Exercise Is Medicine: Grip Strength, VO2 Max and the Clinical Layer

By Dan Remon · Evidence checked November 2026

Your doctor and your trainer have probably never spoken.

For 30 years I’ve watched medicine and fitness run as 2 separate industries. The doctor sees you once a year, reads your blood work and treats what is broken. The trainer sees you 3 times a week, writes your program and has never seen your blood work. The markers most strongly linked to how long people live sit between the two, and nobody owns them.

Some of the strongest cost almost nothing to measure: grip strength, leg power and VO2 max. In the large studies, grip and VO2 max predict death from any cause as well as or better than blood pressure, smoking or diabetes. Most people have never had them tested.

This post covers what the research shows, where it stops, and how Orba Health, the company I co-founded, is bringing the clinical layer into Aspire, my coaching team in Bangkok.

In short:

• Grip strength and VO2 max are 2 of the strongest physical longevity biomarkers. In large studies, each 5 kg lower grip is linked to a 16 to 20% higher risk of death from any cause, and each 1 MET of higher fitness to an 11 to 17% lower risk.
• The least fit carry about 4 to 5 times the risk of death of the fittest, a gap comparable to or larger than smoking or diabetes in the same data.
• Both markers respond to training. 30 to 60 minutes of strength work a week is linked to the largest drop in risk.
• The studies are observational. They show strong links, not proof of cause.

What exercise is medicine means

Exercise is medicine is the idea that training should be prescribed, dosed and measured like any other treatment. The evidence is there. A 2015 review by Pedersen and Saltin set out the case for prescribing exercise as therapy in 26 chronic diseases, from depression and type 2 diabetes to heart failure and osteoarthritis. In 2016 the American Heart Association went further and argued that cardiorespiratory fitness should be recorded as a clinical vital sign, next to blood pressure. Its statement called fitness a potentially stronger predictor of death than smoking, high blood pressure, high cholesterol or type 2 diabetes.

Medicine has the evidence. Most clinics lack the coaching to deliver the dose, and most gyms lack the clinical data to aim it. Nobody owns the space between them.

Grip strength and all-cause mortality

Grip strength needs 1 handheld device to measure. It tells you more than it should.

The PURE study, published in The Lancet, measured grip strength in 139,691 adults across 17 countries and followed them for a median of 4 years. Each 5 kg lower grip was associated with a 16% higher risk of death from any cause. Grip strength predicted all-cause and cardiovascular death better than systolic blood pressure did.

UK Biobank tested it at a larger scale. In 502,293 adults aged 40 to 69, published in The BMJ, each 5 kg lower grip carried a 20% higher hazard of death in women and 16% in men. The researchers defined muscle weakness as under 26 kg for men and under 16 kg for women. Adding grip strength to a standard office risk score (age, sex, diabetes, BMI, blood pressure and smoking) improved its prediction of death.

The pattern holds when the studies are pooled. A 2017 meta-analysis of 42 cohorts and more than 3 million people found that the weakest group had a 41% higher risk of death from any cause and a 63% higher risk of cardiovascular disease than the strongest. The relationship ran in a straight line up to a grip of about 56 kg, and it didn’t differ between men and women.

Now the limits. These studies are observational. They show that weaker people tend to die earlier. They don’t prove that getting stronger adds years, and the PURE authors say plainly that whether improving strength reduces mortality still needs testing.

What is clear is that grip responds to training. A 2019 meta-analysis of 24 trials in 3,018 adults over 60 found that exercise programs raised grip strength, with task-specific and mixed training giving the best stimulus. Grip is a quality you can train, directly and through whole-body strength work, and the retest shows whether it is moving.

Why strength matters more than size

Most people chase muscle they can see. The research points at muscle that works.

A 2018 study of 4,449 American adults aged 50 and over compared muscle mass and muscle strength side by side. People with low strength had roughly 2 to 2.7 times the odds of dying during follow-up, and that held whether their muscle mass was low or normal. Low strength stayed linked to death after the researchers accounted for metabolic syndrome, sitting time and leisure exercise.

This is why a body composition scan on its own doesn’t tell the full story. 2 people with the same lean mass can have very different strength, and strength is the number that tracks with survival. At Aspire we measure both, because the gap between them tells the coach where to aim the program.

Power, capacity and getting off the floor

Strength is how much force you can produce. Power is how fast you can produce it. Getting down to the floor and back up takes both, plus balance and mobility.

A 2026 study in the European Journal of Preventive Cardiology followed 4,282 adults aged 46 to 75 for a median of 12.3 years. Each person was scored from 0 to 10 on how well they could sit down on the floor and stand back up without using their hands or knees. Compared with the top scorers, the lowest scorers had 3.84 times the risk of natural death and 6.05 times the risk of cardiovascular death, after adjusting for age, sex, BMI and clinical factors. The authors note the test reflects muscle strength and power, flexibility, balance and body composition together.

It’s a simple test with a large signal, and it’s observational like the rest. It’s also the reason Aspire tests upper and lower body power and overall capacity, not just how much someone can lift once.

