International Journal of Obesity (2007) 31, 15711578

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ORIGINAL ARTICLE
Body mass index, physical activity and erectile
dysfunction: An U-shaped relationship from
population-based study
JYW Cheng and EML Ng
Department of Psychiatry, University of Hong Kong, Queen Mary Hospital, Hong Kong
Objective: To investigate the relationships between body mass index (BMI), physical activity and erectile dysfunction (ED).
Design and subjects: A population representative cross-sectional analytic study of ED in Hong Kong, with two-stage stratified
random sampling, and face-to-face interviews conducted by trained interviewers with structured questionnaires. Study subjects
were 1506 men aged 2670.
Results: Age (odds ratio (OR) 1.30; 95% confidence interval (CI) 1.201.40), physical activity (OR 0.91 per 500 kcal/week;
95% CI 0.840.98), and general psychological distress (OR 1.03 per GHQ score; 95% CI 1.001.06) were independently
associated with ED after multivariate adjustments. An U-shaped relationship between BMI and ED was observed only among
men with no exercise (oonce/week): BMI o18.5 (OR 2.99; 95% CI 1.018.86), 18.519.9 (OR 2.66; 95% CI 1.046.79),
20.020.9 (OR 1.37; 95% CI 0.493.79), 22.022.9 (OR 1.36; 95% CI 0.583.17), 23.024.9 (OR 1.66; 95% CI 0.70
3.93), X25.0 (OR 2.47; 95% CI 1.085.67) using BMI 21.021.9 as reference, adjusted for age, GHQ and smoking status.
Being physically active (X1000 kcal/week) only reduced the risk of ED (OR 0.40, 95% CI 0.160.95) in men who were obese,
adjusted for age, GHQ, smoking status and BMI.
Conclusions: BMI and physical activity independently and differentially affected ED risk. BMI had greatest influence with low
physical activity, and physical activity exerted greatest influence when BMI was high. This is the first study to demonstrate an
U-shaped relationship between BMI and ED risk, but only in men with no exercise, and to identify underweight as a risk factor for
ED. This relationship has clinical implications for obese as well as underweight individuals.
International Journal of Obesity (2007) 31, 15711578; doi:10.1038/sj.ijo.0803639; published online 24 April 2007
Keywords: body mass index; erectile dysfunction; physical activity; exercise; epidemiology

Introduction
Obesity is a growing public health problem worldwide. It has
been estimated that more than 1 billion adults worldwide are
overweight (body mass index (BMI) 25.029.9), and more
than 300 million adults worldwide are obese (BMIX30.0).1
In the United States between 1980 and 2002, the prevalence
of obesity doubled in adults aged 20 or above, and tripled in
children and adolescents aged 619 years.2 More recent data
continued to demonstrate an increase in the prevalence of
obesity in children, adolescents, and adults between 1999
and 2004 in the United States.3 Epidemiological data on
obesity in Asia are comparatively less complete, and Gu

Correspondence: Dr JYW Cheng, Department of Psychiatry, Li Ka Shing

Faculty of Medicine, University of Hong Kong, Hong Kong.
E-mail: jackieyg@hku.hk
Received 11 October 2006; revised 28 November 2006; accepted 5 March
2007; published online 24 April 2007

et al.4 reported the age-standardized prevalence of overweight (BMIX25.0) to be 26.9% (25.728.1) in men and
31.1% (29.732.5) in women in China. In Hong Kong, 39.2%
of the population was found to be obese (BMI X25.0).5
Obesity is a strong risk factor for diabetes, hypertension,
hypercholesterolaemia, coronary heart disease, gall bladder
disease and certain types of cancer.6 Given the growing
literature on the cardiovascular risk factors7,8 associated with
erectile dysfunction (ED), and the link between obesity and
cardiovascular risk factors, there is strong evidence to suspect
an association between obesity and ED.
The largest cohort to date on ED, the Health Professionals
Follow-up Study (HPFS),9 has found BMI, physical activity
and smoking to be prospectively associated with ED. Obesity
(multivariate relative risk 1.9, 95% confidence interval (CI)
1.62.2) was found to be risk factor, and high BMI was
associated with higher risk of ED: multivariate relative risks
1.1 (1.01.2), 1.2 (1.11.3), 1.3 (1.11.4), 1.7 (1.52.0) for
BMI 23.024.9, 25.026.9, 27.029.9 and 30.0 or greater,

