BACKGROUND: Muscular strength is a powerful marker of current health status and robust predictor of age-related disease and disability. Handgrip strength (HGS) using isometric dynamometry is a convenient, feasible, and widely used method of assessing muscular strength among people of all ages. While adult HGS norms have been published for many countries, no study has yet synthesized available data to produce international norms. The objective of this study was to generate international sex- and age-specific norms for absolute and body size-normalized HGS across the adult lifespan. METHODS: Systematic searches were conducted in 6 databases/web search engines (MEDLINE, SPORTDiscus, Embase, Web of Science, CINAHL, and Google Scholar) up to December 1, 2023. We included full-text peer-reviewed observational studies that reported normative HGS data for adults aged ≥20 years by sex and age. Pseudo data were generated using Monte Carlo simulation following harmonization for methodological variation. Population-weighted Generalized Additive Models for Location, Scale, and Shape were used to develop sex- and age-specific norms for absolute HGS (kg) and HGS normalized by height (Ht, m) squared (i.e., HGS/Ht2 in kg/m2). Norms were tabulated as percentile values (5th to 95th) and visualized as smoothed percentile curves. RESULTS: We included data from 100 unique observational studies representing 2,405,863 adults (51.9% female) aged 20 to 100+ years from 69 countries and regions tested from the year 2000 onward. On average, absolute and normalized HGS values negligibly improved throughout early adulthood, peaked from age 30-39 years (at 49.7 kg (males) and 29.7 kg (females) for absolute HGS or 16.3 kg/m2 (males) and 11.3 kg/m2 (females) for HGS/Ht2), and declined afterwards. The age-related decline in HGS accelerated from middle to late adulthood and was slightly larger for males than for females during middle adulthood. CONCLUSION: This study provides the world's largest and most geographically comprehensive international norms for adult HGS by sex and age. These norms have utility for global peer-comparisons, health screening, and surveillance.

Alliance for Research in Exercise Nutrition and Activity Allied Health and Human Performance University of South Australia Adelaide SA 5000 Australia

Alliance for Research in Exercise Nutrition and Activity Allied Health and Human Performance University of South Australia Adelaide SA 5000 Australia; Baker Heart and Diabetes Institute Melbourne VIC 3004 Australia; Research Centre of Applied and Preventive Cardiovascular Medicine University of Turku Turku 20520 Finland; Centre for Population Health Research University of Turku and Turku University Hospital Turku 20520 Finland

Alliance for Research in Exercise Nutrition and Activity Allied Health and Human Performance University of South Australia Adelaide SA 5000 Australia; Centre for Surveillance and Applied Research Public Health Agency of Canada Ottawa ON K1A 0K9 Canada; School of Epidemiology and Public Health Faculty of Medicine University of Ottawa Ottawa ON K1H 8M5 Canada

Alliance for Research in Exercise Nutrition and Activity Allied Health and Human Performance University of South Australia Adelaide SA 5000 Australia; Menzies Institute for Medical Research University of Tasmania Hobart TAS 7000 Australia

Alliance for Research in Exercise Nutrition and Activity North Dakota State University Fargo ND 58102 USA; Department of Health Nutrition and Exercise Sciences North Dakota State University Fargo ND 58108 USA; Fargo VA Healthcare System Fargo ND 58102 USA; Department of Geriatrics University of North Dakota Grand Forks ND 58202 USA

Australian Centre for Precision Health Allied Health and Human Performance University of South Australia Adelaide SA 5000 Australia

Department of Health Research Methods Evidence and Impact Faculty of Health Sciences McMaster University Hamilton ON L8S 4L8 Canada; Labarge Centre for Mobility in Aging McMaster University Hamilton ON L8P 0A1 Canada; McMaster Institute for Research on Aging McMaster University Hamilton ON L8P 0A1 Canada

Department of Physical Education and Sport Faculty of Science Humanities and Education Technical University of Liberec Liberec 461 17 Czech Republic; Institute of Active Lifestyle Faculty of Physical Culture Palacký University Olomouc Olomouc 779 00 Czech Republic

Department of Physical Education and Sports Faculty of Sport Sciences Sport and Health University Research Institute Instituto de Salud Carlos 3 Granada ES 18071 Spain; Department of Cardiology Stanford University Stanford CA 94305 USA; Veterans Affairs Palo Alto Health Care System Palo Alto CA 94304 USA

Department of Physical Education and Sports Faculty of Sport Sciences Sport and Health University Research Institute Instituto de Salud Carlos 3 Granada ES 18071 Spain; Faculty of Sport and Health Sciences University of Jyväskylä Jyväskylä 40014 Finland

Department of Population Health University of North Dakota Grand Forks ND 58202 USA

Department of Public Health Epidemiology Biostatistics and Biodemography University of Southern Denmark Odense 5230 Denmark

Faculty of Sport Science Nippon Sport Science University Tokyo 158 8508 Japan

School of Physical Education Shanghai University of Sport Shanghai 200438 China; Shanghai Research Center for Physical Fitness and Health of Children and Adolescents Shanghai 200438 China

The Population Health Research Institute McMaster University and Hamilton Health Sciences Hamilton ON L8L 2X2 Canada

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