ORIGINAL RESEARCH—ERECTILE DYSFUNCTION: Abdominal Obesity and Physical Inactivity Are Associated with Erectile Dysfunction Independent of Body Mass Index



      Erectile dysfunction (ED) is common among men with an elevated body mass index (BMI). However, a high waist circumference (WC) and low levels of physical activity may predict ED independently of BMI.


      We investigated the independent relationships between BMI, WC, and physical activity with ED.


      Subjects consisted of 3,941 adult men (age ≥ 20 years) with no history of prostate cancer from the 2001–2004 National Health and Nutrition Examination Survey. Logistic regression analyses were used to examine the relative odds of ED association with categories of BMI, WC, and physical activity.

      Main Outcome Measures

      Established thresholds were used to divide subjects into three WC and BMI categories. Physical activity level was divided into active (≥150 min/week), moderately active (30–149 min/week), and inactive (<30 min/week) categories. A single survey question was used to assess the presence of ED.


      After control for potential confounders, men with either a high WC or an obese BMI had an approximately 50% higher odds of having ED compared with men with a low WC or a normal BMI, respectively. Further, moderately active or inactive men had an approximately 40–60% greater odds of ED compared with active men. When all three predictors (WC, BMI, and physical activity level) were entered into the same logistic regression model, both a high WC and low physical activity level (moderately active and inactive) were independently associated with a greater odds of ED, whereas BMI level was not.


      Maintaining a WC level below 102 cm and achieving the recommended amount of moderate-intensity physical activity (≥150 min/week) is associated with the maintenance of proper erectile function, regardless of BMI level. These findings suggest that the clinical screening for ED risk should include the assessment of WC and physical activity level in addition to BMI. Janiszewski PM, Janssen I, and Ross R. Abdominal obesity and physical inactivity are associated with erectile dysfunction independent of body mass index. J Sex Med 2009;6:1990–1998.


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        • Laumann E.O.
        • Paik A.
        • Rosen R.C.
        Sexual dysfunction in the United States: Prevalence and predictors.
        JAMA. 1999; 281: 537-544
        • McKinlay J.B.
        The worldwide prevalence and epidemiology of erectile dysfunction.
        Int J Impot Res. 2000; 12: S6-11
        • Aytac I.A.
        • McKinlay J.B.
        • Krane R.J.
        The likely worldwide increase in erectile dysfunction between 1995 and 2025 and some possible policy consequences.
        BJU Int. 1999; 84: 50-56
        • Kaiser D.R.
        • Billups K.
        • Mason C.
        • Wetterling R.
        • Lundberg J.L.
        • Bank A.J.
        Impaired brachial artery endothelium-dependent and -independent vasodilation in men with erectile dysfunction and no other clinical cardiovascular disease.
        J Am Coll Cardiol. 2004; 43: 179-184
        • Thompson I.M.
        • Tangen C.M.
        • Goodman P.J.
        • Probstfield J.L.
        • Moinpour C.M.
        • Coltman C.A.
        Erectile dysfunction and subsequent cardiovascular disease.
        JAMA. 2005; 294: 2996-3002
        • Saigal C.S.
        • Wessells H.
        • Pace J.
        • Schonlau M.
        • Wilt T.J.
        Predictors and prevalence of erectile dysfunction in a racially diverse population.
        Arch Intern Med. 2006; 166: 207-212
        • Bacon C.G.
        • Mittleman M.A.
        • Kawachi I.
        • Giovannucci E.
        • Glasser D.B.
        • Rimm E.B.
        Sexual function in men older than 50 years of age: Results from the health professionals follow-up study.
        Ann Intern Med. 2003; 139: 161-168
        • Bacon C.G.
        • Mittleman M.A.
        • Kawachi I.
        • Giovannucci E.
        • Glasser D.B.
        • Rimm E.B.
        A prospective study of risk factors for erectile dysfunction.
        J Urol. 2006; 176: 217-221
        • Feldman H.A.
        • Johannes C.B.
        • Derby C.A.
        • Kleinman K.P.
        • Mohr B.A.
        • Araujo A.B.
        • McKinlay J.B.
        Erectile dysfunction and coronary risk factors: Prospective results from the Massachusetts Male Aging Study.
        Prev Med. 2000; 30: 328-338
        • Larsen S.H.
        • Wagner G.
        • Heitmann B.L.
        Sexual function and obesity.
        Int J Obes (Lond). 2007; 31: 1189-1198
        • Mulhall J.
        • Teloken P.
        • Brock G.
        • Kim E.
        Obesity, dyslipidemias and erectile dysfunction: A report of a subcommittee of the sexual medicine society of North America.
        J Sex Med. 2006; 3: 778-786
        • Karelis A.D.
        • St-Pierre D.H.
        • Conus F.
        • Rabasa-Lhoret R.
        • Poehlman E.T.
        Metabolic and body composition factors in subgroups of obesity: What do we know?.
        J Clin Endocrinol Metab. 2004; 89: 2569-2575
        • Janssen I.
        • Katzmarzyk P.T.
        • Ross R.
        Waist circumference and not body mass index explains obesity-related health risk.
        Am J Clin Nutr. 2004; 79: 379-384
        • Balkau B.
        • Deanfield J.E.
        • Despres J.P.
        • Bassand J.P.
        • Fox K.A.
        • Smith Jr., S.C.
        • Barter P.
        • Tan C.E.
        • Van Gaal L.
        • Wittchen H.U.
        • Massien C.
        • Haffner S.M.
        International Day for the Evaluation of Abdominal Obesity (IDEA): A study of waist circumference, cardiovascular disease, and diabetes mellitus in 168,000 primary care patients in 63 countries.
        Circulation. 2007; 116: 1942-1951
        • Blair S.N.
        • Brodney S.
        Effects of physical inactivity and obesity on morbidity and mortality: Current evidence and research issues.
        Med Sci Sports Exerc. 1999; 31: S646-62
        • Sui X.
        • LaMonte M.J.
        • Laditka J.N.
        • Hardin J.W.
        • Chase N.
        • Hooker S.P.
        • Blair S.N.
        Cardiorespiratory fitness and adiposity as mortality predictors in older adults.
        JAMA. 2007; 298: 2507-2516
        • Lee C.D.
        • Blair S.N.
        • Jackson A.S.
        Cardiorespiratory fitness, body composition, and all-cause and cardiovascular disease mortality in men.
        Am J Clin Nutr. 1999; 69: 373-380
        • Riedner C.E.
        • Rhoden E.L.
        • Ribeiro E.P.
        • Fuchs S.C.
        Central obesity is an independent predictor of erectile dysfunction in older men.
        J Urol. 2006; 176: 1519-1523
      1. Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey Data, 2008. Available at: (accessed April 20, 2009).

