Association between handgrip strength, handgrip strength asymmetry, and anxiety in Korean older adults: The Korean National Health and Nutrition Examination Survey 2022

Sang-Youn Choi; Su-Min Park; Eun-Cheol Park

doi:10.1371/journal.pone.0315256

. 2025 Apr 8;20(4):e0315256. doi: 10.1371/journal.pone.0315256

Association between handgrip strength, handgrip strength asymmetry, and anxiety in Korean older adults: The Korean National Health and Nutrition Examination Survey 2022

Sang-Youn Choi ¹, Su-Min Park ^2,^3,^*, Eun-Cheol Park ^3,^4,^*

Editor: Marina De Rui⁵

PMCID: PMC11978050 PMID: 40198659

Abstract

Low handgrip strength (HGS) and HGS asymmetry are associated with age-related physical and mental disorders in older adults. This study aimed to examine the association between HGS-related factors and anxiety to evaluate whether HGS assessments can assist in identifying anxiety risk. In total, 1,750 participants from the Korea National Health and Nutrition Examination Survey of 2022 were included in this study. Individuals whose HGS values were below the 20th percentile of the study population stratified by sex were classified into the low-HGS group. Anxiety was assessed using the generalized anxiety disorder with a 7-item scale. Multiple logistic regression was used to analyze the relationship between HGS level and asymmetry and anxiety, adjusting for covariates. Overall, 70 (8.7%) men and 123 (13.0%) women had anxiety. Elevated odds of anxiety were observed in older women with low HGS (adjusted odds ratio: 2.17, 95% confidence interval: 1.31–3.61). There was a positive correlation between the degree of asymmetrical HGS and anxiety among women. This study found positive associations between low HGS, HGS asymmetry, and anxiety in older Korean women. This population may require specific interventions to help maintain good mental health.

Introduction

Anxiety is more common in older adults than in young people [1], and its prevalence is increasing. For example, the rates of anxiety among the United States adults increased from 5.12% in 2008 to 6.68% in 2018 [2]. Meanwhile, anxiety among Brazilian adults showed a sharp increase during the COVID-19 pandemic [3].

Populations in which 14% and 20% of people are older than 65 years are considered an “aged” and a “super-aged” society, respectively. Korea became an aged society in 2018 and is expected to become a super-aged society by 2025, as there are currently more than 10 million people older than 65 years [4]. The prevalence of anxiety among older adults in Korea was 11.0%, according to the Korea National Health and Nutrition Examination Survey (KNHANES) in 2022.

Anxiety in older adults is associated with increased morbidity and mortality rates [5–7]. Older adults with anxiety are at higher risk of cardiovascular disease and cognitive decline [8], necessitating specific interventions. However, anxiety symptoms in older adults are often underestimated because mental health changes tend to be attributed to physical diseases in this population [8]. Therefore, novel approaches to screening, diagnosing, and managing anxiety in older adults are required.

We hypothesized that sarcopenia may be a good indicator of anxiety. Sarcopenia is associated with many aging-associated diseases, such as osteoporosis, type 2 diabetes mellitus, and cardiovascular disease [9–11]. Moreover, it has been reported to contribute to depression, which is also a mental disorder related to anxiety [12,13]. Therefore, sarcopenia may be associated with anxiety.

Measuring handgrip strength (HGS) is one way to diagnose sarcopenia [14]. Hence, HGS might be used as an assistant index for diagnosing anxiety if the association between the two factors is shown. Sarcopenia and low HGS are associated with aging-related diseases and depression [15–18]. Measuring HGS involves using portable devices, which makes it an accessible indicator.

Asymmetrical HGS may also be associated with anxiety. HGS difference between hands ranging from 0% to 10% is considered normal [19]. In contrast, an asymmetry of > 10% is associated with depression and age-related disease [20–22].

Some studies have found an association between HGS and age-related or mental diseases in older adults. In addition, a study of Polish older adults found that better HGS is related to a lower frequency of pain and anxiety, which was investigated using the EuroQol-5D questionnaire [23]. However, no study to date has examined the relationship between HGS-related factors and anxiety in older Koreans using the Generalized Anxiety Disorder 7-item (GAD-7), which is more specific for measuring anxiety than the EuroQol-5D questionnaire. Therefore, in this study, we aimed to explore the association between anxiety, low HGS, and HGS asymmetry in Korean older adults.

Methods

The data analyzed in this study were obtained from the 2022 KNHANES IX. KNHANES is a nationwide cross-sectional survey conducted by the Korea Disease Control and Prevention Agency. It assesses the health and nutritional status of Koreans, capturing variables such as obesity status, blood pressure values, and diabetes diagnosis. It is used to inform national policies and for global comparisons of health outcomes.

Study population

The GAD-7 was first included in the 2021 KNHANES. However, as the HGS was not investigated in 2021 and the survey for 2023 was not available at the time of writing, this study only used data from 2022. In total, 6,265 individuals were included in the data for 2022. A total of 4,023 individuals under the age of 60 years, and 492 individuals lacking values for study variables were excluded. Therefore, 1,750 individuals were included in the analysis.

Variables

We used the GAD-7 to select participants with anxiety. The GAD-7 comprises seven questions: participants answered each question on a scale from 0 to 3, with 0 indicating no anxiety at all and 3 indicating anxiety nearly every day. The answers to each question are summed to obtain a final score that ranges from 0 to 21. The score 0–4 indicated no anxiety, 5–9 mild anxiety, 10–14 moderate anxiety, and 15–21 severe anxiety [24]. We used a threshold of 5; therefore, those with a score of 4 or lower were classified as not having anxiety and those with a score of 5 or higher were classified as having anxiety.

The HGS of each hand was measured twice using a digital dynamometer. Individuals with defects of the arm/hand/thumb, defects or fractures of fingers other than the thumb, paralysis of the hand, or cast or bandage of the hand/wrist were excluded from the study. The participants gripped the dynamometer for 3 s with their maximum strength in the upright position. There was a break of 60 s between the two measurements. The strongest measurements were obtained from the dominant hand. Following the criteria suggested by the Asian Working Group of Sarcopenia, we used the 20th percentile of the study population’s HGS, which was stratified by sex, as a threshold: high for 20–100th percentile, and low for 0-20th percentile [25]. For additional analyses, the 10th percentile was used to divide the “low” group for comparisons between “low” and “very low” HGS. HGS asymmetry between two hands lower than 10% is considered normal. To investigate the association between the degree of asymmetry and anxiety, participants were categorized into three groups: symmetry for those with 0–10% asymmetry, moderate asymmetry for those with 10–20% asymmetry, and prominent asymmetry for those with over 20% asymmetry.

The data were stratified according to sex. Age (60–69, 70 years, or older), educational level (high school or lower, college or higher), working status (working or not working), area of residence (metropolitan or rural), and marital status (with or without a spouse) were included as demographic and socioeconomic factors. Obesity (body mass index ≥ 25 kg/m², between 18.5 and 25 kg/m², < 18.5 kg/m²) [26], frequency of drinking (less than once a year, once a year or more), sleep duration (less than 6 h, more than 6 h per night), stress level (a lot, a little), physical activity (sufficient, insufficient), and lifetime smoking history (yes, no) were included as health-related factors. “Sufficient” or “insufficient” physical activity was defined by Aerobic Physical Activity Prevalence guidelines [27]. “Sufficient” physical activity was defined as medium-intensity physical activity of more than 2.5 h per week or high-intensity physical activity of more than 1 h and 15 min per week, or both forms of activity at a total of ≥ 2.5 h per week, using a conversion of 1 min of high-intensity physical activity as equal to 2 min of medium-intensity physical activity. High-intensity physical activities included lifting and carrying heavy objects, digging, running, and swimming. Medium-intensity physical activities included lifting and carrying light objects, golf and jogging.

Statistical analysis

The Chi-square tests were performed to compare participant characteristics. We used stratification, clustering, and weighting variables in the KNHANES data to ensure population representativeness. We used weighting variables that consider both health and nutrition factors. Age, education level, working state, residence, marital status, obesity, drinking, sleep duration, stress level, physical activity, and smoking were used as confounders. These variables were included solely as control variables and not as independent predictors of anxiety. Multiple logistic regression was used to investigate the association between HGS-related factors (low HGS and HGS asymmetry) and anxiety after considering confounding variables. Subgroup analysis stratified by each independent variable was conducted to examine the independent effects of the variables and determine any group with a high association between low HGS and anxiety. Finally, we calculated the odds ratio (OR) of anxiety in the groups with low HGS and HGS asymmetry using multiple logistic regression. For all logistic regression analyses, ORs and 95% confidence intervals (CIs) were calculated. The variance inflation factors for the variables were smaller than 1.15, indicating that there was no problem with multicollinearity. All analyses were performed using SAS software (version 9.4; SAS Institute, Cary, North Carolina, USA), and p-values < 0.05 were considered statistically significant.

