyo et al.^[12], C.-T. Lee et al.^[15], and Vanda Ho et al^[16]. Lower thresholds were also reported, including <27 kg (men) and <16 kg (women) by Almari & Simbawa^[13], <26 kg and <16 kg by Yu-mi Gi et al.^[11], and <26 kg (men) by Hirani et al.^[8] [Supplementary File 1, Table 1]

Table 1: Characteristics of the included studies

Author, Year	Country	Study design	Objective of the study	Sample size	Participants included	Anaemia Definition and estimation method	Dynamometer with HGS threshold
Thein M et al., 2009	USA	Cross sectional study	To evaluate the association of anaemia with health-related quality of life, functional status, depression, disability, and physical strength in older adults, independent of chronic disease.	328	≥ 65 years	WHO standards (anaemia if Hb <13 g/dL in men and <12 g/dL in women	Handheld Dynamometer (in kg)
Hidayat G  et al, 2011	Indonesia	Cross-sectional study	To determine whether anaemia is a risk factor for reduced muscle strength, measured by handgrip strength, in elderly nursing home residents.	118	≥60 years	Females: less than 12 gr/dl and males less than 13 gr/dl were categorized as anaemic	Dynamometer.
Hirani V et al, 2016	Australia	Cross- sectional Longitudinal	To assess the associations between haemoglobin levels and sarcopenia, muscle strength, functional measures, and ADL/IADL disabilities in older Australian men.	1705	Men ≥ 70 years	Absorption spectrophotometry, used for Hb. WHO criteria (anaemia If Hb level < 13 g/dL	JAMAR Dynamometer (Promedics, Blackburn, UK).  grip strength less than 26.0 kg versus grip strength 26.0 kg and more
Amaral C et al., 2020	Brazil	Cross-sectional study on secondary data	To examine factors associated with low handgrip strength in older adults in Rio Branco, Acre, Brazil.	1016	≥60 years	anaemia (haemoglobin ≤13 mg/dL in males, or ≤ 12 mg/dL in females)	SAEHAN SH5001 brand hydraulic hand Dynamometer
Yu-mi Gi et al, 2020	Korea	Cross-sectional study	To examine the association between handgrip strength and anaemia in Korean adults using data from the 6th and 7th KNHANES, addressing previous inconsistencies in the literature.	16,638	> 19 years	The haemoglobin levels were measured using the cyanide-free sodium lauryl sulphate method. WHO standards (Anaemia if Hb <13 g/dL in men and <12 g/dL in women)	Digital grip strength dynamometer (TKK 5401; Takei Scientific Instruments Co, Ltd, Tokyo, Japan) was used 26 kg for men, 16 kg for women is considered
C.-T. LEE et al, 2021	Singapore	Cross- sectional	To estimate the prevalence of anaemia in community-dwelling adults ≥65 years in Singapore and examine its association with cognitive function, physical function, and frailty.	480	≥ 65 years	Automated haematology analyser used for HB, WHO standards (Anaemia if Hb <1 g/dL in men and <12 g/dL in women; Hb level of >10 g/dL for mild,7–10 g/dL for moderate, and <7 g/dl for severe	Dynamometers (Takei A5401, Japan)  Low grip strength <28 kg for men and <18 kg for women
Vanda Ho, 2022	Singapore	Cross sectional on secondary data	To examine the association of handgrip strength (HGS) with iron indices and inflammation.	477	≥60 years	Not specified	hand dynamometers (Takei A5401, Japan) was used where Low muscle strength was defined as HGS < 28 kg for men and < 18 kg for women
Sutandyo N. et al, 2022	Indonesia	Cross-sectional study	To determine the prevalence of anaemia and its association with handgrip strength in Indonesian older adults, addressing gaps in data on anaemia in Southeast Asia using a large, multiprovince sample.	3192	≥60 years	HemoCue method used for HB estimation. WHO standards (Anaemia if Hb <13 g/dL in men and <12 g/dL in women)	Smedley Spring type dynamometer used Weak HGS = <28 kg for men and <18 kg for women
Lee B et al., 2023	Korea	Cross-sectional study on secondary data	To assess the association of anaemia with absolute and relative hand grip strength (HGS) and evaluate whether relative HGS indices are useful as risk markers compared to other cost-effective methods.	24,022	≥30 years	WHO standards (Anaemia if Hb <13 g/dL in men and <12 g/dL in women, less than 11.0 g/dL for pregnant women)	Digital grip strength dynamometer (T.K. K 5401, Japan)
Almari S & Simbawa M, 2024	Saudi Arabia	Cross-sectional study	To examine the correlation between handgrip strength (HGS) and nutritional status, and to evaluate whether HGS can predict nutritional status in hospitalized older adults in Saudi Arabia.	135	≥60 years	Not specified	Electronic handgrip dynamometer (CAMRY, Model 1 EH101) was used to measure HGS.   low grip = <16 kg for women and < 27 kg for men
Hammer T. et al., 2024	Germany	Cohort study	To analyse the association between haemoglobin and grip strength, accounting for ferritin as an indirect marker of iron storage, in community-dwelling older adults.	1294	≥ 65 years	Photometry, 4.4–11.3 Giga/L.	JAMAR
MacLean B et al, 2024	Australia	Cross Sectional study	To develop a non-invasive screening tool for iron deficiency in women aged 18–49 years and evaluate its acceptability in the community.	640	Woman of 18-49 age group	Hemocue Hb801 used for Hb estimation. Anaemia was defined as Hb < 120 g/L, a threshold of Hb < 130 g/L. ferritin <30 μg/L were classed as iron deficient	JAMAR Hydraulic Hand Dynamometer

