Better muscle strength with healthy eating

Abstract

PurposeHand grip strength (HGS) can predict physical function in next year when it is positively associated with nutritional and health status. This study aimed to determine the relationship between the healthy eating index (HEI)-2015 and hand grip strength.Methods
This cross-sectional study was conducted on data from 4010 participants in the Ravansar non-communicable disease (RaNCD) cohort study. HGS was measured using a hand-held hydraulic hand grip dynamometer. HEI-2015 was calculated using data from the food frequency questionnaire.ResultsThe mean of total HEI-2015 score was significantly higher in participants with an optimal HGS than in participants with a weak HGS (P = 0.006). Higher adherence to healthy eating was associated with optimal muscle strength (OR 1.26; CI 95% 1.02–1.62). This association was remained after being adjusted for potential confounders (P = 0.01). Among the HEI-2015 components, we only found association between whole fruit, added sugar, and HGS (P = 0.01, 0.019).Conclusions
Our findings indicated that adherence to HEI-2015 could promote muscle strength. Among the HEI-2015 components, higher intake of whole fruit and lower adherence to added sugar had significantly positive effects on HGS.Level of evidenceLevel V, descriptive cross-sectional study.

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Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity
https://doi.org/10.1007/s40519-020-00863-1
ORIGINAL ARTICLE
Better muscle strength withhealthy eating
YahyaPasdar1· ShimaMoradi1 · MehdiMoradinazar2· BehroozHamzeh3· FaridNaja4
Received: 12 November 2019 / Accepted: 28 January 2020
© Springer Nature Switzerland AG 2020
Abstract
Purpose Hand grip strength (HGS) can predict physical function in next year when it is positively associated with nutritional
and health status. This study aimed to determine the relationship between the healthy eating index (HEI)-2015 and hand
grip strength.
Methods This cross-sectional study was conducted on data from 4010 participants in the Ravansar non-communicable
disease (RaNCD) cohort study. HGS was measured using a hand-held hydraulic hand grip dynamometer. HEI-2015 was
calculated using data from the food frequency questionnaire.
Results The mean of total HEI-2015 score was significantly higher in participants with an optimal HGS than in participants
with a weak HGS (P = 0.006). Higher adherence to healthy eating was associated with optimal muscle strength (OR 1.26;
CI 95% 1.02–1.62). This association was remained after being adjusted for potential confounders (P = 0.01). Among the
HEI-2015 components, we only found association between whole fruit, added sugar, and HGS (P = 0.01, 0.019).
Conclusions Our findings indicated that adherence to HEI-2015 could promote muscle strength. Among the HEI-2015
components, higher intake of whole fruit and lower adherence to added sugar had significantly positive effects on HGS.
Level of evidence Level V, descriptive cross-sectional study.
Keywords Healthy eating index· Muscle strength· Non-communicable disease
Introduction
Hand grip strength (HGS) is defined as the total flexor mus-
cles strength versus palmar muscles as well as extensor mus-
cles, playing a secondary role in this contraction [1]. Evi-
dence suggests that increased muscle strength is associated
with improving health and reducing non-communicable dis-
eases (NCDs) such as cardiovascular disease, diabetes, and
overall mortality [2, 3]. In addition, poor muscle strength
can increase the risk of fall, fractures, and disability in the
years to come [4]. HGS is a simple, reliable, and noninva-
sive tool applied in many epidemiological studies to meas-
ure muscle strength [5, 6] and can predict overall muscle
strength [1]. Inappropriate lifestyle such as sedentary behav-
iors and adherence to unhealthy dietary can accelerate the
process of low muscle mass and strength [6, 7].