Ethics statement

The KCDC Research Ethics Review Committee has reviewed and approved the KNHANES annually since 2007. The KNHANES datasets are published online for research purposes. The committee operates according to the KCDC Research Ethics Review Committee’s standard guidelines. All survey participants filled out a consent form before participation. As this study utilized publicly available data, additional institutional review board approval was not necessary, as per Article 2.2 of the Enforcement Rule of the Bioethics and Safety Act in Korea.

Results

Table 1 shows the general characteristics of the study population stratified by sex. A total of 1,750 participants, including 802 (45.8%) men and 948 (54.2%) women, were included in the analysis. Among them, 70 (8.7%) men and 123 (13.0%) women experienced anxiety. As the HGS threshold was the 20th percentile, 20% of participants in each sex group were classified as having low HGS. Among participants with low HGS, 11.7% of men and 19.8% of women had anxiety. Meanwhile, among participants with high HGS, 8.0% of men and 11.2% of women had anxiety. The Chi-square results showed a statistically significant relationship between low HGS and anxiety in women, but not in men.

Table 1. Socioeconomic and health-related characteristics of all study participants according to anxiety.

Variables	Anxiety
	Male (N = 802)					Female (N = 948)
	NO		YES		p-value	NO		YES		p-value
	N	(%)	N	(%)	p-value	N	(%)	N	(%)	p-value
Handgrip strength					0.1299					0.0016
High	589	(92.0)	51	(8.0)		671	(88.8)	85	(11.2)
Low	143	(88.3)	19	(11.7)		154	(80.2)	38	(19.8)
Handgrip strength symmetry					0.9298					0.2985
Symmetric	464	(91.3)	44	(8.7)		477	(88.0)	65	(12.0)
Asymmetry	268	(91.2)	26	(8.8)		348	(85.7)	58	(14.3)
Age					0.981					0.5165
60-69	388	(91.3)	37	(8.7)		464	(86.4)	73	(13.6)
70-	344	(91.2)	33	(8.8)		361	(87.8)	50	(12.2)
Education Level					0.0095					0.1292
High school or lower	534	(89.7)	61	(10.3)		736	(87.6)	104	(12.4)
College or higher	198	(95.7)	9	(4.3)		89	(82.4)	19	(17.6)
Working state					0.672					0.521
No	354	(91.7)	32	(8.3)		488	(87.6)	69	(12.4)
Yes	378	(90.9)	38	(9.1)		337	(86.2)	54	(13.8)
Residence					0.8969					0.0558
Metropolitan	528	(91.2)	51	(8.8)		611	(88.3)	81	(11.7)
Rural	204	(91.5)	19	(8.5)		214	(83.6)	42	(16.4)
Marital status					0.374					0.363
No	79	(88.8)	10	(11.2)		276	(83.9)	53	(16.1)
Yes	653	(91.6)	60	(8.4)		549	(88.7)	70	(11.3)
Obesity					0.9395					0.0108
Underweight	18	(90.0)	2	(10.0)		16	(66.7)	8	(33.3)
Normal	464	(91.5)	43	(8.5)		508	(87.4)	73	(12.6)
Obese	250	(90.9)	25	(9.1)		301	(87.8)	42	(12.2)
Drink					0.1314					0.153
No	209	(88.9)	26	(11.1)		460	(85.7)	77	(14.3)
Yes	523	(92.2)	44	(7.8)		365	(88.8)	46	(11.2)
Sleep duration					0.4911					0.0212
More than 6h	500	(91.7)	45	(8.3)		493	(89.2)	60	(10.8)
Less than 6h	232	(90.3)	25	(9.7)		332	(84.1)	63	(15.9)
Stress					<0.001					<0.001
Low	241	(99.6)	1	(0.4)		240	(97.6)	6	(2.4)
High	491	(87.7)	69	(12.3)		585	(83.3)	117	(16.7)
Physical Activity					0.6694					0.7343
Insufficient	441	(90.9)	44	(9.1)		556	(87.3)	81	(12.7)
Sufficient	291	(91.8)	26	(8.2)		269	(86.5)	42	(13.5)
Smoke					0.6592					0.009
Non-smoker	558	(91.0)	55	(9.0)		806	(87.5)	115	(12.5)
Smoker	174	(92.1)	15	(7.9)		19	(70.4)	8	(29.6)
Total	732	(91.3)	70	(8.7)		825	(87.0)	123	(13.0)

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Variables are presented as numbers and percentages.

Table 2 shows the results of multiple logistic regression analysis between HGS and anxiety. Both before and after adjusting for covariates, the risk of having anxiety was significantly higher among women who had low HGS (crude OR [cOR]: 1.33, 95% CI: 0.67–2.63 in men, cOR: 1.989, 95% CI: 1.23–3.21 in women, adjusted OR [aOR]: 1.22, 95% CI: 0.62–2.43 in men, aOR: 2.17, 95% CI: 1.31–3.61 in women).

Table 2. Association between handgrip strength and anxiety.

Variables		Anxiety (unadjusted)			Anxiety (adjusted)
Variables		cOR	95% CI	p-value	aOR	95% CI	p-value
Male	HGS			0.4102			0.5654
	High	1			1
	Low	1.33	(0.67–2.63)		1.221	(0.62–2.43)
Female	HGS			0.0050			0.0029
	High	1			1
	Low	1.989	(1.23–3.21)		2.173	(1.31–3.61)

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The results of the subgroup analyses are presented in Tables 3 and 4. Both before and after adjusting for covariates, no statistically significant differences were found in any male subgroup, in contrast to female subgroups. These results show trends similar to those of the main results (Table 2). The female subgroups with a significantly higher aOR for “having anxiety” and “having low HGS” included those aged 70 years and older, with a high school education or lower, both employed or unemployed, married, non-drinkers, those sleeping more than 6 h per night, those with high stress, both physically active and inactive individuals, and non-smokers.

Table 3. Subgroup analysis of the relationship between handgrip strength and anxiety among male.

Variables	Anxiety
	Unadjusted				Adjusted
	High HGS	Low HGS			High HGS	Low HGS
	cOR	cOR	95% CI	p-value	aOR	aOR	95% CI	p-value
Age
60-69	1	0.83	(0.24–2.95)	0.7749	1	0.75	(0.19–2.88)	0.6704
70-	1	2.02	(0.88–4.62)	0.0950	1	1.72	(0.68–4.34)	0.2515
Education Level
High school or lower	1	1.35	(0.69–2.64)	0.3731	1	1.58	(0.78–3.12)	0.2101
College or higher	1	–	–	<0.001	1	–	–	<0.001
Working state
No	1	1.54	(0.60–3.98)	0.3715	1	1.24	(0.48–3.24)	0.6589
Yes	1	1.26	(0.43–3.67)	0.6688	1	0.86	(0.28–2.63)	0.7834
Residence
Metropolitan	1	0.74	(0.32–1.73)	0.4857	1	0.75	(0.31–1.80)	0.5138
Rural	1	5.11	(1.63–15.97)	0.0054	1	3.20	(1.19–8.57)	0.0213
Marital status
No	1	0.72	(0.12–4.40)	0.7154	1	0.34	(0.03–3.77)	0.3739
Yes	1	1.45	(0.69–3.06)	0.3254	1	1.42	(0.66–3.07)	0.3717
Obesity
Underweight	1	1.10	(0.05–23.86)	0.9503	1	–	–	<0.001
Normal	1	1.63	(0.75–3.55)	0.2199	1	1.63	(0.72–3.71)	0.2381
Obese	1	0.77	(0.16–3.81)	0.7506	1	0.64	(0.13–3.20)	0.5482
Drink
No	1	1.85	(0.59–5.81)	0.2870	1	1.58	(0.45–5.50)	0.4704
Yes	1	0.95	(0.40–2.24)	0.9084	1	1.05	(0.43–2.61)	0.9100
Sleep duration
More than 6h	1	1.40	(0.59–3.31)	0.4450	1	1.04	(0.40–2.72)	0.9327
Less than 6h	1	1.19	(0.36–3.89)	0.7741	1	1.23	(0.42–3.55)	0.7100
Stress
Low	1	–	–	<0.001	1	–	–	<0.001
High	1	1.25	(0.60–2.63)	0.5532	1	1.16	(0.57–2.33)	0.6821
Physical Activity
Insufficient	1	1.25	(0.53–0.29)	0.6113	1	1.08	(0.49–2.39)	0.8478
Sufficient	1	1.42	(0.50–4.07)	0.5125	1	1.89	(0.58–6.21)	0.2904
Smoke
Non-smoker	1	1.29	(0.61–2.75)	0.5001	1	1.18	(0.54–2.56)	0.6753
Smoker	1	1.36	(0.33–5.65)	0.6664	1	1.29	(0.27–6.28)	0.7489

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Table 4. Subgroup analysis of the relationship between handgrip strength and anxiety among female.

