Beyond the Annual Check-Up: What to Measure After 40

By Dan Remon, founder, Aspire Coaching & Physio. Evidence checked September 2026

In 2019 the Cochrane Collaboration pooled every good randomised trial of the general health check. That meant fifteen trials with usable data and more than 250,000 people, some offered regular check-ups and some not.

It found no difference in total mortality (risk ratio 1.00). There was no reduction in deaths from cancer, and no clear reduction in deaths from heart disease. The reviewers concluded that general health checks are unlikely to be beneficial [1].

That review doesn’t say your doctor is wasting your time. Many of the trials were old, the checks were generic, and screening for specific conditions in the right people does save lives. What it shows is narrower. A general check-up is built to answer one question, which is whether anything is wrong with you today. For someone in their forties or fifties who feels fine, the answer is usually no, and the process ends there.

The more useful question at that age is how much capacity you’ve got and which way it’s heading. Nothing in a standard check-up measures that.

The short answer

After 40, the measures that tell you most about how you’ll function over the next twenty years fall into two groups.

Capacity measures can be improved by training, nutrition and recovery: cardiorespiratory fitness, strength, muscle mass, visceral fat, balance, and your heart rate variability trend. Measure them, work on them, and retest every twelve weeks.

Risk markers belong with a doctor, either your own or ours through Orba Health: ApoB, Lp(a), HbA1c and, in the right circumstances, a coronary calcium score. Several of them only need testing once, or once in a while.

Most people get a version of the second group once a year and none of the first.

Part one: capacity

Cardiorespiratory fitness

If you measure one thing, measure this. A 2009 meta-analysis of 33 studies in JAMA found that every one-MET increase in fitness was linked to about 13 per cent lower all-cause mortality [2]. A MET is the unit a treadmill or bike test reports. The Cleveland Clinic’s data on 122,007 patients found the least fit had around five times the mortality of the fittest. Below-average fitness carried roughly the same risk as smoking or diabetes, and no upper limit of benefit showed up [3].

It’s measured with a graded exercise test, ideally with gas analysis for a true VO2max, or estimated from a treadmill protocol. Both data sets above are observational, so fitness is a marker as well as a cause. It’s also the marker that responds most reliably to training.

Strength

Grip strength sounds trivial. It’s one of the better single predictors available. The PURE study followed 139,691 adults in 17 countries and found each 5 kg lower grip strength was associated with 16 per cent higher all-cause mortality. Grip predicted cardiovascular death better than systolic blood pressure [4]. In UK Biobank’s half a million adults, the researchers classed a grip below 26 kg in men and 16 kg in women as weak [5].

Grip doesn’t matter in itself. It stands in for whole-body strength, and strength stands in for how well you’ll handle everything from stairs to illness. A hand dynamometer costs very little. Use the same hand, at the same time of day, once a week.

Muscle

Muscle declines slowly and strength declines faster. A review of longitudinal and cross-sectional studies put the median loss of muscle mass at around 0.47 per cent a year in men and 0.37 per cent in women. Strength was lost two to five times faster than mass. The authors noted that loss of strength is a more consistent risk for disability and death than loss of mass [6].

That’s why the scale is the wrong instrument. A man can hold the same weight for ten years while swapping muscle for fat, and look fine on every check-up along the way. Body composition separates lean mass from fat mass. At Aspire we use InBody bioimpedance. It’s less precise than a DEXA scan and entirely good enough for tracking a trend, provided you test under the same conditions each time.

Visceral fat

This is the fat around your organs rather than under your skin, and BMI can’t see it. In the Framingham study, CT-measured visceral fat was linked to higher cardiovascular disease risk (44 per cent per standard deviation) and cancer risk (43 per cent), even after accounting for BMI. It wasn’t linked to overall mortality in that sample, which is worth saying because it’s often oversold [7]. An international expert position statement in 2019 called visceral fat an independent risk marker for cardiovascular and metabolic disease [8].

It’s also one of the numbers that moves fastest when training, sleep and alcohol change, which makes it a useful twelve-week metric.

Balance

This is the cheapest test on the list. Stand on one leg, hands by your sides, other foot resting against the back of your standing leg, for ten seconds. In a Brazilian study of 1,702 adults aged 51 to 75, one in five couldn’t do it. Over about seven years, 17.5 per cent of those who failed died, against 4.6 per cent of those who passed, and failing carried an 84 per cent higher adjusted risk [9].

Treat it as a warning light. The study didn’t control for everything, and it doesn’t show that practising balance extends life. If you can’t hold ten seconds, that’s worth knowing, and it’s highly trainable.