BMI exercise and ED

JYW Cheng and EML Ng

1572
respectively (using BMI o23 as a reference). A cross-sectional
study10 has found significant associations between ED and
several indices of central obesity (waisthip index, sagittal
abdominal diameter, sagittal abdominal diameterheight
index, maximum abdominal circumference and waist
circumference) but not between high BMI (obesity) and
ED. A recent report11 also calls for more rigorous scientific
evidence in supporting obesity and dyslipidaemia as causative factors in the development of ED, despite current
evidence from animal and human studies.
Many studies on obesity were conducted in Western
populations and only a small proportion of study subjects
had low BMI. Using a population representative crosssectional sample from Hong Kong, we examined the
relationships between BMI, physical activity and ED.

Methods
Study design, subjects and data collection
This was a descriptive and analytic population-based crosssectional study, based on the Mens Health Survey conducted
by the Family Planning Association of Hong Kong.
A pilot study was performed in January 2001, and
validated the questionnaire based on 50 interviews. The
main study was conducted between 16 February and 15
March 2001. Two-stage stratified random sampling was
performed. In the first stage, housing quarters were stratified
by districts and type of housing. A random list of households
was generated. In the second stage, home visits and face-toface interviews by trained interviewers were made to each
chosen household. There were three main selection criteria
male gender, aged 2670 and ability to communicate in
Chinese.
A separate self-administered questionnaire was used for
sensitive questions related to sexual problems, knowledge,
attitudes and behaviours, and the completed questionnaires
were sealed in unmarked envelopes to ensure confidentiality.
An interview lasted on average 30 min. To ensure reliability
of collected data, interviewers were trained, interviews
were conducted under supervision by fieldwork supervisors,
and a sample of questionnaires was independently checked
afterwards.
Questionnaire design
The structured questionnaire asked about: demographic
characteristics, such as age (in years), education (no education/primary/secondary/tertiary), marital status (married/
single/divorced and so on); biological data, such as BMI
(below), diseases requiring long-term medication (included
26 common medical conditions); psychological parameters,
such as general psychological distress (GHQ), satisfaction
with current health (five-point Likert); and social lifestyle
information, such as physical activity (below), smoking
(never/current/former), drinking (never/ever) and attention
to health (five-point Likert).
International Journal of Obesity

The GHQ developed by Goldberg et al.12 measures

nonpsychotic psychological disturbances and is usually used
as a first-stage screening instrument in general populations.
We used the Chinese validated13 Likert-scale version as a
proxy measurement for general psychological distress.
Smoking status was determined by the number of cigarettes ever consumed, currently consumed and duration of
quitted smoking, and was classified as never, current and
former smokers, respectively.

Definitions of ED, BMI and physical activity

The National Institutes of Health (NIH) Consensus Panel
has defined ED as the inability to achieve or maintain an
erection sufficient for satisfactory sexual performance.14
Rosen et al.15 paper on the development of the abridged IIEF5 (international index of erectile function) has identified
item 5 (maintenance ability) of the original 15-item version
of IIEF-15 as having a 100% relative importance (that is,
most important compared to the other 14 items) of
discriminating men with and without ED. Item 5 is over
the past six months: during sexual intercourse, how difficult
was it to maintain your erection to completion of intercourse?
In this study, we used the above item on the validated
Chinese version of IIEF16 to assess ED. The responses ranged
from extremely difficulty to not difficult at all and not
difficult at all was used to indicate absence of ED while the
other responses were combined to collectively indicate the
presence of ED. The rationale was because both IIEF-1517 and
IIEF-512 as well as the Massachusetts Male Aging Study18
defined ED as having some degree of ED.
Self-reported body height and weight were used to
calculate Quetelets BMI (weight in kilograms divided by
height in metres squared). We used the BMI definitions
proposed by the World Health Organization (WHO), the
International Association for the Study of Obesity, and the
International Obesity Task Force: BMI o18.5 as underweight, BMI 18.522.9 as normal, BMI 23.024.9 as overweight and BMI X25.0 as obese in Asian populations.19
Owing to a relatively large number of subjects having normal
BMI, we further divided the normal BMI category into
four categories as Gu et al.20 did. This yielded seven BMI
categories for analysis.
The level of physical activity was determined by the
frequency (per day, week or month), duration (in minutes or
hours each time) and type of regular exercise (swimming,
cycling, soccer, basketball, tennis, badminton and so on),
and was converted to metabolic equivalent task (MET) scores
based on the average energy expenditure of that activity (one
MET is equivalent to expending 1 kcal/kg/h). We estimated
the energy expenditure in kilocalories per week (kcal/week)
of the most frequently performed exercise. To allow practical and meaningful comparisons, we further categorized
physical activity into no exercise (exercise oonce/
month), active (exercise Xonce/month, o1000 kcal/week)