Variables	Anxiety
	Unadjusted				Adjusted
	High HGS	Low HGS			High HGS	Low HGS
	cOR	cOR	95% CI	p-value	aOR	aOR	95% CI	p-value
Age
60-69	1	2.05	(0.98–4.27)	0.0553	1	2.16	(1.00–4.70)	0.0513
70-	1	2.32	(1.11–4.85)	0.0253	1	2.20	(1.01–4.79)	0.0467
Education Level
High school or lower	1	2.01	(1.22–3.30)	0.0064	1	2.06	(1.22–3.47)	0.0071
College or higher	1	1.92	(0.45–8.18)	0.3780	1	3.41	(0.70–16.64)	0.1279
Working state
No	1	2.00	(1.07–3.74)	0.0312	1	2.04	(1.03–4.04)	0.0419
Yes	1	2.39	(0.99–5.72)	0.0515	1	2.99	(1.11–8.09)	0.0312
Residence
Metropolitan	1	1.81	(1.03–3.18)	0.0387	1	1.92	(0.98–3.78)	0.0578
Rural	1	2.30	(0.96–5.50)	0.0610	1	2.54	(0.92–6.98)	0.0715
Marital status
No	1	1.61	(0.79–3.28)	0.1876	1	1.96	(0.93–4.13)	0.0762
Yes	1	2.16	(1.02–4.58)	0.0452	1	2.48	(1.16–5.29)	0.0192
Obesity
Underweight	1	6.72	(0.97–46.47)	0.0536	1	–	–	0.0010
Normal	1	1.67	(0.86–3.26)	0.1309	1	2.02	(0.97–4.21)	0.0596
Obese	1	2.00	(0.87–4.61)	0.1015	1	2.45	(0.94–6.38)	0.0668
Drink
No	1	1.91	(1.01–3.62)	0.0460	1	2.44	(1.20–4.95)	0.0137
Yes	1	2.16	(0.93–4.99)	0.0714	1	1.80	(0.71–4.57)	0.2177
Sleep duration
More than 6h	1	2.13	(1.07–4.25)	0.0316	1	2.34	(1.15–4.76)	0.0195
Less than 6h	1	1.78	(0.88–3.58)	0.1078	1	1.94	(0.91–4.14)	0.0878
Stress
Low	1	6.82	(1.51–30.91)	0.0131	1	4.83	(0.94–24.73)	0.0585
High	1	1.96	(0.26–2.53)	0.0123	1	2.04	(1.19–3.50)	0.0096
Physical Activity
Insufficient	1	1.91	(1.13–3.25)	0.0166	1	2.07	(1.11–3.89)	0.0233
Sufficient	1	2.26	(1.00–5.10)	0.0507	1	2.88	(1.21–6.83)	0.0169
Smoke
Non-smoker	1	2.00	(1.23–3.25)	0.0057	1	2.18	(1.30–3.65)	0.0033
Smoker	1	1.47	(0.16–13.84)	0.7326	1	–	–	<0.001

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After subgrouping individuals according to the 10th and 20th HGS percentiles (very low for 0–10% HGS, low for 10–20% HGS, and high for > 20% HGS), we conducted multiple logistic regression analysis using the high group as a reference. To examine the association between HGS asymmetry and anxiety, participants were categorized into three groups by a threshold of 10% and 20% asymmetry, and multiple logistic regression analyses were performed using the symmetry group as a reference. The results of these two analyses are presented in Table 5. No effects were observed among men. However, among women, the very low HGS group had significantly higher odds of anxiety compared to the high HGS group (aOR: 3.22, 95% CI: 1.67–6.20). There was also a positive correlation between lower HGS and higher odds of anxiety (aOR for low HGS group: 1.46, aOR for very low HGS group: 3.22). A similar correlation was observed in women’s HGS asymmetry: The more severe the HGS asymmetry, the higher the odds of anxiety (aOR for the moderate HGS asymmetry group: 1.37; aOR for the prominent HGS asymmetry group: 1.83).

Table 5. Association between HGS-related factors and anxiety.

Variables		Anxiety (unadjusted)			Anxiety (adjusted)
Variables		cOR	95% CI	p-value	aOR	95% CI	p-value
Male	HGS
	High	1			1
	Low	1.16	(0.44–3.03)	0.7601	1.03	(0.39–2.68)	0.9574
	Very low	1.51	(0.65–3.53)	0.3378	1.47	(0.62–3.53)	0.3827
	HGS asymmetry
	Symmetry	1			1
	Moderate asymmetry	1.44	(0.76–2.73)	2.6390	1.52	(0.75–3.07)	0.2407
	Prominent asymmetry	1.05	(0.42–2.67)	0.9128	0.95	(0.38–2.38)	0.9195
Female	HGS
	High	1			1
	Low	1.35	(0.64–2.84)	0.4218	1.46	(0.69–3.08)	0.3176
	Very low	2.77	(1.55–4.94)	<0.001	3.22	(1.67–6.20)	<0.001
	HGS asymmetry
	Symmetry	1			1
	Moderate asymmetry	1.24	(0.79–1.94)	0.3567	1.37	(0.83–2.27)	0.2126
	Prominent asymmetry	1.78	(0.95–3.35)	0.0728	1.83	(0.90–3.72)	0.0948

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Table 6 shows the results of multiple logistic regression analysis for the effects of HGS and HGS asymmetry on anxiety. No effect was observed among men. Among women, the group with “low HGS and moderate asymmetry” (aOR: 2.98, 95% CI: 1.49–5.94) and that with “low HGS and prominent asymmetry” (aOR: 3.16, 95% CI: 1.37–7.29) had higher odds of having anxiety. The odds of anxiety increased as the degree of asymmetry increased and HGS became lower among women.

Table 6. Effects of HGS and HGS asymmetry on anxiety.

Variables			Anxiety
			High HGS			Low HGS
			OR	95% CI	p-value	OR	95% CI	p-value
Male	Unadjusted	Symmetry	1			1.29	(0.52–3.20)	0.5857
		Moderate asymmetry	1.52	(0.70–3.29)	0.2923	1.49	(0.55–4.06)	0.4302
		Prominent asymmetry	0.68	(0.15–3.14)	0.6141	2.08	(0.59–7.31)	0.2528
	Adjusted	Symmetry	1			1.16	(0.45–3.00)	0.7618
		Moderate asymmetry	1.59	(0.70–3.62)	0.2696	1.44	(0.44–4.70)	0.5441
		Prominent asymmetry	0.60	(0.13–2.87)	0.5215	1.98	(0.56–7.00)	0.2849
Female	Unadjusted	Symmetry	1			1.36	(0.58–3.18)	0.4763
		Moderate asymmetry	1.02	(0.58–1.81)	0.9380	2.47	(1.26–4.82)	0.0087
		Prominent asymmetry	1.29	(0.50–3.31)	0.5927	3.01	(1.28–7.04)	0.0116
	Adjusted	Symmetry	1			1.48	(0.61–3.60)	0.3878
		Moderate asymmetry	1.12	(0.60–2.10)	0.7198	2.98	(1.49–5.94)	0.0021
		Prominent asymmetry	1.37	(0.49–3.83)	0.5502	3.16	(1.37–7.29)	0.0075

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Discussion

In this study, we found that a low HGS was significantly associated with a higher odds of anxiety among older Korean women. Furthermore, we found a positive correlation between the degree of HGS asymmetry and risk of anxiety in women.

A previous study showed that high HGS was related to a lower prevalence of pain and anxiety in older Polish adults [23]. Our results generally agree with those of this previous study. However, our results were different from those of previous studies, showing significant effects among women but not among men. Population-level and methodological differences may account for these discrepancies.

Another previous study showed that the weaker the HGS in older Korean women, the higher the risk of depression, while no significant association was found in men [28]. A previous study has shown an association between anxiety and depression [29,30]. Combining these two results, we can infer that there is an association between low HGS and anxiety, specifically in women. The results of this study are consistent with this inference.

Although the mechanism by which low HGS is associated with anxiety remains unclear, we proposed the following explanation: older individuals with low HGS were more likely to have poor physical function. A low HGS is associated with upper limb disability in women with bilateral idiopathic carpal tunnel syndrome [31]. Older people with low physical function may be unable to get out of their beds, restricting their ability to engage in the activities of daily living, which would reduce their quality of life. Low HGS is associated with poor quality of life in cancer survivors [32]. Poor quality of life and functional impairment can lead to anxiety [33]. Anxiety may also contribute to a low HGS. Individuals with anxiety are more likely to experience sleep deprivation, which induces muscle loss and impairs regeneration [34,35].

