Introduction

Handgrip strength (HGS) is widely recognized as a standard measure for assessing human muscle strength and functional capacity [1]. Its widespread use in clinical and public health domains stems from a straightforward measurement method and exceptional reliability [2,3]. A growing corpus of evidence elucidates that HGS functions as a significant indicator of overall health status and exhibits substantial correlations with the prevalence of chronic diseases, functional decline, and heightened mortality risk [4–6]. Recently, Vaishya et al. (2024) proposed a novel conceptualization of HGS as a new “vital sign,” positing its capacity to reflect musculoskeletal health, identify early disease risk, and monitor functional deterioration [7].

Current research on HGS has predominantly focused on older adults [8]. However, recent studies have demonstrated that even among healthy university students, reduced HGS may be associated with elevated cardiometabolic risk factors [9]. According to the life course model, muscle strength and mass peak between 20 and 30 years of age and then gradually decline [5,10]. Given this pattern, optimizing peak muscle strength in early adulthood is critical to mitigating the functional decline in later life. Research also suggests low muscle strength during adolescence may have long-term health consequences. For instance, a longitudinal study encompassing more than one million Swedish male adolescents revealed that each standard deviation elevation in HGS at the age of 18 correlated with an 11% diminished risk of developing coronary heart disease and a 9% reduced risk of experiencing a stroke in later adulthood [11].

While males typically exhibit higher handgrip strength owing to physiological factors [12,13], recent findings show a gradual decline in their muscle strength levels, possibly driven by modern lifestyle changes [14,15]. Similarly, cultural emphasis on thinness among East Asian women [16] may negatively influence muscle health, highlighting an area that warrants further study. Although sex differences in handgrip strength have been explored in previous research, the physiological and behavioral mechanisms underlying these disparities remain insufficiently understood. As such, conducting sex-stratified analyses when examining factors associated with grip strength is essential for identifying potential determinants.

Regarding anthropometric indicators related to grip strength, mid-upper arm circumference (MUAC) and body mass index (BMI) are commonly used and practically valuable measures. Multiple studies have reported a consistent positive correlation between MUAC and grip strength, whereas the relationship between BMI and grip strength tends to be moderate [17,18]. However, some research has shown that in particular subgroups of younger individuals, BMI is not significantly associated with grip strength [19,20]. In addition, lifestyle behaviors such as insufficient physical activity and prolonged sedentary time may adversely affect muscle function. On the other hand, healthy dietary behaviors are considered potential factors that support overall physical fitness and muscle function. Healthy eating patterns, such as regular meal consumption, increased intake of fruits and vegetables, and avoiding high-fat and high-sugar foods, may help maintain proper nutritional status, thereby promoting muscle strength and overall physical function [21].

University is considered a critical stage for lifestyle transitions. After enrollment, students often break away from established family routines and experience major changes in eating habits, physical activity, and other health behaviors [22]. These changes may have potential impacts on muscle health and grip strength performance.

Although HGS is widely recognized as an indicator of overall health, evidence among healthy young adults—particularly within East Asian populations—remains scarce. Existing research has predominantly focused on older or Western cohorts, providing limited understanding of the early determinants of muscle strength across different cultural and physiological contexts. Furthermore, few studies have simultaneously examined behavioral factors (e.g., physical activity, sedentary behavior, diet) and physiological indicators (e.g., BMI, mid-upper arm circumference) or applied sex-stratified analyses to disentangle biological and sociocultural influences [18,23]. Addressing these gaps, the present study investigates lifestyle and physiological correlates of low HGS among Taiwanese university students, with analyses stratified by sex. By focusing on this transitional life stage, the study aims to provide early evidence for muscle-health surveillance and highlight the importance of strengthening interventions during young adulthood, when preventive action may have the greatest long-term benefit.

Methods

Results

Participant characteristics

A total of 501 university students participated in the study, consisting of 168 males (33.5%) and 333 females (66.5%), with a comparable mean age between sexes (males: 20.16 ± 1.58 years; females: 20.10 ± 1.53 years; p = .66). Detailed demographics and basic attribute information are summarized in Table 1. Low HGS was identified in 31 students (6.2% overall), with prevalences of 8.3% in males (14/168) and 5.1% in females (17/333); this sex difference was not statistically significant (p = .16). Participants were distributed across all academic years, with no significant sex-based differences in year level (p = .09). Most students lived in rented housing, shared housing, or dormitories, with no significant differences in current living arrangements between sexes (p = .65).