Heart rate variability, as a trend

HRV is a read on how much capacity your nervous system has left in a given week. A 2013 meta-analysis of eight studies in people without heart disease found low HRV associated with a 32 to 45 per cent higher risk of a first cardiovascular event [10].

HRV earns its place as a trend against your own baseline, and a single number tells you very little. It varies with age, sex and how it’s recorded. Sports scientists who use it with athletes average it over days and read it against the individual’s own history [11]. We use it the same way: to decide whether this is a week to push or a week to back off. The full explanation is in our guide to what HRV is and how to read it.

Part two: for your doctor

These are medical tests, so a doctor orders and interprets them. Aspire doesn’t, and nothing here replaces your doctor’s judgement. Your own doctor can run all of them. If you’d rather have it in one place, our medical partner Orba Health, the company I co-founded, offers a comprehensive blood panel, a private doctor consultation to go through the results and build an action plan, and ongoing tracking of the markers over time. Either route works. What matters is that someone qualified reads the numbers, and that you know which questions to ask.

ApoB, alongside or instead of LDL

Every particle that can lodge in an artery wall carries one ApoB molecule, so ApoB counts the particles directly. LDL cholesterol measures how much cholesterol they carry. A 2019 review in JAMA Cardiology argued that ApoB is the more accurate measure of risk [12]. In 207,368 UK Biobank participants, the particle count predicted coronary disease, and particle size added nothing once count was known [13]. The 2018 American cholesterol guideline lists ApoB above 130 mg/dL as a risk-enhancing factor [14].

Lp(a), once

Lp(a) is largely set by your genes and barely changes through life. The European Atherosclerosis Society’s 2022 consensus statement says it “should be measured at least once in adults”, and estimates that around 1.4 billion people worldwide have raised levels [15]. Their follow-up guidance puts the rule-out threshold at under 30 mg/dL (75 nmol/L) and the rule-in threshold at over 50 mg/dL (125 nmol/L) [16]. In most people one test is enough for life. Knowing it changes how aggressively your doctor may want to manage everything else.

HbA1c

This gives a three-month average of blood sugar. In the ARIC study of 11,092 adults without diabetes, an HbA1c of 5.5 to 5.9 per cent was linked to almost twice the risk of developing diabetes compared with 5.0 to 5.4 per cent, and 6.0 to 6.4 per cent to more than four times the risk. HbA1c also predicted heart disease and death better than fasting glucose [17]. It’s cheaper, more reliable and more useful than wearing a glucose monitor if you don’t have diabetes.

Coronary artery calcium score

A CAC score is a low-dose CT scan that measures calcified plaque in the heart’s arteries. In the MESA study of 6,814 adults followed for eleven years, people with a score of zero had ten-year event rates almost always below 5 per cent. People with scores above 300 had rates between 13 and 26 per cent [18]. The 2018 American guideline suggests considering it in adults aged 40 to 75 when a decision about statins is uncertain. A score of zero may support delaying treatment, except in smokers, people with diabetes and people with a strong family history of early heart disease.

Two cautions. A calcium score sees only hardened plaque. And CT coronary angiography, which images the arteries in more detail, has strong trial evidence in people with chest pain (the SCOT-HEART trial found fewer heart attacks and cardiac deaths over five years) but not in people with no symptoms [19]. If you feel well and want an angiogram, that’s a conversation with a cardiologist, and the trial evidence doesn’t make the decision for you.

How often to measure

Measure	Group	How	How often
Cardiorespiratory fitness	Capacity	Graded exercise test / VO2max	Every 6 to 12 months
Grip strength	Capacity	Hand dynamometer	Weekly at home; formally every 12 weeks
Lean mass and fat mass	Capacity	InBody or DEXA	Every 12 weeks, same conditions
Visceral fat	Capacity	InBody estimate, DEXA, CT or MRI	Every 12 weeks
One-leg balance	Capacity	10-second stand	Every 12 weeks
HRV	Capacity	Morning reading, trended	Daily or weekly average
ApoB, lipids	Doctor	Blood test	As your doctor advises
Lp(a)	Doctor	Blood test	Once
HbA1c	Doctor	Blood test	As your doctor advises
CAC score	Doctor	Low-dose CT	Only when it would change a decision

The retest matters more than any single result. One measurement is a photograph. Two, twelve weeks apart, give you a direction, and a direction is the only thing you can act on.

Where Aspire fits

Every client starts with a first assessment. It measures body composition, runs a structured movement screen and looks at physiological stress markers including HRV. You leave with a written baseline, a plain-English explanation and a recommendation on what to deal with first.