Women appeared to have a greater inclination to experience anxiety due to low HGS compared to men. The 20th percentile HGS threshold for HGS in men (30.0 kg) is the 95th percentile of HGS in women. As low HGS for a man is high HGS for a woman, a man with low HGS may retain sufficient power to engage in daily activities, which would reduce his risk of anxiety. Men may also have a greater margin for HGS decline before experiencing the effects of weakness, compared to women. In addition, women are more likely to experience anxiety than men [36,37]. Therefore, they can be easily affected by factors that cause anxiety. A patriarchal mindset prevalent among the current older Korean adults may also contribute to this difference. Having grown up in a patriarchal society, many of them hold the belief that men should earn money while women should handle housework. As a result, retired men often do not feel obligated to engage in any form of work, including domestic chores, whereas women experience pressure to manage household responsibilities. This dynamic means that women, rather than men, are more likely to feel anxious when low HGS prevents them from fulfilling their expected roles. Given that 49.4% of the male survey population was not working, the disparity between retired men and women may significantly amplify the impact of low HGS on women’s anxiety.

Similar to low HGS, HGS asymmetry was associated with anxiety only in women. A possible reason for this association is as follows. HGS asymmetry can contribute to functional disability [38]. Functional disabilities can lead to anxiety [33]. Therefore, HGS asymmetry may lead to anxiety. The reason men did not show significant results in the HGS asymmetry analysis might be the same as that behind the results of the low HGS analysis. As men have lower odds of experiencing anxiety than women, they are less sensitive to factors contributing to anxiety.

In this study, women with “low HGS and moderate asymmetry” and “low HGS and prominent asymmetry” had increased odds of having anxiety. Tables 2 and 5 showed that the aOR for anxiety among groups were as follows: 2.173 for the low HGS group, 1.374 for the moderate symmetry group, and 1.829 for the prominent asymmetry group. The former aORs are higher than the latter aORs. Therefore, older women with low HGS and HGS asymmetry may require screening for anxiety.

This study had some limitations. First, the data were insufficient to capture details. For example, there were 542 women with a high school education level or lower, and 108 women with a college education level or higher, representing approximately one-fifth of the former group. Although aOR for the college or higher group (aOR: 3.41, 95% CI: 0.70–16.64) was higher than that of the high school or lower group (aOR: 2.06, 95% CI: 1.22–3.47), there was no statistical significance in the college or higher group, while there was statistical significance in the high school or lower group, according to the subgroup analysis for education level after adjusting for covariates (Table 4). Statistical significance in college or higher group might have been found if there were enough participants in that group. Additionally, we identified more cases with high odds ratios that did not achieve statistical significance, including the rural group (aOR: 2.54, 95% CI: 0.92–6.98), the obese group (aOR: 2.45, 95% CI: 0.94–6.38), and the low-stress group (aOR: 4.83, 95% CI: 0.94–24.73). In addition, we found a positive correlation between the degree of asymmetry and the risk of anxiety both before and after adjusting for covariates (Table 5); however, this effect was non-significant likely because of limited data. We also conducted a subgroup analysis to examine the association between low HGS and anxiety disorder severity. However, as only 21 men and 43 women had moderate or severe anxiety, the range of the 95% CI was too wide, and we were unable to find any significant effects. Therefore, we did not use this table in this study. Second, because a cross-sectional design was used, we could not prove whether there was a causal relationship between low HGS and anxiety. It is possible that low HGS caused anxiety. However, reverse causality and no causality are plausible. Third, some variables used in multiple logistic regression analyses, such as physical activity and smoking, were surveyed through self-reported questionnaires, which were not validated, potentially reducing the accuracy of the presented estimates. Finally, as this study included only South Korean participants, the results may not apply to other countries and contexts.

Measuring HGS is an easy, cost-effective, and noninvasive method for examining sarcopenia in older adults. Few studies have identified an association between low HGS and mental health outcomes. To date, only one study has examined the correlation between low HGS and anxiety. However, the study measured anxiety not by the GAD-7 but by the EuroQol-5D questionnaire and did not examine the correlation between the degree of HGS asymmetry and the risk of anxiety [23]. Anxiety disorders in older adults can result in morbidity and mortality; therefore, it is important that older women with low HGS who are more susceptible to anxiety be monitored.

Conclusion

This study’s findings revealed that low HGS can increase the risk of anxiety in older Korean women. In addition, our findings revealed a positive correlation between the degree of HGS asymmetry and the risks of anxiety in older women, suggesting a need for targeted interventions, which may include public health campaigns promoting exercise to improve HGS. However, we could not examine the association between low HGS and anxiety severity due to the limited number of participants. Further studies with larger sample sizes are required to determine the association between these two factors. In addition, we used Korea’s cross-sectional data in this study; further studies are needed to infer causality and identify associations in other ethnic groups.

Acknowledgments

This study used data from the ninth KNHANES, 2022, KCDC. We would like to thank Editage (www.editage.co.kr) for English language editing.

Data Availability

All KNHANES files are available from the KDCA database (URLs https://knhanes.kdca.go.kr/knhanes/sub03/sub03_02_05.do).

Funding Statement

The author(s) received no specific funding for this work.