Healthy eating index (HEI) is developed to assess diet
quality based on the Dietary Guidelines for Americans
(DGA) that is updated every 5years [8]. HEI-2015 empha-
sizes adequacy and moderation. Components of adequacy
part include total fruits, whole fruits, total vegetables, greens
and beans, whole grains, dairy, total protein foods, seafood
* Shima Moradi
Shima.Moradi@kums.ac.ir
Yahya Pasdar
Yahya.pasdar@kums.ac.ir
Mehdi Moradinazar
M.moradinazar@kums.ac.ir
Behrooz Hamzeh
behrooz.hamzeh@kums.ac.ir
Farid Najafi
farid_n32@yahoo.com
1 Department ofNutritional Sciences, Research Center
forEnvironmental Determinants ofHealth (RCEDH), Health
Institute, Kermanshah University ofMedical Sciences,
Kermanshah, Iran
2 Behavioral Disease Research Center, Kermanshah University
ofMedical Sciences, Kermanshah, Iran
3 Environmental Determinates ofHealth Research Center,
School ofPublic Health, Kermanshah University ofMedical
Sciences, Kermanshah, Iran
4 Communing Developmental andHealth Promotion Research
Center, School ofPublic Health, Kermanshah University
ofMedical Sciences, Kermanshah, Iran

Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity
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and plant proteins, and fatty acids, and the other part empha-
sizes the limitation of the consumption of refined grains,
sodium, added sugars, and saturated fats [9]. Adherence to
a Mediterranean diet as a healthy diet can strengthen muscle
strength [6, 10]. This dietary pattern is associated with high
intake of whole grains, fruits, vegetables, nuts, legumes,
olive oil, low-fat dairy, moderate consumption of poultry
and fish, and low consumption of red meat, processed meat,
and sweets [6]. Additionally, a Nordic diet with low intake
of added sugar, dietary fat, and high fiber intake and sea
foods has protective effects on muscle strength and mobil-
ity [4, 10]. To the best of our knowledge, there is no any
study on HEI-2015 and muscle strength. Since recognition
and screening of the muscle status and nutritional quality of
the community are important to prevent NCDs, this study
aimed to assess HEI-2015 and muscle strength in the Ravan-
sar non-communicable diseases (RaNCDs) cohort study.
Methods
Study design andpopulation
This cross-sectional study was conducted using the base-
line data from the RaNCD cohort study. Since 2014, this
study is the first Kurdish population-based study on 10,059
Kurdish participants aged 35–65years living in Ravansar
city, Kermanshah province, Western Iran. The RaNCD is
one of 18 studies developed by the PERSIAN (Prospective
Epidemiological Research Studies in Iran) mega-cohort
study that was approved by the Ethics Committees in the
Ministry of Health and Medical Education, the Digestive
Diseases Research Institute, Tehran University of Medical
Sciences, Iran. The protocol of the RaNCD cohort study
was described in previous studies [11, 12]. The cohort
study was given ethical approval by the Ethics Commit-
tee of Kermanshah University of Medical Sciences (ethics
approval number: KUMS.REC.1394.318).
In the current study, we included the participants with
an available dynamometry status at the baseline. Owing
to loss of muscle mass in CVDs [13], cancer [14], and
thyroid disorders [15, 16], we did not include participants
with these disease as well as participants with pregnancy.
Furthermore, the participants consuming energy intake
less than 800kcal/day and more than 4200kcal/day were
considered under and over energy intake reporter, respec-
tively; therefore, they were not included in this study.
Fourteen participants, who did not have complete infor-
mation to calculate the HEI, were excluded from the study
(Fig.1).
Fig. 1 Flowchart of the study

Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity
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Data collection
We included the demographic data, anthropometric indices,
nutritional assessments, and HGS measurement collected
by well-trained interviewers in the study site in Ravansar.
Anthropometric indices
In the RaNCD cohort study, height was measured by the
automatic stadiometer BSM 370 (Biospace Co., Seoul,
Korea) in a standing position without shoes and with the
precision of 0.1cm. Weight was measured using the InBody
770 device (InBody Co, Seoul, Korea) with at least cloth-
ing and without shoes. Body mass index (BMI) was calcu-
lated by dividing the weight (kg) by the square of the height
(meter).
Hand grip strength
HGS was determined using a hand-held hydraulic hand grip
dynamometer (model SH5003; Saehan Corporation, Masan,
Korea). Calibration of this dynamometer was carried out
according to the manufacturers’ manual. The measurement
was taken with the dominant hand when the participant was
sitting and the elbow was at 90º of flexion. The participant
was asked to squeeze the handle with maximal effort for
10s. The measurement was repeated after 30s, and the lat-
ter was recorded as hand grip strength. Based on the guide-
lines of this device, we considered optimal and weak muscle
strength for each age group and gender [17].
Dietary assessment andHealthy eating index 2015
A total of the 130-item food frequency questionnaire was
completed to assess dietary intake in the previous year that
consisted of ten parts as follows: bread and grains, beans,
meat and its products, dairies, vegetables, fruits, oils, oil-
seeds and butter, added sugar, and spices. The validity and
reliability of this questionnaire were assessed in previous
studies [18]. We obtained the dietary information of this
questionnaire and then calculated HEI-2015, based on the
last revised HEI available in the Department of Agriculture,
Center for Nutrition Policy and Promotion [19]. This index
has two sections: adequacy and moderation. The adequacy
was related to the adequate intake of total fruits, whole
fruits, total vegetables, greens and beans, whole grains,
dairies, total protein foods, seafood and plant proteins, and
fatty acids. Moderation intake of refined grains, sodium,
added sugars, and saturated fats was evaluated using this
index (Table1).