Haemoglobin estimation:

Haemoglobin was estimated via a variety of validated laboratory methods across the included studies. Hammer et al.^[17] measured haemoglobin via photometry, reporting a reference range of 4.4–11.3 giga/L. Sutandyo et al.^[12] and MacLean et al.^[18] used HemoCue analysers, with the latter applying a threshold of <13 g/dL for defining anaemia. Among the twelve studies, eight adhered to the World Health Organization (WHO) criteria for defining anaemia, with cutoffs of <13 g/dL in men and <12 g/dL in women. The remaining studies employed either study-specific thresholds or additional biochemical markers, such as serum ferritin and transferrin saturation, to define anaemia status. 

Association between Handgrip Strength and Anaemia:

Across individual studies, HGS consistently decreased with anaemia, although effect sizes and levels of statistical significance varied. Among the 328 older adults in the US studied by Stauder and Thein^[19], participants with anaemia had significantly lower grip strength than did those without anaemia (21.3 vs. 24.1 kg, p=0.014) and reported greater fatigue, disability, and depressive symptoms. In an Indonesian study by Hidayat G et al.^[20], mild anaemia in women was associated with weaker grip strength (β=3.17, p=0.008). In Hirani V et al.^[8]’s study of Australian men aged 70 years and older, higher Hb levels were strongly associated with stronger grip strength, a reduced risk of sarcopenia, and better functional outcomes, with an adjusted β of 0.82 (95% CI 0.55–1.08) per g/dL increase. A Brazilian household survey of 1,016 older adults conducted by Amaral C et al.^[14] revealed that anaemia conferred more than a fourfold increase in the odds of weak grip in men (aOR 4.15, 95% CI 2.09–8.21) and nearly a twofold increase in women (aOR 1.80, 95% CI 1.06–3.06), independent of body mass index and other covariates. In the large Korean KNHANES dataset (n=16,638), anaemia was associated with weak handgrip strength (OR 1.92, 95% CI 1.58–2.33), with a stronger effect in men (OR 2.13, 95% CI 1.35–3.34) and in participants aged 65 years or older (OR 1.92, 95% CI 1.42–2.58).^[11] A Singaporean cohort of community-dwelling older adults (n=480) revealed that anaemia was significantly associated with frailty and lower grip strength; each 1 g/dL increase in haemoglobin was associated with a 6% reduction in the odds of frailty.^[15] Another Singaporean study, the HOPE cohort (n=477), demonstrated that higher haemoglobin, ferritin, and transferrin saturation were independently associated with greater grip strength, whereas elevated hsCRP was inversely associated with greater grip strength.^[16] An Indonesian multiprovince study of 3,192 older adults conducted by Sutandyo N. et al.^[12] revealed a positive correlation between haemoglobin and grip strength (r=0.35, p<0.001) and an increased risk of weak grip strength in those with anaemia (OR 1.56, 95% CI 1.31–1.85), with the strongest associations among individuals aged 80 years and older. Lee BJ et al^[10] reported that more than 24,000 Korean adults reported lower mean grip strength in anaemic participants than in their nonanemic counterparts, with adjusted odds ratios indicating a stronger effect in men than in women. A Saudi Arabian hospital-based study by Almari S & Simbawa M^[13] of 135 participants revealed that low haemoglobin and malnutrition were independent predictors of reduced grip strength. A German cohort study (n=1,294) by Hammer T. et al.^[14] demonstrated that the association between haemoglobin and grip strength was evident in women younger than 80 years and in men with ferritin concentrations ≥300 μg/L but absent in those over 80 years. MacLean B et al.^[18] studied Australian reproductive-aged women (n=640) and confirmed that haemoglobin and ferritin levels were positively associated with grip strength, extending the relevance of this association to younger populations. The study-specific findings are presented in Table 2.