References

1.Kirmizioglu Y, Doğan O, Kuğu N, Akyüz G. Prevalence of anxiety disorders among elderly people. Int J Geriatr Psychiatry. 2009;24(9):1026–33. doi: 10.1002/gps.2215 [DOI] [PubMed] [Google Scholar]
2.Goodwin R, Weinberger AH, Kim JH, Wu M, Galea S. Trends in anxiety among adults in the United States, 2008–2018: Rapid increases among young adults. J Psychiat Res. 2020:130;441–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Feter N, Caputo E, Doring I, Leite J, Cassuriaga J, Reichert F, et al. Sharp increase in depression and anxiety among Brazilian adults during the COVID-19 pandemic: findings from the PAMPA cohort. Public Health. 2021:190;101–7. doi: 10.1016/j.puhe.2020.11.013 [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Kim B-R, Hwang H-H. Analysis of major factors affecting the quality of life of the elderly in Korea in preparation for a super-aged society. Int J Environ Res Public Health. 2022;19(15):9618. doi: 10.3390/ijerph19159618 [DOI] [PMC free article] [PubMed] [Google Scholar]
5.van Hout HP, Beekman AT, De Beurs E, Comijs H, Van Marwijk H, De Haan M, et al. Anxiety and the risk of death in older men and women. Br J Psychiatry. 2004:185(5);399–404. doi: 10.1192/bjp.185.5.399 [DOI] [PubMed] [Google Scholar]
6.Schoevers RA, Beekman AT, Deeg D, Jonker C, Van Tilburg W. Comorbidity and risk-patterns of depression, generalised anxiety disorder and mixed anxiety-depression in later life: Results from the AMSTEL study. Int J Geriatr Psychiatry. 2003;18(11):994–1001. doi: 10.1002/gps.1001 [DOI] [PubMed] [Google Scholar]
7.Carrière I, Ryan J, Norton J, Scali J, Stewart R, Ritchie K, et al. Anxiety and mortality risk in community-dwelling elderly people. Br J Psychiatry. 2013;203(4):303–9. doi: 10.1192/bjp.bp.112.124685 [DOI] [PubMed] [Google Scholar]
8.Andreescu C, Lee S. Anxiety disorders in the elderly. Anxiety disorders: Rethinking and understanding recent discoveries. 2020:561–76. [DOI] [PubMed] [Google Scholar]
9.Lee D-Y, Shin S. Association of sarcopenia with osteopenia and osteoporosis in community-dwelling older korean adults: A cross-sectional study. J Clin Med. 2021;11(1):129. doi: 10.3390/jcm11010129 [DOI] [PMC free article] [PubMed] [Google Scholar]
10.Mesinovic J, Zengin A, De Courten B, Ebeling PR, Scott D. Sarcopenia and type 2 diabetes mellitus: a bidirectional relationship. Diabetes Metab Syndr Obes. 2019:1057–72. [DOI] [PMC free article] [PubMed] [Google Scholar]
11.Damluji AA, Alfaraidhy M, AlHajri N, Rohant NN, Kumar M, Al Malouf C, et al. Sarcopenia and Cardiovascular Diseases. Circulation. 2023;147(20):1534–53. doi: 10.1161/CIRCULATIONAHA.123.064071 [DOI] [PMC free article] [PubMed] [Google Scholar]
12.Li Z, Liu B, Tong X, Ma Y, Bao T, Yue J, et al. The association between sarcopenia and incident of depressive symptoms: a prospective cohort study. BMC Geriatr. 2024;24(1):74. doi: 10.1186/s12877-023-04653-z [DOI] [PMC free article] [PubMed] [Google Scholar]
13.Lee J-D, Lee J-H. Association between possible sarcopenia and depressive symptoms in korean older adults: Results from the Korea National Health and Nutrition Examination Survey in 2018. Korean J Fam Med. 2023;44(3):143–50. doi: 10.4082/kjfm.22.0145 [DOI] [PMC free article] [PubMed] [Google Scholar]
14.Lee SH, Gong HS. Measurement and interpretation of handgrip strength for research on sarcopenia and osteoporosis. J Bone Metab. 2020;27(2):85–96. doi: 10.11005/jbm.2020.27.2.85 [DOI] [PMC free article] [PubMed] [Google Scholar]
15.Brooks JM, Titus AJ, Bruce ML, Orzechowski NM, Mackenzie TA, Bartels SJ, et al. Depression and handgrip strength among U.S. adults aged 60 years and older from NHANES 2011-2014. J Nutr Health Aging. 2018;22(8):938–43. doi: 10.1007/s12603-018-1041-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
16.Ling CHY, Taekema D, de Craen AJM, Gussekloo J, Westendorp RGJ, Maier AB. Handgrip strength and mortality in the oldest old population: the Leiden 85-plus study. CMAJ. 2010;182(5):429–35. doi: 10.1503/cmaj.091278 [DOI] [PMC free article] [PubMed] [Google Scholar]
17.Kim KH, Park SK, Lee DR, Lee J. The relationship between handgrip strength and cognitive function in elderly Koreans over 8 years: A prospective population-based study using Korean longitudinal study of ageing. Korean J Fam Med. 2019;40(1):9–15. doi: 10.4082/kjfm.17.0074 [DOI] [PMC free article] [PubMed] [Google Scholar]
18.Han K-M, Chang J, Yoon H-K, Ko Y-H, Ham B-J, Kim Y-K, et al. Relationships between hand-grip strength, socioeconomic status, and depressive symptoms in community-dwelling older adults. J Affect Disord. 2019;252:263–70. doi: 10.1016/j.jad.2019.04.023 [DOI] [PubMed] [Google Scholar]
19.Armstrong CA, Oldham JA. A comparison of dominant and non-dominant hand strengths. J Hand Surg Br. 1999;24(4):421–5. doi: 10.1054/jhsb.1999.0236 [DOI] [PubMed] [Google Scholar]
20.Song Q, Shu X, Zhao Y, Ge N, Yue J. Association of handgrip strength asymmetry and weakness with depression among middle-aged and older population in China: A cohort study. J Affect Disord. 2024;363:401–8. doi: 10.1016/j.jad.2024.07.120 [DOI] [PubMed] [Google Scholar]
21.Lin S, Wang F, Huang Y, Yuan Y, Huang F, Zhu P. Handgrip strength weakness and asymmetry together are associated with cardiovascular outcomes in older outpatients: A prospective cohort study. Geriatr Gerontol Int. 2022;22(9):759–65. doi: 10.1111/ggi.14451 [DOI] [PMC free article] [PubMed] [Google Scholar]
22.McGrath R, Tomkinson GR, LaRoche DP, Vincent BM, Bond CW, Hackney KJ. Handgrip Strength Asymmetry and Weakness May Accelerate Time to Mortality in Aging Americans. J Am Med Dir Assoc. 2020;21(12):2003-2007. doi: 10.1016/j.jamda.2020.04.030 [DOI] [PubMed] [Google Scholar]
23.Sosowska N, Guligowska A, Sołtysik B, Borowiak E, Kostka T, Kostka J. Better handgrip strength is related to the lower prevalence of pain and anxiety in community-dwelling older adults. J Clin Med. 2023;12(11):3846. doi: 10.3390/jcm12113846 [DOI] [PMC free article] [PubMed] [Google Scholar]
24.Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092–7. doi: 10.1001/archinte.166.10.1092 [DOI] [PubMed] [Google Scholar]
25.Chen L-K, Liu L-K, Woo J, Assantachai P, Auyeung T-W, Bahyah KS, et al. Sarcopenia in Asia: consensus report of the Asian Working Group for Sarcopenia. J Am Med Dir Assoc. 2014;15(2):95–101. doi: 10.1016/j.jamda.2013.11.025 [DOI] [PubMed] [Google Scholar]
26.Purnell JQ. Definitions, classification, and epidemiology of obesity. 2015.
27.KDCA. Trends in prevalence of aerobic physical activity, 2014-2022. The Korea Disease Control and Prevention Agency. 2024. Report No.: 2005-811X 2586-0860 Contract No.: 11.
28.Hurh K, Park Y, Kim GR, Jang S-I, Park E-C. Associations of handgrip strength and handgrip strength asymmetry with depression in the elderly in Korea: A cross-sectional study. J Prev Med Public Health. 2020;54(1):63–72. doi: 10.3961/jpmph.20.315 [DOI] [PMC free article] [PubMed] [Google Scholar]
29.Kalin NH. The critical relationship between anxiety and depression. Am Psychiatric Assoc. 2020;365–7. [DOI] [PubMed] [Google Scholar]
30.Hettema JM. What is the genetic relationship between anxiety and depression? American journal of medical genetics part C: Seminars in medical genetics. 2008. Wiley Online Library; [DOI] [PubMed] [Google Scholar]
31.Yoshida A, Kurimoto S, Iwatsuki K, Saeki M, Nishizuka T, Nakano T, et al. Upper extremity disability is associated with pain intensity and grip strength in women with bilateral idiopathic carpal tunnel syndrome. NeuroRehabilitation. 2019;44(2):199–205. doi: 10.3233/NRE-182589 [DOI] [PubMed] [Google Scholar]
32.Kim H, Yoo S, Kim H, Park SG, Son M. Cancer survivors with low hand grip strength have decreased quality of life compared with healthy controls: The Korea National Health and Nutrition Examination Survey 2014-2017. Korean J Fam Med. 2021;42(3):204–11. doi: 10.4082/kjfm.20.0060 [DOI] [PMC free article] [PubMed] [Google Scholar]
33.de Waal MWM, Arnold IA, Eekhof JAH, van Hemert AM. Somatoform disorders in general practice: prevalence, functional limitations and comorbidity with anxiety and depression. Ned Tijdschr Geneeskd. 2006;150(12):671–6. [PubMed] [Google Scholar]
34.Dattilo M, Antunes HKM, Medeiros A, Mônico-Neto M, Souza H de S, Lee KS, et al. Paradoxical sleep deprivation induces muscle atrophy. Muscle Nerve. 2012;45(3):431–3. doi: 10.1002/mus.22322 [DOI] [PubMed] [Google Scholar]
35.Mônico-Neto M, Dáttilo M, Ribeiro DA, Lee KS, de Mello MT, Tufik S, et al. REM sleep deprivation impairs muscle regeneration in rats. Growth Factors. 2017;35(1):12–8. doi: 10.1080/08977194.2017.1314277 [DOI] [PubMed] [Google Scholar]
36.Grenier S, Payette M-C, Gunther B, Askari S, Desjardins FF, Raymond B, et al. Association of age and gender with anxiety disorders in older adults: A systematic review and meta-analysis. Int J Geriatr Psychiatry. 2019;34(3):397–407. doi: 10.1002/gps.5035 [DOI] [PubMed] [Google Scholar]
37.McLean CP, Asnaani A, Litz BT, Hofmann SG. Gender differences in anxiety disorders: prevalence, course of illness, comorbidity and burden of illness. J Psychiatr Res. 2011;45(8):1027–35. doi: 10.1016/j.jpsychires.2011.03.006 [DOI] [PMC free article] [PubMed] [Google Scholar]
38.McGrath R, Vincent BM, Jurivich DA, Hackney KJ, Tomkinson GR, Dahl LJ, et al. Handgrip Strength Asymmetry and Weakness Together Are Associated With Functional Disability in Aging Americans. J Gerontol A Biol Sci Med Sci. 2021;76(2):291–6. doi: 10.1093/gerona/glaa100 [DOI] [PubMed] [Google Scholar]

PLoS One. 2025 Apr 8;20(4):e0315256. doi: 10.1371/journal.pone.0315256.r001

Author response to Decision Letter 0

22 Nov 2024

PLoS One. doi: 10.1371/journal.pone.0315256.r002

Decision Letter 0

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18 Jan 2025

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Reviewer #1: This study explores the association between handgrip strength (HGS), HGS asymmetry, and anxiety among older adults in Korea, utilizing data from the 2022 Korea National Health and Nutrition Examination Survey (KNHANES). The finding of a significant correlation between low HGS and anxiety in women is particularly noteworthy. The research addresses an important public health topic and highlights the potential utility of HGS as a marker for mental health issues.

However, the study suffers from critical limitations, particularly the restricted sample size for subgroup analyses, insufficient depth in the interpretation of findings, and a lack of clarity on whether complex sampling analysis was conducted. Additionally, challenges in presenting data effectively further limit the study’s clarity and generalizability.