Statistical analysis
Statistical analyses were conducted using Stata, version 14
(Stata Corp, College Station, TX). All quantitative variables
were presented as mean ± standard deviation. Qualitative vari-
ables were reported using frequency (%). Comparison of base-
line characteristics was assessed according to the HEI-2015
quartiles using ANOVA and Chi-square tests. In addition,
comparison of components of HEI-2015 between participants
with weak and optimal muscle strength was made using the
ANOVA test. Radar graphs were constructed using the Excel
software (Microsoft Office 2010) to show difference in the
obtained score of HEI-2015 components between participants
with weak and optimal muscle strength. Binary logistic regres-
sion was used in crude and adjusted models. In adjusted Model
1, we controlled the variables of age, gender, smoking, and
alcohol use. Furthermore, in adjusted Model 2, in addition
to the variables of Model 1, we controlled the variables of
physical activity and diabetes. First, the quartile of HEI-2015
was considered the reference category in all binary logistic
regression analyses. P-values were considered significant at
the level of < 0.05.
Results
In the current study, the mean of total HEI-2015 score was
significantly higher in participants with an optimal HGS
than in participants with a weak HGS (P = 0.006) (Table1).
In addition, the mean of HGS was significantly increased
with the increase in the HEI-2015 score (P < 0.001). Table2
presents the baseline characteristics according to HEI-2015
quintiles.
Our findings indicated that higher adherence to healthy
eating was associated with optimal muscle strength (OR
1.26; CI 95% 1.02–1.62). This association was remained
after being adjusted for potential confounders (P = 0.01)
(Table3).
Although totally all HEI-2015 components were higher
than in participants with an optimal HGS than in participants
with a weak HGS, this difference was only significant for
whole fruit and added sugar components.
In this study, we found that higher intake of whole
fruits was associated with an optimal HGS (OR 1.01; CI
95% 1.02–1.18). In addition, participants who consumed
less added sugar had an optimal HGS (OR 1.06; CI 95%
1.01–1.12) (Table4).
Discussion
This study highlights that higher adherence to healthy eat-
ing is associated with an optimal HGS. Epidemiological
studies have indicated that proper nutrition can prevent the

Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity
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progression of frailty during aging, which is characterized
by a low HGS [6, 7]. Since low muscle strength is associated
with decreased physical function [20], increased fractures
[21], worsening cardiometabolic status [3], and all-cause
mortality [22], identification of dietary components is an
effective strategy to prevent low muscle strength. To the best
of our knowledge, this study is the first study evaluating
HEI-2015 and its components using HGS.
Stress oxidative and inflammation contribute to develop-
ment of low muscle strength and its subsequence frailty [23,
24]. The HEI-2015 confirms an adequate intake of fruits,
vegetables, whole grain, seafood, plant protein, dairy, and
essential fatty acid. In addition, consumption of refined
grain, added sugar, sodium, and saturated fatty acid should
be moderate [8]. Fruits and vegetables are high in antioxi-
dants and play a key role in systemic inflammation [25].
Furthermore, omega-3 fatty acid had beneficial effects on
decreasing inflammation [26]. Dairy products, sea food,
and plant protein spatially soy protein can promote muscle
strength and muscle mass [27–29]. Moreover, dairy products
are rich in high biological value protein and important min-
erals, including calcium and phosphorus [30]. In addition to
high biological value protein, seafood can provide omega-3
fatty acid, contributing to reduction in inflammation [31,
32].