VO2 max and all-cause mortality

VO2 max is the most oxygen your body can use at full effort. It’s the clearest single number for cardiorespiratory fitness, and the evidence behind it is the deepest of any marker in this post.

A 2009 meta-analysis in JAMA pooled 33 studies of healthy adults. Every 1 MET of higher fitness, roughly a 1 km/h faster running speed, was associated with a 13% lower risk of death from any cause. People below 7.9 METs (about 28 ml/kg/min of oxygen) had a 70% higher risk of death than the fittest group.

Cleveland Clinic data on 122,007 patients who did a treadmill test shows the same pattern over a median 8.4 years. The least fit group had about 5 times the risk of death of the fittest (adjusted hazard ratio 5.04). That gap was comparable to or larger than smoking (1.41), diabetes (1.40) and coronary artery disease (1.29). The authors found no upper limit to the benefit.

The largest single cohort is 750,302 US veterans aged 30 to 95, followed for a median of 10.2 years and published in the Journal of the American College of Cardiology. The least fit had about 4 times the risk of death of the most fit (hazard ratio 4.09). The pattern held in men and women, across races, and in people in their 70s and 80s. Lowest risk sat at about 14 METs, and extreme fitness showed no added risk. The authors’ conclusion was blunt: being unfit carried a greater risk than any of the cardiac risk factors they examined.

A 2024 overview in the British Journal of Sports Medicine pulled together 199 cohort studies and more than 20.9 million observations. High fitness was linked to a 53% lower risk of death from any cause compared with low fitness, and each 1 MET higher to an 11 to 17% lower risk.

The limits again. These are observational studies. Some used patients referred for testing, and several estimated fitness from treadmill performance rather than measuring gas exchange. The 2024 overview rated the certainty of the evidence as very low to moderate. Observational data can’t prove cause. The consistency across millions of people is still the reason the American Heart Association wants fitness measured in clinical practice.

How much VO2 max you can build

VO2 max moves with training too, and by a measurable amount.

A 2015 meta-analysis of 28 controlled trials in healthy adults aged 18 to 45 found that steady endurance training raised VO2 max by about 4.9 ml/kg/min compared with no exercise. High-intensity interval training raised it by about 5.5 ml/kg/min, a small edge over steady work. Lower starting fitness and longer programs both produced bigger gains.

4.9 ml/kg/min is about 1.4 METs, and 1 MET is the unit the mortality studies above count in. The trials were in younger adults, so the size of the gain in a 50-year-old executive will differ. The direction won’t. This is the part of the file you can change fastest, which is why it gets tested first and retested often.

The evidence at a glance

The core studies in this post, in one place. All 10 are observational, so read each figure as a link, not proof of cause.

Why medicine and fitness still work apart

The research has been clear for more than 15 years. Delivery hasn’t caught up.

A doctor can tell you to exercise more. Few have the time or the team to write the program, watch you run it and retest. A good coach can write the program, but can’t order blood work, interpret an ApoB result or prescribe. Each side sees half the file, so the client ends up as the messenger between them, carrying a lab report to the gym and a training log to the clinic, and neither one reads the other.

The cost shows up slowly. A blood pressure trend can get treated with medication while nobody checks the person’s fitness. A training program can push intensity while a blood marker says recovery is the bottleneck. Both sides are doing their job. Neither is doing the whole job.

How Orba brings the clinical layer into Aspire

Aspire is a coaching team, and it stays one. We don’t diagnose and we don’t prescribe. That is the job of the clinical layer, and in Bangkok that layer is Orba Health, the company I co-founded.

Orba runs a blood panel of more than 100 biomarkers: heart and lipids (including ApoB and Lp(a)), metabolic health (glucose, HbA1c and insulin), liver, kidney, inflammation, thyroid and hormones, plus 4 calculated risk scores. Doctors read and interpret the results and build the plan from them. Where a result needs medical treatment, that stays with Orba’s doctors.

Aspire measures the physical markers on the gym floor: grip strength and grip endurance, VO2 max, body composition, capacity, and upper and lower body power. Both sets of numbers sit in one client record, so the coach writing the program sees the same picture as the doctor reading the panel.

That shared record changes the decisions. A VO2 result reads differently next to an HbA1c or a blood pressure trend. A grip score means more when you can see what is happening underneath it. When the doctor sees a metabolic marker drifting, the coach knows which training lever to pull. When the coach sees capacity stall, the doctor can check whether something in the blood work explains it.

The referral runs both ways. Orba sends training, nutrition and recovery to Aspire. Aspire sends clinical questions to Orba. Orba retests blood every 4 to 6 months, and that cadence sets the rhythm of the program. Nothing gets guessed twice.

Running the loop with Stealth OS

Stealth OS runs on 4 modes: Audit, Install, Execute, Compound. Here is how each one maps onto medicine and training.

Audit. Set the baseline before writing a single session: blood work through Orba, then grip strength, VO2 max, body composition and power at Aspire. You can’t upgrade what you refuse to audit. The baseline also shows which marker is furthest behind, and that is where the first block of training goes.