1. The data source, KNHANES, uses a complex sampling design involving stratification, clustering, and weighting to ensure population representativeness. However, the manuscript does not mention whether these design features were accounted for in the analysis.

A. Clarify whether the complex sampling design was incorporated into the analysis

B. Discuss the implications of not using complex sampling in the limitations section if it cannot be incorporated retroactively.

2. Subgroup analyses (e.g., by education level or area of residence) are undermined by small sample sizes, leading to wide confidence intervals and a lack of statistical significance, even in cases where the effect size appears substantial. For example, in the "college or higher" education subgroup among women, a high odds ratio (OR) was reported, but it did not achieve statistical significance due to the limited sample size.

A. Aggregate or simplify subgroup categories where appropriate to strengthen the robustness of statistical analyses.

B. Discuss the impact of small sample sizes on the interpretation of results more explicitly in the limitations section.

3. The observed gender differences in the results, particularly the lack of significant findings in men, are not sufficiently explained.

A. Elaborate on the biological, social, or cultural factors that may account for the gender differences observed in the association between HGS and anxiety.

B. Include additional references to explain why men might be less affected by HGS changes in relation to anxiety compared to women.

4. The presentation of data in tables can be improved to enhance readability.

A. Including both the odds ratio (OR) and the corresponding p-value in the results table is essential for a more complete and transparent understanding of the findings.

By addressing these points, the study’s rigor and clarity can be improved, enabling a better understanding of the relationship between handgrip strength and anxiety in older adults.

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PLoS One. 2025 Apr 8;20(4):e0315256. doi: 10.1371/journal.pone.0315256.r003

Author response to Decision Letter 1

25 Jan 2025

This study explores the association between handgrip strength (HGS), HGS asymmetry, and anxiety among older adults in Korea, utilizing data from the 2022 Korea National Health and Nutrition Examination Survey (KNHANES). The finding of a significant correlation between low HGS and anxiety in women is particularly noteworthy. The research addresses an important public health topic and highlights the potential utility of HGS as a marker for mental health issues.

-> Thank you for your thorough review of our manuscript. We will carefully read your comments and thoughtfully consider your valuable suggestions. Following the review, we have completely revised our manuscript. Below is our response to each comment.

Point 1

A. Clarify whether the complex sampling design was incorporated into the analysis

B. Discuss the implications of not using complex sampling in the limitations section if it cannot be incorporated retroactively.

Response 1: We thank for pointing this out. We have added explanation about the complex sampling design incorporated into the analysis.

Revised manuscript, line 126-128, page 7, Method: We used stratification, clustering, and weighting variables in the KNHANES data to ensure population representativeness. We used weighting variables that consider both health and nutrition factors.

Point 2

A. Aggregate or simplify subgroup categories where appropriate to strengthen the robustness of statistical analyses.

B. Discuss the impact of small sample sizes on the interpretation of results more explicitly in the limitations section.

Response 2: We thank you for the comments. Following your suggestions, we attempted to simplify the subgroup categories. However, all the variables were necessary, and we could not aggregate the subgroup categories because each variable had only two categories, except for obesity, which had three. While we initially discussed this limitation in the discussion section, we realized that our explanation was insufficient. Therefore, we have elaborated more explicitly on the limitation of small sample sizes.

Revised manuscript, line 260-263, page 17, Discussion: Additionally, we identified more cases with high odds ratios that did not achieve statistical significance, including the rural group (aOR: 2.54, 95% CI: 0.92–6.98), the obese group (aOR: 2.45, 95% CI: 0.94–6.38), and the low-stress group (aOR: 4.83, 95% CI: 0.94–24.73).

Point 3

3. The observed gender differences in the results, particularly the lack of significant findings in men, are not sufficiently explained.

A. Elaborate on the biological, social, or cultural factors that may account for the gender differences observed in the association between HGS and anxiety.

B. Include additional references to explain why men might be less affected by HGS changes in relation to anxiety compared to women.

Response 3: We thank you for the comments. Initially, we attributed the difference in results to the disparity in average HGS between men and women. However, we found this explanation insufficient and identified the patriarchal mindset as an additional contributing factor.

Revised manuscript, line 230-239, page 16, Discussion: A patriarchal mindset prevalent among the current older Korean adults may also contribute to this difference. Having grown up in a patriarchal society, many of them hold the belief that men should earn money while women should handle housework. As a result, retired men often do not feel obligated to engage in any form of work, including domestic chores, whereas women experience pressure to manage household responsibilities. This dynamic means that women, rather than men, are more likely to feel anxious when low HGS prevents them from fulfilling their expected roles. Given that 49.4% of the male survey population was not working, the disparity between retired men and women may significantly amplify the impact of low HGS on women’s anxiety.

Point 4

4. The presentation of data in tables can be improved to enhance readability.

A. Including both the odds ratio (OR) and the corresponding p-value in the results table is essential for a more complete and transparent understanding of the findings.

Response 4: We thank you for the comments. We have added p-values to all the results tables that were previously missing them.

Revised manuscript, Table 2,3,4,5: You can see the revised tables in 'response to reviewers' file.

Attachment

Submitted filename: Response to Reviewers_sangyoun_choi.docx

pone.0315256.s002.docx^{(223.4KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0315256.r004

Decision Letter 1

Marina De Rui

6 Feb 2025

Dear Dr. Park,

Please submit your revised manuscript by Mar 23 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Marina De Rui, MD PhD

Academic Editor

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Reviewer #1: Yes

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The PLOS Data policy

Reviewer #1: Yes

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Reviewer #1: This manuscript presents an important study on the association between Handgrip Strength (HGS) and Anxiety. However, there are some concerns regarding the clarity of confounding variables and the lack of Crude OR (Unadjusted OR) in the results tables (Table 2, 3, 4, 5). These issues may reduce the reliability of the findings. To improve the manuscript, the following revisions are strongly recommended.

1. The "Statistical Analysis" section should clearly specify which variables were used as confounders. A detailed list of confounders (e.g., age, education level, marital status, obesity, drinking, sleep duration, stress level, physical activity, smoking, etc.) should be explicitly provided. It should also be clearly stated whether these variables were used only as control variables or analyzed as independent predictors of anxiety.

2. Currently, only Adjusted OR (aOR) is provided, making it difficult to evaluate the effect of confounders on the results. Crude OR (Unadjusted OR) should be included in the tables to allow a direct comparison with Adjusted OR. This will enhance the transparency of how confounding variables affect the observed associations.

3. The current tables (Table 2, 3, 4, 5) provide Adjusted ORs for confounders such as age, education level, marital status, etc.

Confounders are not the primary exposure variables in this study, so providing Adjusted OR for them is not appropriate. The tables should report OR values only for the key independent variables.

Addressing these revisions will improve the clarity and credibility of the study findings.

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Reviewer #1: No

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PLoS One. 2025 Apr 8;20(4):e0315256. doi: 10.1371/journal.pone.0315256.r005

Author response to Decision Letter 2

20 Feb 2025

This manuscript presents an important study on the association between Handgrip Strength (HGS) and Anxiety. However, there are some concerns regarding the clarity of confounding variables and the lack of Crude OR (Unadjusted OR) in the results tables (Table 2, 3, 4, 5). These issues may reduce the reliability of the findings. To improve the manuscript, the following revisions are strongly recommended.

-> We sincerely appreciate the detailed review of our manuscript. We will thoroughly examine your comments and give careful consideration to your insightful suggestions. In response to your feedback, we have made comprehensive revisions to the manuscript. Below, we address each of your comments individually.

Point 1. The "Statistical Analysis" section should clearly specify which variables were used as confounders. A detailed list of confounders (e.g., age, education level, marital status, obesity, drinking, sleep duration, stress level, physical activity, smoking, etc.) should be explicitly provided. It should also be clearly stated whether these variables were used only as control variables or analyzed as independent predictors of anxiety.

Response 1: Thank you for your valuable feedback. We have revised the "Statistical Analysis" section to specify the confounders used in the analysis. As suggested, we have provided a detailed list of confounders, including age, education level, working state, residence, marital status, obesity, drinking, sleep duration, stress level, physical activity, and smoking. Additionally, we have clarified that these variables were included solely as control variables and were not analyzed as independent predictors of anxiety.

Revised manuscript, line 129-131, page 7, Methods: Age, education level, working state, residence, marital status, obesity, drinking, sleep duration, stress level, physical activity, and smoking were used as confounders. These variables were included solely as control variables and not as independent predictors of anxiety.

Point 2 & 3 (related to Table 2,3,4,5)

Point 2. Currently, only Adjusted OR (aOR) is provided, making it difficult to evaluate the effect of confounders on the results. Crude OR (Unadjusted OR) should be included in the tables to allow a direct comparison with Adjusted OR. This will enhance the transparency of how confounding variables affect the observed associations.