Table 2: Summary of Findings

Author, Year	Participants	Outcome	Effect size	Other Key Findings
Thein M et al. (2009)	328	Anemic participants had lower HGS compared to nonanemic individuals (21.3 kg vs. 24.1 kg; p = 0.014).	21.3 vs. 24.1 kg; P = 0.014	Anemia was associated with  low HGS, along with higher fatigue, depressive symptoms, and increased disability
Hidayat G  et al (2011)	118	In women, mild anemia was linked to lower HGS in women	12.36 kg vs. 14.68 kg; p = 0.027. B = 3.172, SE = 1.179, β = 0.230, p = 0.008	Each 1 g/dL increase in hemoglobin was associated with a 3.1 kg increase in HGS; age, physical activity, and anemia were independent predictors of reduced HGS
Hirani V et al (2016)	1705	A consistent positive association between hemoglobin and grip strength was observed	β = 1.52, 95% CI: 1.27–1.78, age-adjusted (β = 1.05, 95% CI: 0.80–1.30), and multivariate-adjusted (β = 0.82, 95% CI: 0.55–1.08).	1 gm increase in Hb was associated with reduced risk of sarcopenia, slow walking speed, poor HGS, activities of daily life, instrumental activities of daily life, and inability to stand from a chair.
Amaral C et al. (2020)	1016	Low HGS was associated with anemia in both men and women	Anemic men had more than fourfold increased odds of low HGS (aOR = 4.15; 95% CI: 2.09–8.21), and anemic women had nearly double the odds (aOR = 1.80; 95% CI: 1.06–3.06), compared to their nonanemic counterparts.	Low BMI and anemia were independently linked to reduced handgrip strength (HGS) in both sexes. Diabetes was associated with low HGS in men. Other factors in males were current or past smoking, poorer self-rated health, and dependence for daily activities. Among women, altered waist-to-hip ratio, insomnia, and physical activity related to commuting or work were also associated with low HGS.
Yu-mi Gi et al (2020)	16,638	Anemia was associated with weak HGS, particularly in men and older adults	Anemia occurs in the weak HGS group than the strong HGS group with OR = 1.92, 95% CI: 1.58–2.33 Association was greater for males (OR = 2.13, 95% CI: 1.35–3.34) and for those aged ≥65 years (OR = 1.92, 95% CI: 1.42–2.58).	High prevalence in participants with ≥65 years than below 65 years. Anemic Men reflected twice the odds of weak HGS
C.-T. LEE et al (2021)	480	Anemia was significantly associated with weak HGS and frailty	Hemoglobin levels and anemia were significantly associated with frailty (OR=2.28; 95% CI=1.02-5.10) odds after adjusting for potential covariates (OR = 0.94, 95% CI: 0.90-0.99).	Each 1 g/dL increase in hemoglobin was associated with a 6% decrease in frailty
Vanda Ho et al. (2022)	477	Higher HGS was correlated with higher hemoglobin and iron indices	In univariate analysis revealed that HGS was significantly associated with higher Hb (β = 2.10 95%CI 1.67–2.53, p < 0.01	High hand grip strength was also associated with high iron, ferritin, TSAT, and lower transferrin and TIBC. Ferritin, TSAT, and hsCRP were independent predictors of HGS in multivariate analysis.
Sutandyo N. et al (2022)	3192	Hb was positively correlated with HGS (r = 0.349, p < 0.001). Anemia increased the risk of weak grip (OR = 1.557), especially in those ≥80 years (p < 0.001).	OR: 1.557; 95% CI: 1.314-1.846; p value: <0.001	Weak HSG was associated with age ≥80 (OR: 5.234), age 70–79 (OR: 3.152), low BMI (OR: 1.827), and hypertension (OR: 1.340)
Lee B et al.  (2023)	24,022	Mean HGS was higher in nonanemic vs. anemic individuals 38.97 kg vs. 30.84 kg in men, and 22.64 kg vs. 21.85 kg in women—with a stronger association observed in men.	Adjusted OR of association of anemia and HGS in dominant hand in Men was 0.58 (0.51–0.66) < 0.001 (Age) 0.63 (0.55–0.72) < 0.001 (Other covariates) and in women 0.81 (0.76–0.86) < 0.001 (Age adjusted) 0.87 (0.81–0.93) < 0.001 (Other covariate adjusted)	The mean value of HGS was lower in anemic individuals. Relative HGS was associated with anemia.
Almari S & Simbawa M (July 2024)	135	Low hemoglobin was an independent predictor of weak HGS	Participants with low HGS had low hemoglobin levels (p < 0.001)	Participants with low HGS had low lymphocyte levels (p = 0.040), high creatinine levels (p = 0.004), high blood urea nitrogen levels (p = 0.007), high CRP levels (p = 0.007), high HbA1c levels (p = 0.029), and high vitamin B12 levels (p = 0.042). Also 16% were malnourished and 38.74% were at the risk of malnutrition with low HGS.
Hammer T. et al. (2024)	1294	Positive association between hemoglobin and HGS in women <80 years and in men <80 years with ferritin ≥300 µg/L. No association was found in those >80 years.	The average grip strength in the study population was 38.73 ± 9.35 kg for men and 23.99 ± 7.14 kg for women. In women <80 years, β 0.923[95% CI 0.196, 1.650], In Men < 80 years, the association was significant when ferritin was ≥ 300 μg/L, β 2.028 [95% CI0.910, 3.146]	In men with ferritin ≥ 300 μg/L 1 gm of HB was associated with 2.559 kg in HGS. Each 1 g/dL increase in Hb corresponded to a 0.923 kg gain in women and 2.028 kg in men.
MacLean B et al (2024)	640	HGS was positively linked to Hb (p = 0.004) and ferritin level (p = 0.005).	Adjusted R2 = 0.012, p = 0.004	HGS demonstrated potential as a noninvasive marker of iron deficiency in women of reproductive age