Among the HEI-2015 components, higher adherence to
whole fruits intake was related to better muscle strength. In
the components, all fruits were considered without fruits
Table 1 Healthy eating index—2015
Intakes between the minimum and maximum standards are scored proportionately
*P value was obtained independent samples T test
a 100% fruit juice
b All forms except juice
c Legumes (beans and peas)
d All milk products, such as fluid milk, yogurt, and cheese, and fortified soy beverages
e Seafood, nuts, seeds, soy products (other than beverages), and legumes (beans and peas)
d Ratio of poly- and monounsaturated fatty acids (PUFAs and MUFAs) to saturated fatty acids (SFAs)
Component Standard for maximum
score
Standard for minimum
score of zero
Maxi-
mum
points
Weak muscle strength Optimum
muscle
strength
P value*
Adequacy
Total fruitsa≥ 0.8 cup equivalent per
1000kcal
No fruit 5 2.59 ± 1.25 2.69 ± 1.26 0.881
Whole fruitsb≥ 0.4 cup equivalent per
1000kcal
No whole fruit 5 3.78 ± 1.3 3.93 ± 1.24 0.004
Total vegetablesc≥ 1.1 cup equivalent per
1000kcal
No vegetables 5 3.43 ± 1.1 3.46 ± 1.1 0.837
Greens and beansc≥ 0.2 cup equivalent per
1000kcal
No dark green vegetables
or legumes
53.19 ± 1.25 3.23 ± 1.27 0.432
Whole grains ≥ 1.5 cup equivalent per
1000kcal
No whole grains 10 1.37 ± 0.97 1.35 ± 0.92 0.476
Dairyd≥ 1.3 cup equivalent per
1000kcal
No dairy 10 4.95 ± 2.81 4.99 ± 2.74 0.291
Total protein foodsc≥ 2.5 cup equivalent per
1000kcal
No protein foods 5 3.02 ± 1.09 3.1 ± 1.08 0.736
Seafood and plant
proteinsc,e
≥ 0.8 cup equivalent per
1000kcal
No seafood or plant
Proteins
54.13 ± 0.67 4.17 ± 0.69 0.136
Fatty acidsf(PUFAs + MUFAs)/
SFAs ≥ 2.5
(PUFAs + MUFAs)/
SFAs ≤ 1.2
10 4.69 ± 3.04 4.85 ± 3 0.512
Moderation
Refined grains ≤ 1.8oz equivalent per
1000kcal
≥ 4.3oz equivalent per
1000kcal
10 0.09 ± 0.6 0.07 ± 0.62 0.199
Sodium ≤ 1.1 grams per 1000kcal ≥ 2.0 grams per 1000kcal 10 2.11 ± 2.59 2.15 ± 2.62 0. 809
Added sugars ≤ 6.5% of energy ≥ 26% of energy 10 8.72 ± 1.97 8.92 ± 1.76 0.001
Saturated fats ≤ 8% of energy ≥ 16% of energy 10 7.47 ± 2.54 7.54 ± 2.54 0.784
Total score 100 49.54 ± 6.97 52.46 ± 6.89 0.006

Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity
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juice. In one study by Barrea etal. [6], fruits consumption
more than three times per day in women was associated with
a better HGS. The higher intake of fruits as a component
of the Mediterranean diet had positive effects on muscle
strength and fat-free mass [33–35]. Lima Ribeiro etal. [36]
indicated that intake of the fruits juice worsened muscle
strength. Fruits are rich in vitamins having anti-oxidative
and anti-inflammatory effects. They can also prevent muscle
atrophy owing to the effect of fruits on the gut microbiota in
animal models [33, 37].
In this study, the other component contributing to cal-
culation of HEI-2015 was added sugar in which its lower
Table 2 Demographic and baseline characteristics according to the healthy eating index-2015 quintiles
BMI body mass index
P value was obtained ANOVA and Chi-square tests
Determinants Total (n = 4010) HEI quintiles P value
Q1
(n = 1121)
Q2
(n = 903)
Q3
(n = 1011)
Q4
(n = 975)
Age (years), mean ± SD 47.77 ± 8.36 49.25 ± 8.38 48.33 ± 8.31 46.84 ± 8.25 46.55 ± 8.21 < 0.001
Weight (kg), mean ± SD 70.96 ± 13.6 67.96 ± 13.53 70.22 ± 13.13 72.35 ± 13.76 73.68 ± 13.25 < 0.001
BMI (kg/m2), mean ± SD 27 ± 4.68 26.13 ± 4.77 26.71 ± 4.50 27.41 ± 4.75 27.89 ± 4.48 < 0.001
Muscle strength (kg), mean ± SD 31.47 ± 11.16 30.23 ± 10.81 30.96 ± 10.84 32.24 ± 10.99 32.59 ± 11.86 < 0.001
Physical activity (MET hour/ day),
Mean ± SD
41.19 ± 7.47 42.32 ± 7.61 41.47 ± 7.29 40.68 ± 7.55 40.19 ± 7.25 < 0.001
Gender (%)
Male 44.5 43.9 46 44.7 43.8 0.763
Education year (%)
Illiterate 29.5 40.8 33.8 22.3 20.1 < 0.001
1–5years 38.6 38.4 39.3 41.6 35.0
6–12years 26.8 19.6 24.3 30.8 33.3
≥ 13years 5.1 1.2 2.7 5.3 11.6
Income status (%)
Very poor 24.7 36.4 27 22 12.7 < 0.001
Poor 22.5 24.4 25.2 20.5 19.8
Normal 20.9 22.1 20.8 22.3 18.9
Rich 18.4 12.2 18.2 20.5 22.8
Wealthy 13.5 5 8.8 14.9 25.7
Smoking (%)
No 80.2 73.8 78.2 83.3 86.4 < 0.001
Yes 19.8 26.2 21.8 16.7 13.6
Alcohol consumption (%)
No 94.2 94.5 94.4 94.3 93.7 0.904
Yes 5.8 5.5 5.6 5.7 6.3
Diabetic (%)