Response 2: Thank you for your valuable feedback regarding the presentation of the results. We agree that providing both Crude OR (Unadjusted OR, cOR) and Adjusted OR (aOR) in the tables would enhance transparency and allow for a clearer evaluation of the effect of confounders on the observed associations.

In response to your comment, we have revised Tables 2, 3, 4, and 5 to include both Crude OR and Adjusted OR. This modification allows for a direct comparison between unadjusted and adjusted estimates, providing a more comprehensive understanding of how confounding variables influence the results. We also added explanations in manuscript to clarity if the results were adjusted for covariates or not.

After appending the Crude ORs to Table 3, the table became excessively large. To improve readability and organization, we divided the content into two separate tables: Table 3 and Table 4. Subsequently, all following tables were renumbered accordingly.

We believe these changes improve the clarity and robustness of our findings. Thank you for your constructive suggestion, which has significantly strengthened the manuscript.

Point 3. The current tables (Table 2, 3, 4, 5) provide Adjusted ORs for confounders such as age, education level, marital status, etc.

Confounders are not the primary exposure variables in this study, so providing Adjusted OR for them is not appropriate. The tables should report OR values only for the key independent variables.

Response 3: Thank you for your insightful comment regarding the presentation of Adjusted Odds Ratios (ORs) for confounders in the tables. We agree that confounders such as age, education level, marital status, etc., are not the primary exposure variables in this study, and reporting Adjusted ORs for these variables may not be appropriate.

In response to your feedback, we have revised Table 2 to remove the Adjusted ORs for confounders. Also, we have deleted the accompanying sentences in the text that explained the Adjusted ORs for confounders. The tables now focus solely on reporting aOR values for the key independent variables, as recommended.

We divided the participants by each confounder for Table 3 and 4 (previously Table 3). We conducted multiple logistic regression analysis between HGS and anxiety in each subgroup. Since these subgroup analyses provided meaningful insights, we have retained them in the manuscript.

In Tables 5 and 6 (previously Tables 4 and 5), ORs for confounders were not provided because the confounders were used exclusively to adjust for covariates. Therefore, we have retained Tables 5 and 6 in the manuscript.

We believe these changes improve the clarity and relevance of the results presented. Thank you for your valuable suggestion, which has helped enhance the quality of our manuscript.

Revised manuscript, line 162-164, page 10, Results: Both before and after adjusting for covariates, the risk of having anxiety was significantly higher among women who had low HGS (crude OR [cOR]: 1.33, 95% CI: 0.67–2.63 in men, cOR: 1.989, 95% CI: 1.23–3.21 in women, adjusted OR [aOR]: 1.22, 95% CI: 0.62–2.43 in men, aOR: 2.17, 95% CI: 1.31–3.61 in women).

Revised manuscript, line 172-175, page 11, Results: Both before and after adjusting for covariates, no statistically significant differences were found in any male subgroup, in contrast to female subgroups.

Revised manuscript, line 261-265, page 18, Discussion: Although aOR for the college or higher group (aOR: 3.41, 95% CI: 0.70–16.64) was higher than that of the high school or lower group (aOR: 2.06, 95% CI: 1.22–3.47), there was no statistical significance in the college or higher group, while there was statistical significance in the high school or lower group, according to the subgroup analysis for education level after adjusting for covariates (Table 4).

Revised manuscript, line 269-271, page 18, Discussion: In addition, we found a positive correlation between the degree of asymmetry and the risk of anxiety both before and after adjusting for covariates (Table 5);

Revised manuscript, Table 2,3,4,5,6 : Please refer to "Respond to Reviewers" file or manuscript file.

Attachment

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PLoS One. doi: 10.1371/journal.pone.0315256.r006

Decision Letter 2

Marina De Rui

3 Mar 2025

Association between handgrip strength, handgrip strength asymmetry, and anxiety in Korean older adults: The Korean National Health and Nutrition Examination Survey 2022

PONE-D-24-53685R2

Dear Dr. Park,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

**********

Reviewer #1: Tables 2 to 5, both unadjusted (crude) and adjusted odds ratios are presented, which is commendable for transparency. However, for ease of interpretation, it is recommended that the order of the estimates be reversed so that the unadjusted (crude) odds ratios are listed first, followed by the adjusted odds ratios. Presenting the crude values first will clearly delineate the impact of confounding variables and allow readers to directly compare the effect of adjustment on the associations.

**********

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Reviewer #1: No

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PLoS One. doi: 10.1371/journal.pone.0315256.r007

Acceptance letter

Marina De Rui

PONE-D-24-53685R2

PLOS ONE

Dear Dr. Park,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

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Data Availability Statement

All KNHANES files are available from the KDCA database (URLs https://knhanes.kdca.go.kr/knhanes/sub03/sub03_02_05.do).

[pone.0315256.ref001] 1.Kirmizioglu Y, Doğan O, Kuğu N, Akyüz G. Prevalence of anxiety disorders among elderly people. Int J Geriatr Psychiatry. 2009;24(9):1026–33. doi: 10.1002/gps.2215 [DOI] [PubMed] [Google Scholar]

[pone.0315256.ref002] 2.Goodwin R, Weinberger AH, Kim JH, Wu M, Galea S. Trends in anxiety among adults in the United States, 2008–2018: Rapid increases among young adults. J Psychiat Res. 2020:130;441–6. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0315256.ref003] 3.Feter N, Caputo E, Doring I, Leite J, Cassuriaga J, Reichert F, et al. Sharp increase in depression and anxiety among Brazilian adults during the COVID-19 pandemic: findings from the PAMPA cohort. Public Health. 2021:190;101–7. doi: 10.1016/j.puhe.2020.11.013 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0315256.ref004] 4.Kim B-R, Hwang H-H. Analysis of major factors affecting the quality of life of the elderly in Korea in preparation for a super-aged society. Int J Environ Res Public Health. 2022;19(15):9618. doi: 10.3390/ijerph19159618 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0315256.ref005] 5.van Hout HP, Beekman AT, De Beurs E, Comijs H, Van Marwijk H, De Haan M, et al. Anxiety and the risk of death in older men and women. Br J Psychiatry. 2004:185(5);399–404. doi: 10.1192/bjp.185.5.399 [DOI] [PubMed] [Google Scholar]

[pone.0315256.ref006] 6.Schoevers RA, Beekman AT, Deeg D, Jonker C, Van Tilburg W. Comorbidity and risk-patterns of depression, generalised anxiety disorder and mixed anxiety-depression in later life: Results from the AMSTEL study. Int J Geriatr Psychiatry. 2003;18(11):994–1001. doi: 10.1002/gps.1001 [DOI] [PubMed] [Google Scholar]

[pone.0315256.ref007] 7.Carrière I, Ryan J, Norton J, Scali J, Stewart R, Ritchie K, et al. Anxiety and mortality risk in community-dwelling elderly people. Br J Psychiatry. 2013;203(4):303–9. doi: 10.1192/bjp.bp.112.124685 [DOI] [PubMed] [Google Scholar]

[pone.0315256.ref008] 8.Andreescu C, Lee S. Anxiety disorders in the elderly. Anxiety disorders: Rethinking and understanding recent discoveries. 2020:561–76. [DOI] [PubMed] [Google Scholar]

[pone.0315256.ref009] 9.Lee D-Y, Shin S. Association of sarcopenia with osteopenia and osteoporosis in community-dwelling older korean adults: A cross-sectional study. J Clin Med. 2021;11(1):129. doi: 10.3390/jcm11010129 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0315256.ref010] 10.Mesinovic J, Zengin A, De Courten B, Ebeling PR, Scott D. Sarcopenia and type 2 diabetes mellitus: a bidirectional relationship. Diabetes Metab Syndr Obes. 2019:1057–72. [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0315256.ref011] 11.Damluji AA, Alfaraidhy M, AlHajri N, Rohant NN, Kumar M, Al Malouf C, et al. Sarcopenia and Cardiovascular Diseases. Circulation. 2023;147(20):1534–53. doi: 10.1161/CIRCULATIONAHA.123.064071 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0315256.ref012] 12.Li Z, Liu B, Tong X, Ma Y, Bao T, Yue J, et al. The association between sarcopenia and incident of depressive symptoms: a prospective cohort study. BMC Geriatr. 2024;24(1):74. doi: 10.1186/s12877-023-04653-z [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0315256.ref013] 13.Lee J-D, Lee J-H. Association between possible sarcopenia and depressive symptoms in korean older adults: Results from the Korea National Health and Nutrition Examination Survey in 2018. Korean J Fam Med. 2023;44(3):143–50. doi: 10.4082/kjfm.22.0145 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0315256.ref014] 14.Lee SH, Gong HS. Measurement and interpretation of handgrip strength for research on sarcopenia and osteoporosis. J Bone Metab. 2020;27(2):85–96. doi: 10.11005/jbm.2020.27.2.85 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0315256.ref015] 15.Brooks JM, Titus AJ, Bruce ML, Orzechowski NM, Mackenzie TA, Bartels SJ, et al. Depression and handgrip strength among U.S. adults aged 60 years and older from NHANES 2011-2014. J Nutr Health Aging. 2018;22(8):938–43. doi: 10.1007/s12603-018-1041-5 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0315256.ref016] 16.Ling CHY, Taekema D, de Craen AJM, Gussekloo J, Westendorp RGJ, Maier AB. Handgrip strength and mortality in the oldest old population: the Leiden 85-plus study. CMAJ. 2010;182(5):429–35. doi: 10.1503/cmaj.091278 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0315256.ref017] 17.Kim KH, Park SK, Lee DR, Lee J. The relationship between handgrip strength and cognitive function in elderly Koreans over 8 years: A prospective population-based study using Korean longitudinal study of ageing. Korean J Fam Med. 2019;40(1):9–15. doi: 10.4082/kjfm.17.0074 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0315256.ref018] 18.Han K-M, Chang J, Yoon H-K, Ko Y-H, Ham B-J, Kim Y-K, et al. Relationships between hand-grip strength, socioeconomic status, and depressive symptoms in community-dwelling older adults. J Affect Disord. 2019;252:263–70. doi: 10.1016/j.jad.2019.04.023 [DOI] [PubMed] [Google Scholar]