Quantitative Synthesis:

Three independent estimates were eligible for quantitative pooling because they provided comparable effect measures (odds ratios with corresponding confidence intervals or sufficient raw data) for the association between anaemia and weak handgrip strength. In the primary meta-analysis, the sex-specific strata from Amaral et al.^[14] (2020) were combined using inverse-variance weighting to generate a single overall estimate. Together with estimates from Gi et al.^[11] (2020) and Sutandyo et al.^[12] (2022), the pooled analysis showed that anaemia was associated with increased odds of weak handgrip strength (OR 1.59, 95% CI 1.07–2.37). Between-study heterogeneity was considerable (I² = 88.0%; τ² = 0.1047; Q = 11.63, df=2). Importantly, all three study-level estimates showed a consistent direction of effect, indicating higher odds of weak grip strength among participants with anaemia (Figure 2). The remaining included studies were not pooled because they lacked sufficient quantitative data, used different outcome definitions or reporting formats, or did not provide effect estimates suitable for meta-analysis.

In a sensitivity analysis, the male and female strata from Amaral et al.^[14] (2020) were retained as separate estimates, resulting in four pooled effects. The association remained robust and slightly stronger (OR 1.94, 95% CI 1.46–2.57). The heterogeneity decreased but remained substantial (I² = 71.1%; τ² = 0.0509; Q = 8.69, df = 3) (Figure 3). This demonstrates that the findings were not an artifact of combining sex-specific estimates and confirms the stability of the association across analytic choices.