BMI exercise and ED

JYW Cheng and EML Ng

1573
or inactive (exercise Xonce/month, X1000 kcal/week)
physical activity status, based on the recommendations from
the Centers for Disease Control and Prevention, the American
College of Sports Medicine, and the US surgeon general,
which recommend 30 min/day most days of the week or the
equivalent of 1000 kcal/week of energy expenditure.21,22

Data analysis
All statistical analyses were performed by STATA version 8.2.
(STATA Corporation, College Station, TX, USA). We calculated the prevalence of ED in each of the BMI and physical
activity categories as well as the overall prevalence of ED.
To assess the associations between ED and other variables,
we calculated logistic regression models using ED as the
dependent variable and other variables of interest as
independent variables. Since a large number of biological,
psychological and social lifestyle risk factors are known to be
associated with ED, each variable was first adjusted for age
and then adjusted for all other variables. Age was chosen
because it is one of the most consistent predictor of ED in
observational studies.
We analyzed each of BMI and physical activity in the
absence of the other variable to independently assess each
variables relationship with ED. To assess for interaction
between BMI and physical activity, we added an interaction
term to a model for BMI and physical activity. Since the
logistic regression method assumes linearity of the log odds
of independent variables, and the relationships between
BMI, physical activity and ED may be nonlinear, we analysed
BMI and physical activity first as continuous variables
(linearity assumed) and then as categorical variables (nonlinearity allowed) using logistic regression. Since the standard regression methods rely heavily on its underlying
assumptions (including relationships among independent
variables and between independent and dependent variables) for statistical adjustment of confounding,23 we
performed stratified analyses on each of BMI and physical
activity in addition to standard statistical regression adjustments to isolate and statistically control for the confounding
effects of the variable respectively. BMI was stratified into
four categories (underweight, normal, overweight and
obese), and three physical activity levels (no exercise, active
and inactive physical activity levels) were assessed in each of
the BMI categories using no exercise as the reference group.
Physical activity was stratified into three categories (no
exercise, active and inactive physical activity levels), and
seven BMI groups (o18.5, 18.519.9, 20.020.9, 21.021.9,
22.022.9, 23.025.0, 425.0) were assessed in each of the
physical activity levels using BMI 21.021.9 as reference.
Odds ratios (OR) were reported with 95% CI, and P-values
were two-tailed with statistical significance defined as o0.05.