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Table 1. Demographics and Basic Attributes by Sex.

https://doi.org/10.1371/journal.pone.0350147.t001

In terms of commuting patterns, males were more likely to commute by private vehicle, while females reported higher rates of walking, cycling, or using public transportation (p < .001). Daily smartphone usage was similar between groups (males: 6.2 ± 2.5 hr/day; females: 6.1 ± 2.6 hr/day; p = .52). There was no significant difference in dietary scores between male and female students (p = .91). More than half of the students exhibited average dietary habits (males: 59.4%; females: 56.5%); approximately 14% in each group reported very unhealthy eating patterns, and only 1.2% of students in both groups reported very healthy diets.

Significant sex-based differences were observed in sedentary time and physical activity levels. Female students reported longer average sedentary time than males (9.3 ± 3.0 vs. 8.0 ± 2.7 hr/day; p < .001), and a higher proportion of males reported engaging in ≥150 minutes of MVPA per week (63.7% vs. 24.2%; p < .001). Regarding BMI, a greater proportion of females were underweight (BMI < 18.5 kg/m²: 16.5% vs. 6.0%), while more males were classified as overweight or obese (BMI ≥ 25.0 kg/m²: 19.0% vs. 9.3%; p < .001).

Sex differences in handgrip strength, nutritional status, and lifestyle behaviors

As shown in Table 2, male participants demonstrated significantly higher HGS (38.0 ± 7.8 kg) compared to females (24.6 ± 4.4 kg; p <.001). Males also had significantly higher BMI (22.4 ± 3.3 vs. 21.2 ± 3.2 kg/m²; p <.001), and greater MUAC (31.7 ± 3.8 cm vs. 27.4 ± 3.0 cm; p <.001). In contrast, dietary behavior scores did not differ significantly between sexes (male: 17.6 ± 4.9; female: 17.8 ± 5.0; p =  .65), suggesting similar dietary habits among male and female students. Significant sex-based differences were observed in sedentary and regular MVPA time. Additionally, female students reported longer average sedentary time than males (9.3 ± 3.0 vs. 8.0 ± 2.7 hr/day; p <.001), and a higher proportion of males reported engaging in ≥150 minutes of MVPA per week (63.7% vs. 24.2%; p <.001).

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Table 2. Comparison of Handgrip Strength, Nutritional Indicators, and Physical Activity by Sex.

https://doi.org/10.1371/journal.pone.0350147.t002

Correlation between handgrip strength and health indicators by sex

Table 3 shows that in the overall sample, HGS was weakly but significantly negatively associated with sedentary time (r = –0.170, p < .001), and positively associated with BMI (r = 0.301, p < .001) and MUAC (r = 0.713, p < .001). No significant association was found with dietary score (r = 0.031, p = .497). When stratified by sex, MUAC demonstrated the strongest and most consistent correlations with HGS in both males (r = 0.424, p < .001) and females (r = 0.854, p < .001). As shown in Fig 1, the scatter plot illustrates the strong positive association between MUAC and handgrip strength. BMI also showed moderate positive correlations with HGS in both males (r = 0.233, p < .002) and females (r = 0.310, p < .001). Sedentary time was negatively correlated with HGS in males (r = –0.110), though not statistically significant (p = .155), and showed no meaningful association in females (r = 0.039, p = .475). Dietary score remained unrelated to HGS in both sexes.

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Table 3. Pearson Correlation Coefficients Between Handgrip Strength and Health Indicators, Stratified by Sex.

https://doi.org/10.1371/journal.pone.0350147.t003

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Fig 1. Association between mid-upper arm circumference and handgrip strength.