No 93.2 94.5 94.1 93 90.8 0.006
Yes 6.8 5.5 5.9 7 9.2
Table 3 Relationship between
HEI-2015 and muscle strength
Model 1 adjusted with age, gender, smoking, and use alcohol
Model 2 adjusted with variable in Model 1, physical activity, and diabetes
Muscle strength Quartiles of HEI—2015, OR (CI 95%) P-trend
Q1 Q2 Q3 Q4
Crude 1 0.96 (0.73–1.26) 1.39 (1.09–1.78) 1.26 (1.02–1.62) 0.009
Model 1 1 0.95 (0.73–1.25) 1.38 (1.07–1.76) 1.24 (1.01–1.6) 0.015
Model 2 1 0.96 (0.73–1.26) 1.36 (1.09–1.79) 1.26 (1.02–1.64) 0.01

Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity
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intake was associated with optimal muscle strength. In
animal models, no change in strength was shown after
drinking sugar-sweetened beverages [38]. Cameron etal.
[39] did not observe any association between dietary
carbohydrates and fat-free mass; however, high pro-
tein intake can predict high fat-free mass. Additionally,
Hashemi etal. did not find any association between adher-
ence Western diet and sarcopenia; in this case, Western
diet was introduced by high sugar, fat, desserts, and fast
food [40]. Since reduction in simple carbohydrates intake
is accompanied by an increase in the intake of complex
carbohydrates and proteins to provide energy, it seems
that this relationship was owing to an increase in intake
of complex carbohydrates, not necessarily a decrease in
added sugar intake.
This study had several limitations; HEI-2015 was
calculated based on FFQ. Although it is considered an
appropriate nutritional assessment tool in large epidemio-
logical studies, it can be affected by the recall bias. Fur-
thermore, this study design was cross sectional in which
a causal relationship maybe is inferred.
In conclusion, our findings indicated that adherence
to HEI-2015 could enhance muscle strength. Although
the score of all HEI-2015 components was higher in par-
ticipants with an optimal HGS than in participants with
a weak HGS, these associations were significant only
between two HEI-2015 components (including whole
fruits and added sugar) and HGS. Therefore, these results
reflect that higher adherence to HEI-2015, especially
adequate intake of whole fruits and moderation intake of
added sugar, is an appropriate strategy to improve muscle
strength.
What isalready known onthis subject?
Over 80% of the study participants had poor muscle
strength. Previous studies have shown that weak muscle
strength is associated with decreased mobility, increased
fractures, and increased risk of cardiometabolic diseases.
Identification and screening of nutritional factors affecting
muscle strength can play a crucial role in muscle strength
improvement.
What does this study add?
The study findings indicated that adherence to the HEI-2015
guidelines enhanced HGS, especially an adequate intake of
whole fruits and a moderation intake of added sugar.
Acknowledgments RaNCD is part of PERSIAN national cohort,
and we would like to thank Professor Reza Malekzadeh, Deputy of
Research and Technology at the Ministry of Health and Medical Educa-
tion of Iran and Director of the PERSIAN cohort, and also Dr. Hossein
Poustchi Executive Director of PERSIAN cohort for all their supports
during design and running of RaNCD.
Funding This study was supported by Ministry of Health and Medi-
cal Education of Iran and Kermanshah University of Medical Science
(Grant No: 92472).
Availability of data and materials Data will be available upon request
from the corresponding author.
Compliance with ethical standards
Conflict of interest The authors have no conflict of interest to disclose.
Ethical approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the insti-
tutional and/or national research committee and with the 1964 Helsinki
Declaration and its later amendments or comparable ethical standards.
This study was approved by the Ethics Committee of Kermanshah
University of Medical Sciences (ethics approval number: KUMS.
REC.1394.318).
Informed consent Written informed consent was obtained from each
studied subject after explaining the purpose of the study. The right of
subjects to withdraw from the study at any time and subjects informa-
tion is reserved and will not be published.
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