Subgroup analyses by sex were possible via data from Gi et al.^[11] (2020) and Amaral et al.^[14] (2020). Among men, anaemia was associated with markedly greater odds of weak grip strength (pooled OR 2.82, 95% CI 1.48–5.39), with moderate heterogeneity (I² = 60.6%; τ² = 0.1348; Q = 2.54, df = 1) (Figure 4a). In contrast, the pooled analysis for women suggested a weaker association (OR 1.27, 95% CI 0.72–2.25), accompanied by substantial heterogeneity (I² = 75.1%; τ² = 0.1297; Q = 4.01, df = 1) (Figure 4b). These divergent patterns suggest potential effect modification by sex, although the small number of available studies limits confidence in this interpretation. Assessment of small-study effects was not undertaken, in line with the Cochrane guidelines, given the inclusion of fewer than ten studies.

Taken together, the evidence from the available observational datasets consistently indicates that anaemia is associated with reduced muscle strength, measured objectively by handgrip strength testing. The primary and sensitivity analyses revealed higher odds of weak grip among individuals with anaemia, with the strongest and most consistent effects observed in men. Findings in women were less consistent and more heterogeneous. Studies incorporating biochemical indices of iron status (e.g., Ho et al.^[16], 2022; Hammer et al.^[17], 2024; MacLean et al.^[18], 2024) further strengthen biological plausibility, showing positive associations of ferritin and transferrin saturation with grip strength and inverse associations for CRP.

Although substantial heterogeneity existed across studies, it likely stemmed from real differences in populations, protocols, and definitions rather than random noise. The effect direction remained consistent, with no contrary findings, strongly supporting anaemia as an independent driver of reduced muscle strength most clearly in men. These results emphasize incorporating anaemia screening into sarcopenia and frailty prevention, alongside calls for standardized methods and longitudinal research on age and sex-specific mechanisms.

A formal GRADE certainty assessment was not conducted. As all included studies were observational (cross-sectional or cohort designs) and generally judged at serious risk of bias, the certainty of evidence for all outcomes would begin at “low” and be further downgraded for risk of bias, inconsistency, and imprecision. Accordingly, overall certainty was considered “very low,” and no GRADE evidence table was presented.

Table 3: Risk of bias (JBI)

Study No.	First Author (Year)	Was the sample frame appropriate to address the target population?	Were study participants sampled in an appropriate way?	Was the sample size adequate?	Were the study subjects and the setting described in detail?	Was the data analysis conducted with sufficient coverage of the identified sample?	Were valid methods used for the identification of the condition?	Was the condition measured in a standard, reliable way for all participants?	Was there appropriate statistical analysis?	Was the response rate adequate, and if not, was the low response rate managed appropriately?	Overall Appraisal	Comments
1	Alamri (2024)	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Unclear	Include	Appropriate sampling, valid measures, but response rate not reported.
2	Sutandyo (2022)	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Include	Very large national dataset with robust methodology.
3	Lee B (2023)	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Unclear	Include	Large sample, consistent tools, strong statistical analysis.
4	Hammer (2022)	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Unclear	Include	Response rate was 20% but data are available of 1294
5	Hidayat (2011)	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes	include	Valid measurement tools, but small sample size (~118).
7	Gi yu (2020)	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Include	Survey based study
8	MacLean (2025)	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Include	Well-designed, high response rate, solid methodology.
9	Lee C.-T. (2021)	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Include	Well-designed, high response rate, solid methodology.
10	Vanda ho (2022)	Yes	No	No	Yes	unclear	Yes	Yes	Yes	unclear	Exclude	No randomization in the sampling of participants, no evidence on the sample size calculation, no evidence on the response rate
11	Amaral (2020)	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Include	structured methodology and concrete statistical analysis
12	Thein (2010)	Yes	Unclear	Unclear	Yes	Unclear	Yes	Yes	Unclear	Unclear	Exclude	No evidence on randomization of participants, sample size calculation and response rate, unstructured methodology

Discussion

Conclusion

Declarations

References

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