        • Siegel T.
        • Moul J.W.
        • Spevak M.
        • Alvord W.G.
        • Costabile R.A.
        The development of erectile dysfunction in men treated for prostate cancer.
        J Urol. 2001; 165: 430-435
        • O'Donnell A.B.
        • Araujo A.B.
        • Goldstein I.
        • McKinlay J.B.
        The validity of a single-question self-report of erectile dysfunction. Results from the Massachusetts Male Aging Study.
        J Gen Intern Med. 2005; 20: 515-519
        • Selvin E.
        • Burnett A.L.
        • Platz E.A.
        Prevalence and risk factors for erectile dysfunction in the US.
        Am J Med. 2007; 120: 151-157
        • U.S. Department of Health and Human Services
        Physical activity and health: A report of the surgeon general.
        National Center for Chronic Disease Prevention and Health Promotion, 1996
        • Yusuf S.
        • Hawken S.
        • Ounpuu S.
        • Bautista L.
        • Franzosi M.G.
        • Commerford P.
        • Lang C.C.
        • Rumboldt Z.
        • Onen C.L.
        • Lisheng L.
        • Tanomsup S.
        • Wangai Jr., P.
        • Razak F.
        • Sharma A.M.
        • Anand S.S.
        Obesity and the risk of myocardial infarction in 27,000 participants from 52 countries: A case-control study.
        Lancet. 2005; 366: 1640-1649
        • Rexrode K.M.
        • Carey V.J.
        • Hennekens C.H.
        • Walters E.E.
        • Colditz G.A.
        • Stampfer M.J.
        • Willett W.C.
        • Manson J.E.
        Abdominal adiposity and coronary heart disease in women.
        JAMA. 1998; 280: 1843-1848
        • Janiszewski P.M.
        • Janssen I.
        • Ross R.
        Does waist circumference predict diabetes and cardiovascular disease beyond commonly evaluated cardiometabolic risk factors?.
        Diabetes Care. 2007; 30: 3105-3109
        • Bigaard J.
        • Tjonneland A.
        • Thomsen B.L.
        • Overvad K.
        • Heitmann B.L.
        • Sorensen T.I.
        Waist circumference, BMI, smoking, and mortality in middle-aged men and women.
        Obes Res. 2003; 11: 895-903
        • Aronne L.J.
        Classification of obesity and assessment of obesity-related health risks.
        Obes Res. 2002; 10: 105S-115S
        • Vague J.
        The degree of masculine differentiation of obesities: A factor determining predisposition to diabetes, atherosclerosis, gout, and uric calculous disease.
        Am J Clin Nutr. 1956; 4: 20-34
        • Lau D.C.
        • Douketis J.D.
        • Morrison K.M.
        • Hramiak I.M.
        • Sharma A.M.
        • Ur E.
        2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children [Summary.
        CMAJ. 2007; 176: S1-13
        • Paffenbarger Jr, R.S.
        • Wing A.L.
        • Hyde R.T.
        Physical activity as an index of heart attack risk in college alumni. 1978.
        Am J Epidemiol. 1995; 142: 889-903
        • Mokdad A.H.
        • Marks J.S.
        • Stroup D.F.
        • Gerberding J.L.
        Actual causes of death in the United States, 2000.
        JAMA. 2004; 291: 1238-1245
        • Cheng J.Y.
        • Ng E.M.
        • Ko J.S.
        • Chen R.Y.
        Physical activity and erectile dysfunction: Meta-analysis of population-based studies.
        Int J Impot Res. 2007; 19: 245-252
        • Esposito K.
        • Giugliano F.
        • Di Palo C.
        • Giugliano G.
        • Marfella R.
        • D'Andrea F.
        • D'Armiento M.
        • Giugliano D.