The scatter plot shows the relationship between mid-upper arm circumference (MUAC) and handgrip strength (HGS) ‌‌among participants. MUAC, mid-upper arm circumference; HGS, handgrip strength.

https://doi.org/10.1371/journal.pone.0350147.g001

Logistic regression model including lifestyle and physiological factors

A stepwise logistic regression model was constructed to evaluate the association between HGS and a broader set of factors, including MVPA, gender, commuting method, BMI category, average sedentary time, and MUAC. The final model retained three significant factors: MVPA, gender, and MUAC (see Table 4). Compared to students who engaged in <150 minutes of MVPA per week, those who exercised ≥150 minutes were less likely to exhibit low risk for low handgrip strength (OR = 0.395, 95% CI: 0.153–1.022, p = .055). Male sex has a higher risk of low handgrip strength compared to females, with an odds ratio of 5.275 (OR = 5.275, 95% CI: 1.982–14.040, p = .001). Arm circumference was negatively associated with the likelihood of low grip strength (OR = 0.80, 95% CI: 0.691–0.926, p = .003), indicating that for each 1 cm increase in arm circumference, the odds of low grip strength decreased by approximately 20%. Greater arm circumference was associated with lower odds of low grip strength (OR = 0.80, p = .003). Other variables initially considered in the model, including commuting method, BMI, and sedentary time, were excluded in the final step due to lack of statistical significance.

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Table 4. Logistic regression to identify significant factors of low handgrip strength.

https://doi.org/10.1371/journal.pone.0350147.t004

Discussion

This study assessed 501 Taiwanese university students (168 males and 333 females) based on the HGS cut-off values proposed by the Asian Working Group for Sarcopenia 2019 (AWGS-2019) [41]. This criterion is less frequently applied to university-aged populations. Low HGS was identified in 31 participants (6.2% overall), including 8.3% of males and 5.1% of females. Three independent factors associated with low strength were identified: insufficient MVPA (<150 min/week, doubling the risk), smaller MUAC (each additional centimeter associated with an estimated 20% reduction in risk), and male sex (five-fold higher adjusted risk).These findings highlight physical activity and regional muscularity as modifiable factors for early intervention and affirm sex as a key covariate despite modest prevalence differences. This study fills an evidence gap regarding muscle strength in university-aged populations and identifies actionable targets for prevention.

Notably, although the proportion classified as having low HGS was relatively small under the AWGS-2019 criteria, the 25th percentile average HGS in this sample (31.95 kg in males and 21.7 kg in females) exceeded the respective cut-off points. This suggests that the true prevalence of low HGS, if defined by sample-based percentiles, would be significantly higher. This highlights the challenge of applying geriatric-derived screening criteria to younger adult populations, where normative strength levels are substantially higher. Moreover, the fact that some male students were classified as low strength despite relatively high absolute values suggests a possible trend of declining muscular fitness among younger males. This phenomenon has been reported in prior studies, indicating a secular decline in male grip strength over recent decades, possibly due to increased sedentary behavior and reduced physical demands in daily life [14,15]. Although males generally exhibited higher absolute HGS values than females, logistic regression identified male sex as a factor associated with low HGS when using the AWGS-2019 sex-specific cut-off points (<28 kg for males; < 18 kg for females). This finding reflects the relative proportion of males who did not reach their sex-specific reference threshold rather than an overall lower muscle strength compared to females. In other words, while average male grip strength is higher, the criterion-adjusted definition of “low HGS” classifies a subset of males as below standard, resulting in an odds ratio greater than 1. This interpretation aligns with previous findings suggesting that normative thresholds derived from older adult populations may not optimally represent younger cohorts. Such findings underscore the importance of sex-stratified analysis and the need to establish age-appropriate normative grip strength references for early identification and prevention strategies.

In this study, male students had significantly higher HGS than female counterparts, which is consistent with previous literature [43,44]. This sex difference can be primarily attributed to physiological and anatomical characteristics, including greater skeletal muscle mass, upper limb muscle cross-sectional area, and larger forearm circumference and hand width in males [12,45]. In the present sample, male participants also reported higher levels of physical activity, greater BMI, and larger MUAC, further supporting the critical role of physiological factors in the development of muscular strength. Beyond biological determinants, sociocultural and psychosocial influences may also contribute to sex-based disparities in muscular strength. In East Asian societies, such as Taiwan, women often face societal pressure to maintain a thin body shape, resulting in lower participation in resistance training and physical activity in general [46,47]. According to national health statistics, 15.5% of Taiwanese women aged 18–24 are classified as underweight [21], which may further constrain muscle development and functional performance. Many young women aiming for an ideal body weight tend to have reduced lean body mass (LBM) [48,49], and underweight females often exhibit lower dietary diversity and insufficient energy and protein intake, conditions linked to decreased muscular strength and increased risks of malnutrition [50,51]. Additionally, dietary patterns common in East Asian countries, such as a higher reliance on carbohydrates and lower protein intake, may also play a role in muscle development and functional strength. In Taiwan, diets are typically high in carbohydrates—mainly from refined staples such as rice and noodles, while sources of animal protein are comparatively limited [52,53].