Install. Start with the minimum effective dose. A 2022 meta-analysis in the British Journal of Sports Medicine found the largest drop in risk of death, about 10 to 20%, at roughly 30 to 60 minutes of muscle-strengthening work a week. People who combined strength and aerobic work had lower risk again. My own dose is 3 strength sessions of 20 minutes, which lands at 60. For clients, 2 sessions a week is the minimum and 3 works best for most. Add aerobic work aimed at moving VO2 up, steady and interval, because every MET counts.

Execute. The Stealth Tracker is a 60-second daily check-in on the habits that move these numbers: sessions done, sleep, energy. It shows the drift in days, before it shows up in a test months later.

Compound. Retest every 4 to 6 months, blood and physical markers together. If the numbers move, keep going. If they stall, change the program. The data decides the next block.

How to start

Take The 1% Scorecard. It’s 8 questions, takes 2 minutes and is free, and it shows where your week is leaking energy and time.

If you’re in Bangkok and want the testing and the coaching working from one file, start with an assessment at Aspire. Blood work runs through Orba Health’s blood test in Bangkok.

FAQ

Sources

1. Pedersen BK, Saltin B. Exercise as medicine: evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci Sports. 2015, 25 Suppl 3: 1-72. doi:10.1111/sms.12581
2. Ross R, Blair SN, Arena R, et al. Importance of assessing cardiorespiratory fitness in clinical practice: a case for fitness as a clinical vital sign. A scientific statement from the American Heart Association. Circulation. 2016, 134(24): e653-e699. doi:10.1161/CIR.0000000000000461
3. Leong DP, Teo KK, Rangarajan S, et al. Prognostic value of grip strength: findings from the Prospective Urban Rural Epidemiology (PURE) study. Lancet. 2015, 386(9990): 266-273. doi:10.1016/S0140-6736(14)62000-6
4. Celis-Morales CA, Welsh P, Lyall DM, et al. Associations of grip strength with cardiovascular, respiratory, and cancer outcomes and all cause mortality: prospective cohort study of half a million UK Biobank participants. BMJ. 2018, 361: k1651. doi:10.1136/bmj.k1651
5. Wu Y, Wang W, Liu T, Zhang D. Association of grip strength with risk of all-cause mortality, cardiovascular diseases, and cancer in community-dwelling populations: a meta-analysis of prospective cohort studies. J Am Med Dir Assoc. 2017, 18(6): 551.e17-551.e35. doi:10.1016/j.jamda.2017.03.011
6. Labott BK, Bucht H, Morat M, Morat T, Donath L. Effects of exercise training on handgrip strength in older adults: a meta-analytical review. Gerontology. 2019, 65(6): 686-698. doi:10.1159/000501203
7. Li R, Xia J, Zhang XI, et al. Associations of muscle mass and strength with all-cause mortality among US older adults. Med Sci Sports Exerc. 2018, 50(3): 458-467. doi:10.1249/MSS.0000000000001448
8. Araújo CGS, de Souza e Silva CG, Myers J, et al. Sitting-rising test scores predict natural and cardiovascular causes of deaths in middle-aged and older men and women. Eur J Prev Cardiol. 2026, 33(12): 2170-2178. doi:10.1093/eurjpc/zwaf325
9. Kodama S, Saito K, Tanaka S, et al. Cardiorespiratory fitness as a quantitative predictor of all-cause mortality and cardiovascular events in healthy men and women: a meta-analysis. JAMA. 2009, 301(19): 2024-2035. doi:10.1001/jama.2009.681
10. Mandsager K, Harb S, Cremer P, Phelan D, Nissen SE, Jaber W. Association of cardiorespiratory fitness with long-term mortality among adults undergoing exercise treadmill testing. JAMA Netw Open. 2018, 1(6): e183605. doi:10.1001/jamanetworkopen.2018.3605
11. Kokkinos P, Faselis C, Samuel IBH, et al. Cardiorespiratory fitness and mortality risk across the spectra of age, race, and sex. J Am Coll Cardiol. 2022, 80(6): 598-609. doi:10.1016/j.jacc.2022.05.031
12. Lang JJ, Prince SA, Merucci K, et al. Cardiorespiratory fitness is a strong and consistent predictor of morbidity and mortality among adults: an overview of meta-analyses representing over 20.9 million observations from 199 unique cohort studies. Br J Sports Med. 2024, 58(10): 556-566. doi:10.1136/bjsports-2023-107849
13. Milanović Z, Sporiš G, Weston M. Effectiveness of high-intensity interval training (HIT) and continuous endurance training for VO2max improvements: a systematic review and meta-analysis of controlled trials. Sports Med. 2015, 45(10): 1469-1481. doi:10.1007/s40279-015-0365-0
14. Momma H, Kawakami R, Honda T, Sawada SS. Muscle-strengthening activities are associated with lower risk and mortality in major non-communicable diseases: a systematic review and meta-analysis of cohort studies. Br J Sports Med. 2022, 56(13): 755-763. doi:10.1136/bjsports-2021-105061

This article is general information, not medical advice.