eligible men for the study. Of the remaining 1941 households, 1506 were interviewed successfully. The overall
response rate of the survey was 77.6% (1506/1941). We
excluded 583 men who did not answer the ED (507), BMI
(10) and physical activity (66) assessment questions, who
tended to be older (P o0.01) and less likely to be married
(P o0.01) than the 923 men included in the final analysis.
Of the 507 excluded participants who did not answer the ED
question, 89.2% (452/507) were excluded because of sexual
inactivity: 311 were married but have ceased sexual intercourse, 30 were divorced, separated or widowed and had no
sexual partner and 111 were single with no sexual partner.
The characteristics of the study subjects are shown in
Table 1.
Table 2 shows the prevalence of ED in each BMI and
physical activity category. Notice an U-shaped relationship
between BMI and ED prevalence. The lowest ED prevalence
was in the normal BMI range (33.9%, 95% CI 25.142.7), and
the highest prevalence rates were in underweight (48.3%,
95% CI 35.061.5), overweight (38.1%, 31.444.9) and obese
BMI (36.5%, 29.943.0) categories.
Table 3 shows the univariate, age-adjusted and multivariate regression models for ED. Only age (OR 1.30; 95%
CI 1.201.40), GHQ score (OR 1.03; 95% CI 1.001.06), and
physical activity (OR 0.91; 95% CI 0.840.98) remained
significantly associated with ED after multivariate adjustments. Current smoking status of X30 cigarettes per day was
marginally significant (P 0.07). Note that BMI was not
statistically significant when analysed as a linear continuous
variable (possibly due to nonlinear relationship).
Figure 1 shows the effect of BMI in each physical activity
level. An U-shaped relationship between BMI and ED risk was
present in men with no exercise, with significant risk elevation
in underweight BMI o18.5 (OR 2.99; 95% CI 1.018.86;
P 0.04), BMI 18.519.9 (OR 2.66; 95% CI 1.046.79;
P 0.04) and obese BMI X25.0 (OR 2.47, 95% CI 1.08
5.67; P 0.03) using BMI 21.021.9 as reference, adjusted for
age, GHQ and smoking status. No discernable relationship was
present in those who exercise o1000 or 41000 kcal/week.
Figure 2 shows the effect of physical activity level in each
BMI category. A significant protective effect of active physical
activity level (X1000) was present in obese men (OR 0.40,
95% CI 0.160.95; P 0.04) using no exercise as reference
group, adjusted for age, GHQ, smoking status and BMI.
No significant finding was present in other BMI categories.
Table 4 shows the stratified regression analyses for obese
BMI and no exercise categories. We tested for interaction
between BMI and physical activity, but it was not statistically
significant (P 0.64).

Discussion
Results
Of the 2049 households randomly sampled for the study, 108
were nondomestic or demolished quarters or did not have

This is the first study to demonstrate an U-shaped relationship between BMI and ED risk, and to demonstrate risk
elevation of ED in underweight BMI. The fact that this
International Journal of Obesity

BMI exercise and ED

JYW Cheng and EML Ng

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Table 1

Characteristics of the 923 study subjects included in this study

N

Age

2630
3140
4150
5160
6170

115
308
293
188
95

11.5
30.8
29.3
18.8
9.5

Education

No education/kindergarden
Primary
Secondary
Tertiary

10
191
654
144

1.0%
19.1%
65.5%
14.4%

Marital status

Married
Single or cohabiting
Divorced/separated/widowed

852
131
16

85.3
13.1
1.6

Regular drinker

No
Yes

629
369

63.0
37.0

Smoking status

Never
Current
Former

455
387
157

45.6
38.7
15.7

Physical activity

None (oonce/month)
Inactive (o1000 kcal/week)
Active (X1000 kcal/week)

355
433
155

37.3
45.4
16.3

BMI

Underweight
Normal
Overweight
Obese

54
484
188
197

5.9
52.4
20.4
21.3

ED

No
Yes

583
340

63.2
36.8

Comorbidities

Any
Cardiovascular diseases
Endocrine diseases
Gastrointestinal diseases
Muscles and joints diseases

122
48
20
15
9

13.2
5.2
2.2
1.7
1.0

Abbreviations: BMI, body mass index; ED, erectile dysfunction.

Table 2

Prevalence of ED in each BMI and physical activity category

All men
N Prevalence (%)

BMI

o18.5 (underweight)
18.519.9
20.020.9
21.021.9
22.022.9
23.024.9 (overweight)
X25.0 (obese)

Physical activity None (oonce/month)

Inactive (o1000 kcal/week)
Active (X1000 kcal/week)
Overall

(95% CI)

58
103
115
113
187
202
211

48.3
35.0
33.9
34.5
36.4
38.1
36.5

(35.061.5)
(25.644.3)
(25.142.7)
(25.643.4)
(29.443.3)
(31.444.9)
(29.943.0)

357
436
170
989

37.3
37.1
37.0
36.7

(32.242.3)
(32.641.7)
(29.744.4)
(33.739.7)

Abbreviations: BMI, body mass index; CI, confidence interval; ED, erectile
dysfunction.

