Muscle-strengthening activity as a public health pillar

Muscle-strengthening exercise (MSE) has quietly become one of the most important but least followed recommendations in modern public health. Global physical activity guidelines do not stop at steps, running or cycling; they explicitly ask adults to include work that challenges the muscles on at least two days each week. Yet a large, up to date synthesis of national surveys shows that, on average, fewer than one in four adults reach this basic standard of muscle-strengthening activity.

What counts as sufficient muscle-strengthening activity

The World Health Organization states that adults should do muscle-strengthening activities that involve the major muscle groups on two or more days per week. These activities can be performed with body weight, free weights, machines or resistance bands; the key is that they challenge muscles at a moderate or greater intensity and are repeated regularly across the week. The recommendation appears in the same core guidance that sets out the well known target of at least 150 minutes of moderate intensity aerobic activity or 75 minutes of vigorous activity per week.

In this framework muscle-strengthening exercise is not an optional extra. It is described as providing additional health benefits beyond aerobic exercise alone, particularly for musculoskeletal health. Twice weekly strength work is therefore treated as a basic ingredient of a healthy movement pattern for adults at any age, not just for athletes or gym enthusiasts.

How many adults meet the muscle-strengthening standard

A 2024 systematic review and meta analysis pulled together 30 observational studies with a combined sample of 2,629,508 adults to estimate how many people around the world adhere to the muscle-strengthening guidelines. The authors defined adherence in a way that matches the global recommendation: at least two days per week of muscle-strengthening exercise.

Across 21 studies suitable for pooling, the overall prevalence of adults who met this standard was 22.8 percent, with a 95 percent confidence interval from 18.18 to 27.77 percent. In other words, slightly less than one quarter of adults in the combined datasets perform muscle-strengthening exercise often enough to satisfy the guideline. The review concludes that “less than a quarter of adults meet the MSE guidelines” and describes muscle-strengthening exercise as important for population level public health.

Beneath that single global estimate the variation between studies and countries is striking. In the same review, the prevalence of adherence to muscle-strengthening guidelines ranged from 1.3 percent to 76.2 percent across the included studies. A survey of English adults found that only 1.3 percent of participants met the guideline. Data from the Korea National Health and Nutrition Examination Survey indicated adherence of approximately 6.3 percent among Korean adults. A large United States sample of 383,928 adults reported that 9.9 percent met the muscle-strengthening guideline. Across 28 European countries in 2021, the pooled prevalence was 17.3 percent among adults.

Taken together these figures suggest that the global average of 22.8 percent hides both very low engagement in some populations and comparatively high engagement in a few specific groups. The outlying upper value of 76.2 percent came from a population of military personnel, which illustrates that when strength work is built into daily routines and institutional structures, adherence can approach universality.

Who is most likely to miss out on strength training

The same systematic review did not stop at counting how many people lift, push or pull against resistance each week. It also examined correlates of adherence using a socioecological framework. Across the included studies sex, age, education level and socioeconomic status emerged as consistent sociodemographic factors that distinguish those who meet the muscle-strengthening guideline from those who do not.

In statistical terms men were more likely than women to adhere to the guideline in most of the studies that reported sex differences. Younger adults were more likely to meet the standard than the oldest adults sampled. Higher education and higher socioeconomic status were associated with greater adherence, while people with unhealthy weight status, such as underweight, overweight or obesity, were less likely to meet the guideline. Better self rated health and being physically active in general were also consistently associated with higher odds of doing sufficient muscle-strengthening exercise.

These patterns point to a clear equity problem. Muscle-strengthening activity is more common among people who are already advantaged by youth, education, income and overall health, and less common among those who may benefit most from its protective effects. The review further notes that adherence tends to be higher in urban areas than in outer or rural regions and that national or regional context matters, reflecting differences in culture, built environments and access to facilities.

What muscle-strengthening activity does for health

The case for treating muscle-strengthening exercise as a public health priority rests on its documented associations with a wide range of outcomes. The systematic review of guideline adherence emphasizes that regular muscle-strengthening exercise has been associated with lower risks of physical and mental health problems, including reduced risk of obesity, cardiometabolic health problems, chronic diseases, depressive symptoms, poorer sleep health and psychological distress. These links are based on observational data, but they are consistent across multiple national samples and align with biological mechanisms related to muscle mass, insulin sensitivity, bone health and neural adaptations.