In contrast, male students in East Asia may experience less pressure related to body image ideals but often face strong sociocultural expectations emphasizing academic achievement over physical fitness [54]. Such academic-oriented cultural values may overshadow the importance of exercise and contribute to lower physical activity levels among some male students. Moreover, research suggests that young East Asian men perceive body image through culturally specific frameworks, where the interaction between physique ideals and academic performance is influenced by broader social norms and cultural values [55]. These findings emphasize the need for culturally appropriate interventions that promote both physical activity and healthy body image across genders in East Asia.

In comparison, the average HGS of Taiwanese university students is generally lower than that of their peers in Western countries. This may be influenced by multiple factors, including interethnic genetic differences, physical education systems, fitness culture, nutritional intake, and body composition [56,57]. According to a United Nations Educational, Scientific and Cultural Organization (UNESCO) survey, East Asian countries typically allocate less time to school-based physical education compared to Western nations [58]. In addition, heavier academic workloads and limited access to exercise resources may adversely affect physical development. However, even within Asia, the HGS of these Taiwanese male students is lower than that of their Japanese and Thai counterparts, while the grip strength of female students is slightly higher than that of Korean females. This variation may be related to prevailing cultural values in Taiwan and South Korea, where thin body ideals are widely promoted in media [46,47], potentially influencing body-related behaviors and body composition among younger generations. Overall, the results of this study emphasize the importance of early exercise intervention and health promotion for young people. Future research should further explore the impact of gender and cultural factors on grip strength development.

Among the various indicators examined, MUAC demonstrated the strongest and most consistent association with HGS, particularly in females (r = 0.854, p < .001), and to a lesser extent in males (r = 0.424, p < .001). This highlights the importance of upper-arm muscle mass as a determinant of functional strength in university students, as also supported by previous studies [17,59]. BMI also showed moderate positive correlations with HGS in both sexes (female: r = 0.310; male: r = 0.233), which aligns with previous studies indicating that higher BMI, particularly with greater lean mass, may be associated with stronger grip [18]. Sedentary time was negatively correlated with HGS in the total sample (r = –0.170, p < .001), yet not statistically significant when stratified by sex. This could suggest subtle sex-specific differences in response to sedentary behavior or insufficient statistical power in subgroup analyses. Interestingly, dietary behavior showed no significant association with HGS (r = 0.031, p = .497 overall). This lack of association might reflect limitations of the brief self-reported scoring system, which primarily captures short-term eating patterns rather than long-term dietary habits that may have a stronger influence on muscle strength.

The findings from the logistic regression model highlight the combined influence of weekly MVPA time, sex, and MUAC on HGS in the studied student population. Among these factors, sex exhibited the strongest association, with male students being over five times more likely to have a higher risk of low HGS compared to females (OR = 5.275, p = .001). This substantial odds ratio underscores the impact of biological sex on muscular strength vulnerabilities in this cohort, suggesting that certain male subgroups may be particularly susceptible due to factors such as lower physical activity levels or unfavorable body composition [60]. MUAC demonstrated a significant protective association against low HGS (OR = 0.80, p = .003). Specifically, for each 1 cm increase in arm circumference, the odds of exhibiting low grip strength decreased by approximately 20%. This result suggests that greater arm girth, potentially reflecting greater muscle mass, serves as a protective factor against strength deficits [12,45]. Weekly MVPA time (≥150 minutes versus <150 minutes) exhibited a borderline significant inverse association with low handgrip strength (OR = 0.395, p = .055). Although the p-value slightly exceeded the conventional significance threshold, the trend indicates that higher levels of physical activity might mitigate the risk of diminished HGS. Nevertheless, the borderline significance and absence of detailed classification regarding exercise type and intensity necessitate cautious interpretation and warrant further investigation [61,62].