International Journal of Obesity

relationship exists only in men with no exercise (oonce/

month) suggests complex interactions between BMI, exercise
and ED. The HPFS prospective cohort9 found that BMI and
physical activity were independently associated with the
development of ED. However, it did not demonstrate an
U-shaped relationship between BMI and ED, but a linear
relationship between BMI and ED risk. The BMI categories
used in this study were different from that in the HPFS. The
HPFS used BMI o23 as a reference group, and grouped
subsequent categories by an increment of 2 units of BMI
(that is, 23.024.9, 25.026.9, 27.029.9 and 430.0). Most of
the BMI categories that we used were less than 23.0, but we
also demonstrated an elevation of risk in those who were
obese (Asian BMIX25.0), only that we did not further divide
the obese category into more categories. It was possible that
the HPFS captured only the increasing range of the U-shaped
relationship between BMI and ED.
The U-shaped relationship could be real or apparent. If it
was real, it suggests that BMI had a larger influence on ED
when no exercise was present, and if exercise was present
its influence will mask that of BMI and hence statistical
nonsignificance. The multivariate regression model (Table 3)
involving both physical activity and BMI illustrates that
physical activity was significant (P 0.02) but BMI was not
(P 0.47). Since sedentary lifestyle is becoming more
common in urban life, the population impact of BMI on
ED will increase as populations become less physically
active.11 Alternatively, if the relationship was not real, which
was supported by the lack of discernable relationships in
other physical activity levels (active and inactive) and the
marginally significant P-values (0.03 or 0.04), the U-shaped
relationship might be a chance finding. However, this was
unlikely since the U-shaped relationship was also present in
the aggregate analysis between ED prevalence and BMI.
Furthermore, only 355 men were included in the stratified
analysis with no exercise status, and if statistical significance
was reached even with such a small sample, it was likely that
the P-values would be more significant as more subjects
were included. It also suggests a huge population effect if
the relationship was already detectable in 355 men. Also the
existence of the U-shaped relationship in a subgroup of the
population, despite its nonuniversality, could still be useful
for that population subgroup.
Obesity is a relatively well-studied risk factor for ED,
and even a randomized controlled trial (RCT) was
undertaken to assess the therapeutic impact of weight
reduction on ED in obese men.24 However not many
population-based epidemiological studies measured BMI,
and for those that did, the study focus was usually obesity
not underweight. Our results show that the ED risk in
underweight (OR 2.99) individuals were comparable and
possibly higher than those who were obese (OR 2.47)
among men with no exercise. The BMI 18.519.9 category,
despite being a normal BMI, also had elevated ED risk
(OR 2.66) compared to men with BMI 21.021.9. This
suggests that even within the normal BMI range, there is an

BMI exercise and ED

JYW Cheng and EML Ng

1575
Table 3

Regression models on risk of ED

Univariate

Age
Education
Married
Any medication
GHQ
BMI
Physical activity (per 500 kcal/week)
Regular drinking
Smoking
Never
Current (o30 c.p.d.)
Current (X30 c.p.d.)
Former

Multivariate a

Age-adjusted

OR

(95% CI)

Sig.

OR

(95% CI)

Sig.

OR

(95% CI)

Sig.