        Effect of lifestyle changes on erectile dysfunction in obese men: A randomized controlled trial.
        JAMA. 2004; 291: 2978-2984
        • Kloner R.A.
        Introduction: Erectile dysfunction and cardiovascular risk factors.
        Am J Cardiol. 2003; 92: 1-2
        • Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults
        Executive summary of the Third Report of The National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III).
        JAMA. 2001; 285: 2486-2497
        • Pate R.R.
        • Pratt M.
        • Blair S.N.
        • Haskell W.L.
        • Macera C.A.
        • Bouchard C.
        • Buchner D.
        • Ettinger W.
        • Heath G.W.
        • King A.C.
        Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine.
        JAMA. 1995; 273: 402-407
        • Troiano R.P.
        • Berrigan D.
        • Dodd K.W.
        • Masse L.C.
        • Tilert T.
        • McDowell M.
        Physical activity in the United States measured by accelerometer.
        Med Sci Sports Exerc. 2008; 40: 181-188
        • Li C.
        • Ford E.S.
        • McGuire L.C.
        • Mokdad A.H.
        Increasing trends in waist circumference and abdominal obesity among US adults.
        Obesity. 2007; 15: 216-224
        • Kirby M.
        • Jackson G.
        • Simonsen U.
        Endothelial dysfunction links erectile dysfunction to heart disease.
        Int J Clin Pract. 2005; 59: 225-229
        • Laufs U.
        • Wassmann S.
        • Czech T.
        • Munzel T.
        • Eisenhauer M.
        • Bohm M.
        • Nickenig G.
        Physical inactivity increases oxidative stress, endothelial dysfunction, and atherosclerosis.
        Arterioscler Thromb Vasc Biol. 2005; 25: 809-814
        • Perticone F.
        • Ceravolo R.
        • Candigliota M.
        • Ventura G.
        • Iacopino S.
        • Sinopoli F.
        • Mattioli P.L.
        Obesity and body fat distribution induce endothelial dysfunction by oxidative stress: Protective effect of vitamin C.
        Diabetes. 2001; 50: 159-165
        • Despres J.P.
        Abdominal obesity: The most prevalent cause of the metabolic syndrome and related cardiometabolic risk.
        Eur Heart J Suppl. 2006; 8: B4-12
        • Hall S.A.
        • Esche G.R.
        • Araujo A.B.
        • Travison T.G.
        • Clark R.V.
        • Williams R.E.
        • McKinlay J.B.
        Correlates of low testosterone and symptomatic androgen deficiency in a population-based sample.
        J Clin Endocrinol Metab. 2008; 93: 3870-3877
        • Rosen R.C.
        • Riley A.
        • Wagner G.
        • Osterloh I.H.
        • Kirkpatrick J.
        • Mishra A.
        The international index of erectile function (IIEF): A multidimensional scale for assessment of erectile dysfunction.
        Urology. 1997; 49: 822-830
        • Ross R.
        • Berentzen T.
        • Bradshaw A.J.
        • Janssen I.
        • Kahn H.S.
        • Katzmarzyk P.T.
        • Kuk J.L.
        • Seidell J.C.
        • Snijder M.B.
        • Sorensen T.I.
        • Despres J.P.
        Does the relationship between waist circumference, morbidity and mortality depend on measurement protocol for waist circumference?.
        Obes Rev. 2008; 9: 312-325
        • Snijder M.B.
        • Zimmet P.Z.
        • Visser M.
        • Dekker J.M.
        • Seidell J.C.
        • Shaw J.E.
        Independent association of hip circumference with metabolic profile in different ethnic groups.
        Obes Res. 2004; 12: 1370-1374