A separate systematic review and meta analysis of cohort studies examined the relationship between muscle-strengthening activities and major non communicable diseases as well as mortality. Sixteen eligible cohort studies showed that performing muscle-strengthening activities was associated with a 10 to 17 percent lower risk of all cause mortality, cardiovascular disease, total cancer, diabetes and lung cancer compared with doing none. The analysis found J shaped associations for all cause mortality, cardiovascular disease and total cancer, with maximum risk reduction of approximately 10 to 20 percent at about 30 to 60 minutes per week of muscle-strengthening activities. For diabetes the association was L shaped, with a large risk reduction up to around 60 minutes per week.

The same work reported that combining muscle-strengthening activities with aerobic physical activity was associated with a substantially lower risk of all cause, cardiovascular and total cancer mortality compared with doing neither, suggesting that muscle work and aerobic work complement each other rather than compete for importance.These findings reinforce what current guidelines imply: muscle-strengthening exercise is not just about building visible strength. It is part of a broader strategy to reduce the risk of major non communicable diseases and premature death.

Evidence from intervention studies provides more specific glimpses into function and injury. For example, a randomized controlled trial in community dwelling women aged 80 years and older tested a home based program that combined muscle strengthening and balance retraining. The programme reduced falls and injuries related to falls over two years, demonstrating that structured strength and balance exercises can improve safety and independence in very old age, even though the trial did not show a clear reduction in overall health service costs.

Although not every study focuses exclusively on muscle-strengthening activities, public health agencies also point to broader benefits of being physically active, including improved quality of life and extended years of active life in older adults. (CDC) Muscle-strengthening work contributes to these outcomes through preservation of muscle mass, bone strength and functional capacity, which together underpin mobility, autonomy and resilience as people age. That link between strength, independence and quality of life is a central reason why experts describe muscle-strengthening exercise as essential for healthy ageing.

Economic and societal implications

The underuse of muscle-strengthening exercise also has economic dimensions. The United States Centers for Disease Control and Prevention estimates that inadequate levels of physical activity are associated with 117 billion dollars in annual health care costs and notes that increased physical activity can improve health and quality of life and reduce healthcare costs. These figures refer to physical activity as a whole rather than to muscle-strengthening activity alone, but they highlight the scale of the burden created by insufficient movement.

Given that muscle-strengthening exercise is part of the standard package of recommended activity and that it is associated with lower risks of major non communicable diseases and mortality, it is reasonable to infer that raising global adherence to the muscle-strengthening guideline would contribute to reducing both disease burden and related healthcare expenditure. This inference fits with emerging economic analyses that link low muscle strength and inactivity to higher costs for health systems, although precise global cost estimates specific to muscle-strengthening remain limited.

At a societal level, the pattern of who does and does not engage in muscle-strengthening activity matters. Because adherence is higher among younger, more educated and more affluent groups, current practice risks widening health inequalities: those with the greatest structural advantages gain additional protection from chronic disease, while those with fewer resources and poorer baseline health are least likely to receive the benefits of regular strength work. Changing that pattern requires more than individual motivation. It involves access to safe and welcoming facilities, culturally appropriate programs, time and financial support and clear communication that strength training is for everyone, not only for a narrow fitness subculture.

From neglected guideline to practical priority

Researchers sometimes refer to muscle-strengthening recommendations as the forgotten guideline, precisely because adherence is far lower than for aerobic activity, and because surveillance systems and public messaging have traditionally focused on steps, minutes and heart rate rather than on sets, repetitions and load. The global estimate that only 22.8 percent of adults adhere to the muscle-strengthening guideline, together with national data showing values as low as 1.3 percent in some populations, underlines how far current practice falls short of what evidence based guidelines advise.

The conclusion of the 2024 systematic review is explicit. It states that less than a quarter of adults meet the muscle-strengthening exercise guidelines and that multiple correlates, especially sociodemographic factors, shape who does so. It argues for further promotion of muscle-strengthening exercise and for interventions that not only provide opportunities but also build skills and confidence to engage in it. In parallel, epidemiological work shows that regular strength work is linked with meaningful reductions in the risk of major diseases and death, particularly when combined with aerobic activity.

Bringing these strands together, muscle-strengthening activity stands out as a critical yet underused pillar of global public health. The numbers suggest a simple, profound tension. On one side sit robust findings that relatively modest amounts of weekly strength work are associated with better metabolic and mental health, lower risk of non communicable diseases and reduced mortality. On the other side, most adults worldwide do not perform even two sessions per week that meet these criteria. Narrowing that gap is one of the clearest opportunities to add healthy, independent years to life at scale and, by reducing the burden of preventable disease, to ease pressures on healthcare systems. The evidence is already strong; the remaining challenge is to turn a forgotten guideline into a practical norm.