It’s a performance assessment. It doesn’t diagnose anything, and it doesn’t replace your doctor. When blood work or family history raises a question, we send you to the right person: your own doctor, or Orba Health if you want the medical side alongside your coaching. What we do is the capacity half of this article, measured on a cycle and coached in between. The retest is where it earns its keep.

If you want the baseline first, book a free consultation.

FAQ

Sources

1. Krogsøll LT, Jørgensen KJ, Gøtzsche PC. General health checks in adults for reducing morbidity and mortality from disease. Cochrane Database Syst Rev 2019. doi.org/10.1002/14651858.CD009009.pub3
2. Kodama 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. doi.org/10.1001/jama.2009.681
3. Mandsager K et al. Association of cardiorespiratory fitness with long-term mortality among adults undergoing exercise treadmill testing. JAMA Netw Open 2018. doi.org/10.1001/jamanetworkopen.2018.3605
4. Leong DP et al. Prognostic value of grip strength: findings from the Prospective Urban Rural Epidemiology (PURE) study. Lancet 2015. doi.org/10.1016/S0140-6736(14)62000-6
5. Celis-Morales CA 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. doi.org/10.1136/bmj.k1651
6. Mitchell WK et al. Sarcopenia, dynapenia, and the impact of advancing age on human skeletal muscle size and strength; a quantitative review. Front Physiol 2012. doi.org/10.3389/fphys.2012.00260
7. Britton KA et al. Body fat distribution, incident cardiovascular disease, cancer, and all-cause mortality. J Am Coll Cardiol 2013. doi.org/10.1016/j.jacc.2013.06.027
8. Neeland IJ et al. Visceral and ectopic fat, atherosclerosis, and cardiometabolic disease: a position statement. Lancet Diabetes Endocrinol 2019. doi.org/10.1016/S2213-8587(19)30084-1
9. Araujo CG et al. Successful 10-second one-legged stance performance predicts survival in middle-aged and older individuals. Br J Sports Med 2022. doi.org/10.1136/bjsports-2021-105360
10. Hillebrand S et al. Heart rate variability and first cardiovascular event in populations without known cardiovascular disease: meta-analysis and dose-response meta-regression. Europace 2013. doi.org/10.1093/europace/eus341
11. Plews DJ et al. Training adaptation and heart rate variability in elite endurance athletes: opening the door to effective monitoring. Sports Med 2013. doi.org/10.1007/s40279-013-0071-8
12. Sniderman AD et al. Apolipoprotein B particles and cardiovascular disease: a narrative review. JAMA Cardiol 2019. doi.org/10.1001/jamacardio.2019.3780
13. Morze J et al. ApoB-containing lipoproteins: count, type, size, and risk of coronary artery disease. Eur Heart J 2025. doi.org/10.1093/eurheartj/ehaf207
14. Grundy SM et al. 2018 AHA/ACC guideline on the management of blood cholesterol. Circulation 2019. doi.org/10.1161/CIR.0000000000000625
15. Kronenberg F et al. Lipoprotein(a) in atherosclerotic cardiovascular disease and aortic stenosis: a European Atherosclerosis Society consensus statement. Eur Heart J 2022. doi.org/10.1093/eurheartj/ehac361
16. Kronenberg F et al. Frequent questions and responses on the 2022 lipoprotein(a) consensus statement of the European Atherosclerosis Society. Atherosclerosis 2023. doi.org/10.1016/j.atherosclerosis.2023.04.012
17. Selvin E et al. Glycated hemoglobin, diabetes, and cardiovascular risk in nondiabetic adults. N Engl J Med 2010. doi.org/10.1056/NEJMoa0908359
18. Budoff MJ et al. Ten-year association of coronary artery calcium with atherosclerotic cardiovascular disease (ASCVD) events: the Multi-Ethnic Study of Atherosclerosis (MESA). Eur Heart J 2018. doi.org/10.1093/eurheartj/ehy217
19. SCOT-HEART Investigators. Coronary CT angiography and 5-year risk of myocardial infarction. N Engl J Med 2018. doi.org/10.1056/NEJMoa1805971

This article is for education and isn’t medical advice. Aspire provides coaching and performance assessment. It doesn’t diagnose or treat medical conditions. Blood tests and cardiac imaging should be ordered and interpreted by a qualified doctor.

About the author. Dan Remon has worked in health and human performance for 30 years and founded Fitcorp in Bangkok in 2002. Aspire Coaching & Physio in Asoke coaches executives on the measures that decide how they perform.