1.27
0.86
1.80
1.97
1.02
0.98
0.96
1.05

(1.191.35)
(0.770.96)
(1.222.67)
(1.372.86)
(1.001.04)
(0.951.02)
(0.891.03)
(9.811.37)

0.00*
0.01*
0.00*
0.00*
0.02*
0.44
0.32
0.72

0.94
1.03
1.32
1.03
0.97
0.90
1.09

(0.851.06)
(0.671.58)
(0.891.97)
(1.011.06)
(0.931.02)
(0.840.98)
(0.821.43)

0.36
0.89
0.15
0.00*
0.33
0.01*
0.56

1.30
0.94
1.04
1.41
1.03
0.98
0.91
1.06

(1.201.40)
(0.831.07)
(0.651.68)
(0.922.15)
(1.001.06)
(0.941.02)
(0.840.98)
(0.791.44)

0.00*
0.37
0.85
0.10
0.01*
0.47
0.02*
0.66

0.96
2.23
1.40

(0.711.28)
(1.074.66)
(0.972.03)

0.79
0.03*
0.06*

1.06
2.27
1.03

Ref
(0.781.44)
(1.074.80)
(0.701.53)

0.68
0.03*
0.86

1.05
2.01
1.01

(0.751.46)
(0.934.34)
(0.661.54)

0.76
0.07
0.94

Abbreviations: BMI, body mass index; CI, confidence interval; c.p.d., cigarettes per day; ED, erectile dysfunction; OR, odds ratio. aMultivariate adjustment for all the
other variables in the Table. *Po0.05.

Figure 1 Effect of BMI in each level of physical activity. BMI, body mass index; CI, confidence interval; ED, erectile dysfunction; OR, odds ratio.

optimal BMI with lowest risk of ED, and from our results it
appeared to be BMI 21.021.9.
From a previous ED study in Hong Kong by Thomas
et al.,25 BMI was significantly lower among diabetics who
had ED compared to diabetics without ED, and this might
suggest that underweight plays a more important role in
Asians. This might partly explain the lack of association
between high BMI (427.0) and ED in a large-scale Korean ED
study.26
A low BMI can be an extreme end of a physiological
spectrum or the result of a pathological process (such as

cachexia). Since this was a population representative sample

that included healthy and infirm subjects, it was hard to
pinpoint whether the low BMI was attributed to or
confounded by poor general health. We used medication
intake as a proxy for general health and medication side
effects, and it was not significantly associated with ED.
Furthermore, the stratified analysis was adjusted for age
(associated with general health) and other significant risk
factors. There was already an elevation of risk within the
normal BMI range, suggesting that a marginally low BMI
(whether attributed to diseases or not) already carried
International Journal of Obesity

BMI exercise and ED

JYW Cheng and EML Ng

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Figure 2 Effect of active physical activity in each BMI category. BMI, body mass index; CI, confidence interval; ED, erectile dysfunction; OR, odds ratio.

Table 4
exercise

Stratified analyses: Risk of ED in obese men and men with no

Erectile dysfunction
Multivariate OR
Obese BMI Age
(n 200)
GHQ
Smoking status (X30 cpd)
Physical activity
No exercise (oonce/month)
Inactive (o1000 kcal/week)
Active (X1000 kcal/week)
BMI
No exercise Age
(n 355)
GHQ
Smoker status (X30 cpd)
BMI
o18.5 (underweight)
18.519.9
20.020.9
21.021.9
22.022.9
23.024.9(overweight)
X25.0 (obese)

(95% CI)

Sig.

1.51
1.05
1.29

(1.271.80) 0.00*
(1.001.10) 0.04*
(0.961.32) 0.13

0.50
0.40
0.97

Ref
(0.251.02) 0.06
(0.160.95) 0.04*
(0.86-1.09) 0.68

1.28
1.01
1.03

(1.141.45) 0.00*
(0.971.05) 0.40
(0.901.18) 0.60

2.99
2.66
1.37

(1.018.86)
(1.046.79)
(0.493.79)
Ref
(0.583.17)
(0.703.93)
(1.085.67)

1.36
1.66
2.47

0.04*
0.04*
0.54
0.47
0.24
0.03*

*Po0.05.