This study has several notable strengths and limitations. First, it addresses a critical gap in epidemiological data on muscular strength among young adults by applying the updated AWGS-2019 criteria to a university-aged population. Second, the sample size was adequate (N = 501), and both subjective (self-reported lifestyle questionnaires) and objective (HGS and MUAC) indicators were employed. This multimethod approach helps mitigate the risk of common method bias and enables sex-stratified analyses, which enhance the interpretability and relevance of the findings. Importantly, the results support the notion that sex may exert an independent effect on muscular strength, even in contexts with only minimal differences in prevalence. The study also identifies two modifiable factors—MVPA and MUAC—that could serve as practical indicators for early monitoring and intervention, before the onset of age-related declines in muscle function. These findings offer actionable insights for university health services and public health initiatives aimed at the early prevention of sarcopenia. Moreover, grip strength in early adulthood may serve as a valuable predictor of future sarcopenia and functional decline. Research has shown that lower HGS at a young age is associated with an increased risk of developing sarcopenia later in life [63,64]. Early identification of low HGS among university students, therefore, provides an opportunity for preventive strategies to maintain muscle health across the lifespan. These findings offer actionable insights for university health services and public health initiatives aimed at the early prevention of sarcopenia.

However, several limitations should be acknowledged. First, the lifestyle variables—including physical activity, sedentary time, and dietary behaviors—were assessed using self-reported questionnaires, which may be influenced by recall and social desirability bias. In addition, brief self-report dietary measures in young adults may exhibit limited discrimination, which could attenuate associations between dietary behaviors and health outcomes. Furthermore, because our measure of physical activity excluded walking and domestic activities and focused on structured exercise, it likely underestimated total physical activity and may have introduced non-differential misclassification. Nevertheless, similar self-administered instruments have been widely applied and validated in epidemiological studies among college students and young adults [40,65,66], with evidence demonstrating acceptable reliability and validity, as well as the feasibility of simplified measures of physical activity, lifestyle, and dietary behaviors in these populations. Additionally, the brief dietary behavior questionnaire used in this study may not fully capture detailed nutrient intake, such as protein or micronutrients, which are important for muscle strength. However, this simplified tool was selected to ensure feasibility and reduce respondent burden, as longer dietary surveys may lower completion rates among university students. Second, the definition of low grip strength used the AWGS-2019 criteria, which were derived from an older adult population, which may underestimate the actual prevalence of weak grip in young adults. It is thus recommended to establish local normative data for grip strength in young adults to more accurately identify muscle strength deficiencies in this population. Third, this study employed a cross-sectional design, which limits the ability to infer causal relationships between handgrip strength and associated risk factors. To address this limitation, future studies using longitudinal designs may better clarify temporal changes to track temporal changes in handgrip strength and related health outcomes, thereby enhancing the understanding of its role in predicting health risks among young populations. Finally, the study sample was primarily composed of university students from a specific region and educational background, which may limit the generalizability of the findings. Given that lifestyle behaviors, nutritional intake, and physical activity levels can vary substantially across regions, the external validity of the results may be constrained. Furthermore, as all participants were enrolled at a medical university, their health awareness, academic workload, and lifestyle patterns may differ from those of students in non–health-related disciplines, which could further limit the generalizability of the findings. To improve the broader applicability of future findings, it is advisable to include more diverse population samples‌‌ that reflect the heterogeneity of young individuals across different cultural and socio-demographic contexts.

Conclusions

This study identified male sex, smaller MUAC, and insufficient MVPA as key factors associated with low HGS in a sample of Taiwanese university students. These findings underscore the need for early surveillance and intervention strategies to promote muscular fitness in young adults, particularly targeting at-risk male subgroups. Given the established link between muscular strength and long-term health outcomes, integrating physical activity promotion and muscle mass preservation into early adulthood health initiatives is crucial. Although limitations such as the use of cutoffs derived from older adult populations and self-reported data exist, this study highlights the importance of developing age-appropriate strength norms and advancing longitudinal research to inform effective public health interventions. Promoting muscular strength from early adulthood may serve as a foundational strategy to prevent future functional decline and chronic disease, contributing to healthier aging trajectories at the population level.

Supporting information

Acknowledgments

The authors thank the participating institution for its support and all students who took part in the study.