[pone.0315256.ref019] 19.Armstrong CA, Oldham JA. A comparison of dominant and non-dominant hand strengths. J Hand Surg Br. 1999;24(4):421–5. doi: 10.1054/jhsb.1999.0236 [DOI] [PubMed] [Google Scholar]

[pone.0315256.ref020] 20.Song Q, Shu X, Zhao Y, Ge N, Yue J. Association of handgrip strength asymmetry and weakness with depression among middle-aged and older population in China: A cohort study. J Affect Disord. 2024;363:401–8. doi: 10.1016/j.jad.2024.07.120 [DOI] [PubMed] [Google Scholar]

[pone.0315256.ref021] 21.Lin S, Wang F, Huang Y, Yuan Y, Huang F, Zhu P. Handgrip strength weakness and asymmetry together are associated with cardiovascular outcomes in older outpatients: A prospective cohort study. Geriatr Gerontol Int. 2022;22(9):759–65. doi: 10.1111/ggi.14451 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0315256.ref022] 22.McGrath R, Tomkinson GR, LaRoche DP, Vincent BM, Bond CW, Hackney KJ. Handgrip Strength Asymmetry and Weakness May Accelerate Time to Mortality in Aging Americans. J Am Med Dir Assoc. 2020;21(12):2003-2007. doi: 10.1016/j.jamda.2020.04.030 [DOI] [PubMed] [Google Scholar]

[pone.0315256.ref023] 23.Sosowska N, Guligowska A, Sołtysik B, Borowiak E, Kostka T, Kostka J. Better handgrip strength is related to the lower prevalence of pain and anxiety in community-dwelling older adults. J Clin Med. 2023;12(11):3846. doi: 10.3390/jcm12113846 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0315256.ref024] 24.Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092–7. doi: 10.1001/archinte.166.10.1092 [DOI] [PubMed] [Google Scholar]

[pone.0315256.ref025] 25.Chen L-K, Liu L-K, Woo J, Assantachai P, Auyeung T-W, Bahyah KS, et al. Sarcopenia in Asia: consensus report of the Asian Working Group for Sarcopenia. J Am Med Dir Assoc. 2014;15(2):95–101. doi: 10.1016/j.jamda.2013.11.025 [DOI] [PubMed] [Google Scholar]

[pone.0315256.ref026] 26.Purnell JQ. Definitions, classification, and epidemiology of obesity. 2015.

[pone.0315256.ref027] 27.KDCA. Trends in prevalence of aerobic physical activity, 2014-2022. The Korea Disease Control and Prevention Agency. 2024. Report No.: 2005-811X 2586-0860 Contract No.: 11.

[pone.0315256.ref028] 28.Hurh K, Park Y, Kim GR, Jang S-I, Park E-C. Associations of handgrip strength and handgrip strength asymmetry with depression in the elderly in Korea: A cross-sectional study. J Prev Med Public Health. 2020;54(1):63–72. doi: 10.3961/jpmph.20.315 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0315256.ref029] 29.Kalin NH. The critical relationship between anxiety and depression. Am Psychiatric Assoc. 2020;365–7. [DOI] [PubMed] [Google Scholar]

[pone.0315256.ref030] 30.Hettema JM. What is the genetic relationship between anxiety and depression? American journal of medical genetics part C: Seminars in medical genetics. 2008. Wiley Online Library; [DOI] [PubMed] [Google Scholar]

[pone.0315256.ref031] 31.Yoshida A, Kurimoto S, Iwatsuki K, Saeki M, Nishizuka T, Nakano T, et al. Upper extremity disability is associated with pain intensity and grip strength in women with bilateral idiopathic carpal tunnel syndrome. NeuroRehabilitation. 2019;44(2):199–205. doi: 10.3233/NRE-182589 [DOI] [PubMed] [Google Scholar]

[pone.0315256.ref032] 32.Kim H, Yoo S, Kim H, Park SG, Son M. Cancer survivors with low hand grip strength have decreased quality of life compared with healthy controls: The Korea National Health and Nutrition Examination Survey 2014-2017. Korean J Fam Med. 2021;42(3):204–11. doi: 10.4082/kjfm.20.0060 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0315256.ref033] 33.de Waal MWM, Arnold IA, Eekhof JAH, van Hemert AM. Somatoform disorders in general practice: prevalence, functional limitations and comorbidity with anxiety and depression. Ned Tijdschr Geneeskd. 2006;150(12):671–6. [PubMed] [Google Scholar]

[pone.0315256.ref034] 34.Dattilo M, Antunes HKM, Medeiros A, Mônico-Neto M, Souza H de S, Lee KS, et al. Paradoxical sleep deprivation induces muscle atrophy. Muscle Nerve. 2012;45(3):431–3. doi: 10.1002/mus.22322 [DOI] [PubMed] [Google Scholar]

[pone.0315256.ref035] 35.Mônico-Neto M, Dáttilo M, Ribeiro DA, Lee KS, de Mello MT, Tufik S, et al. REM sleep deprivation impairs muscle regeneration in rats. Growth Factors. 2017;35(1):12–8. doi: 10.1080/08977194.2017.1314277 [DOI] [PubMed] [Google Scholar]

[pone.0315256.ref036] 36.Grenier S, Payette M-C, Gunther B, Askari S, Desjardins FF, Raymond B, et al. Association of age and gender with anxiety disorders in older adults: A systematic review and meta-analysis. Int J Geriatr Psychiatry. 2019;34(3):397–407. doi: 10.1002/gps.5035 [DOI] [PubMed] [Google Scholar]

[pone.0315256.ref037] 37.McLean CP, Asnaani A, Litz BT, Hofmann SG. Gender differences in anxiety disorders: prevalence, course of illness, comorbidity and burden of illness. J Psychiatr Res. 2011;45(8):1027–35. doi: 10.1016/j.jpsychires.2011.03.006 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pone.0315256.ref038] 38.McGrath R, Vincent BM, Jurivich DA, Hackney KJ, Tomkinson GR, Dahl LJ, et al. Handgrip Strength Asymmetry and Weakness Together Are Associated With Functional Disability in Aging Americans. J Gerontol A Biol Sci Med Sci. 2021;76(2):291–6. doi: 10.1093/gerona/glaa100 [DOI] [PubMed] [Google Scholar]

PERMALINK

Association between handgrip strength, handgrip strength asymmetry, and anxiety in Korean older adults: The Korean National Health and Nutrition Examination Survey 2022

Sang-Youn Choi

Su-Min Park

Eun-Cheol Park

Roles

Abstract

Introduction

Methods

Study population

Variables

Statistical analysis

Ethics statement

Results

Table 1. Socioeconomic and health-related characteristics of all study participants according to anxiety.

Table 2. Association between handgrip strength and anxiety.

Table 3. Subgroup analysis of the relationship between handgrip strength and anxiety among male.

Table 4. Subgroup analysis of the relationship between handgrip strength and anxiety among female.

Table 5. Association between HGS-related factors and anxiety.

Table 6. Effects of HGS and HGS asymmetry on anxiety.

Discussion

Conclusion

Acknowledgments

Data Availability

Funding Statement

References

Author response to Decision Letter 0

Decision Letter 0

Marina De Rui

Roles

Author response to Decision Letter 1

Decision Letter 1

Marina De Rui

Roles

Author response to Decision Letter 2

Decision Letter 2

Marina De Rui

Roles

Acceptance letter

Marina De Rui

Roles

Associated Data

Supplementary Materials

Data Availability Statement

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PERMALINK

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