increased risk for ED, without the need for the presence of
chronic wasting, cachexia or in extremis states.
The association of reduced ED risk with active physical
activity status in obese men supported the results of the RCT
International Journal of Obesity

by Esposito et al.,24 in which reduction of obese BMI by

exercise and dietary modification achieved increase of IIEF
scores.
Physical activity, therefore, appears to have the greatest
effect on ED risk when BMI is high (obese). Taken together
with the greatest effect of BMI when physical activity is low
(no exercise), and that no significant interaction (P 0.64)
was detected between BMI and physical activity, it suggests
that each of BMI and physical activity may act independently and differentially on ED risk.
It has to be mentioned that the WHO BMI classification
proposed for Asians was only provisional and the authorities
called for their validation in more research studies.10 The
U-shaped association between all-cause mortality and BMI
in Asians investigated by Gu et al.4,20 was similar to that of
Western populations, with the lowest all-cause mortality
between 23.0 and 27.0, and the authors used this finding to
support the use of a common recommendation for defining
overweight and obesity in all racial and ethnic groups. The
HPFS demonstrated an elevation of adjusted relative risks
for men with BMI 25.029.9, which is overweight by
conventional BMI classification. A BMI of X25.0 is already
considered to be obese by the provisional WHO Asian BMI
classification, and we also found a significant elevation of
risk in this range. However, we did not demonstrate an
elevation of risk for men with BMI 23.024.9, which is
overweight by the WHO Asian BMI classification, and this
appears to support the use of the conventional BMI
classification with regard to ED in Asians.

BMI exercise and ED

JYW Cheng and EML Ng

1577
Despite excluding 38.7% (583/1506) of the original
sample, there are good reasons to believe that the generalizability and representativeness of this population-based
study remain high. Since the majority (87.0%; 507/583) of
the excluded participants were excluded because they did
not answer the ED question, and in turn the majority of them
(89.2%; 452/507) were excluded because of sexual inactivity,
the apparent low percentage of participant inclusion into
our analyses (61.3%; 923/1506) was because some men were
unable to assess their own erectile function and who in various
natural stages of life ceased to have sexual intercourse (some
married men) or did not have any sexual partner (single,
separated, divorced or widowed). Furthermore, the IIEF15,17
was validated in sexually active men, and inclusion of sexually
inactive men may give false-positive results.
We acknowledge the limitation of using a self-reported
single-question composite measure for ED, and that our ED
definition did not capture the NIH consensus definition
fully, particularly the part on satisfactory sexual performance. However, the IIEF-15 item for sexual satisfaction
only ranked 6th in its ability to discriminate between men
with and without ED.7 Another potential limitation is the
absence of statistical adjustment for self-image and obesityinduced distress or anxiety, which may mediate or confound
the observed relationship between BMI and ED.
Since this study is conducted in an Asian population, the
results may have limited generalizability to the Western
populations.
We also acknowledge the limitation of using crosssectional study design to establish causal relationships, but
since the U-shaped relationship is a new finding, this study
served more in identifying associations and the crosssectional design is well suited for this purpose. This study
has implications for researchers, clinicians and health policy
makers. Researchers can conduct large scale observational
studies (cohort or cross-sectional) to confirm the U-shaped
relationship, and better characterize underweight BMI in
association with ED. Clinicians can advocate better BMI
control in their patients, as it will not only reduce risks of
cardiovascular diseases or cancer, but the benefit may even
extend to ED. Health policy makers should devote more
resources and have more political commitment to tackle the
growing epidemics of obesity worldwide.

Acknowledgements
We thank the staff at the Family Planning Association of Hong
Kong for their assistance in the collection of data. Based on the
Mens Health Survey 2002 conducted by the Family Planning
Association of Hong Kong and designed by EML Ng.

References
1 Abelson P, Kennedy D. The obesity epidemic. Science 2004; 304:
1413.

2 Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin LR, Flegal
KM. Prevalence of overweight and obesity among US children,
adolescents, and adults, 19992002. JAMA 2004; 291: 28472850.
3 Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal
KM. Prevalence of overweight and obesity in the United States,
19992004. JAMA 2006; 295: 15491555.
4 Gu D, Reynolds K, Wu X, Chen J, Duan X, Reynolds RF, et al.,
Inter ASIA Collaborative Group. Prevalence of the metabolic
syndrome and overweight among adults in China. Lancet 2005;
365: 13981405.
5 Thomas GN, Ho SY, Lam KS, Janus ED, Hedley AJ, Lam TH. Hong
Kong Cardiovascular Risk Factor Prevalence Study Steering
Committee. Impact of obesity and body fat distribution on
cardiovascular risk factors in Hong Kong Chinese. Obes Res 2004;
12: 18051813.
6 Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH.
The disease burden associated with overweight and obesity. JAMA
1999; 282: 15231529.
7 Jackson G, Rosen RC, Kloner RA, Kostis JB. The second Princeton
consensus on sexual dysfunction and cardiac risk: new guidelines
for sexual medicine. J Sex Med 2006; 3: 2836.
8 Montorsi P, Ravagnani PM, Galli S, Salonia A, Briganti A, Werba JP
et al. Association between erectile dysfunction and coronary
artery disease: Matching the right target with the right test in the
right patient. Eur Urol 2006; 50: 721731.
9 Bacon CG, Mittleman MA, Kawachi I, Giovannucci E, Glasser DB,
Rimm EB. A prospective study of risk factors for erectile
dysfunction. J Urol 2006; 176: 217221.
10 Riedner CE, Rhoden EL, Ribeiro EP, Fuchs SC. Central obesity is
an independent predictor of erectile dysfunction in older men.
J Urol 2006; 176 (4 Part 1): 15191523.
11 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: 778786.
12 Goldberg DP, Rickels K, Downing R, Hesbacher P. A comparison of
two psychiatric screening tests. Br J Psychiatry 1976; 129: 6167.
13 Pan PC, Goldberg DP. A comparison of the validity of GHQ-12
and CHQ-12 in Chinese primary care patients in Manchester.
Psychol Med 1990; 20: 931940.
14 NIH Consensus Development Panel on Impotence. JAMA 1993;
270: 8390.
15 Rosen RC, Cappelleri JC, Smith MD, Lipsky J, Pena BM.
Development and evaluation of an abridged, 5-item version of
the International Index of Erectile Function (IIEF-5) as a
diagnostic tool for erectile dysfunction. Int J Impot Res 1999; 11:
319326.
16 Chan PSF. The sexual health inventory for men, a diagnostic tool
for erectile dysfunction. Abstract, 5th Asian Congress of Sexology,
Seoul, Korea.
17 Rosen RC, Cappelleri JC, Gendrano III N. The international index
of erectile function (IIEF): a state-of-the-science review. Int J Impot
Res 2002; 14: 226244.
18 Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, MaKinlay
JB. Impotence and its medical and psychological correlates: results
of the Massachusetts male aging study. J Urol 1994; 151: 5461.
19 The World Health Organization Western Pacific Region; The
International Association for the Study of Obesity; The International Obesity Task Force. The Asia-Pacific Perspective: Redefining Obesity and Its Treatment. Health Communications Australia
Pty Limited: Sydney, Australia, 2000.
20 Gu D, He J, Duan X, Reynolds K, Wu X, Chen J et al. Body weight
and mortality among men and women in China. JAMA 2006;
295: 776783.
21 Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C
et al. 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: 402407.
22 US Dept of Health and Human Services. Physical Activity and
Health: A Report of the Surgeon General. Centers for Disease

International Journal of Obesity

BMI exercise and ED

JYW Cheng and EML Ng

1578
Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion: Atlanta, Ga, 1996.
23 McNamee R. Regression modelling and other methods to control
confounding. Occup Environ Med 2005; 62: 500506.
24 Esposito K, Giugliano F, Di Palo C, Giugliano G, Marfella R,
DAndrea F et al. Effect of lifestyle changes on erectile dysfunction
in obese men: a randomized controlled trial. JAMA 2004; 291:
29782984.

International Journal of Obesity

25 Thomas GN, Tomlinson B, Abdullah AS, Yeung VT, Chan JC,

Wong KS. Association of erectile dysfunction with cardiovascular
risk factors and increasing existing vascular disease in
male Chinese type 2 diabetic patients. Diabetes Care 2005; 28:
20512053.
26 Cho BL, Kim YS, Choi YS, Hong MH, Seo HG, Lee SY et al.
Prevalence and risk factors for erectile dysfunction in primary
care: results of a Korean study. Int J Impot Res 2003; 15: 323328.