Review | Published:

Sexual function and obesity

Abstract

Objective:

To review the literature on the relationship between obesity and sexual function.

Method:

A search in the medical literature from 1966 and onwards was carried out through Medline and Embase for publications on obesity, in combination with Medical Subject Heading words related to sexual function and dysfunction.

Comments:

Four prospective and seven cross-sectional studies were found describing association between obesity and erectile dysfunction (ED). One cross-sectional study was found describing obesity and female sexual dysfunction (FSD). The prospective studies on ED all demonstrated a direct association and so did five of the seven cross-sectional studies. The single FSD study did not find any relationship. Eight intervention studies on weight loss and sexual difficulties were identified. All included few individuals and results were mixed even if most indicated an increase of sexual activity among both men and women after weight loss intervention.

Conclusion:

Support for the assumption that obesity is associated with ED was found in both prospective and cross-sectional studies. FSD was not adequately described in the literature and prospective studies are needed here. Results from weight loss intervention studies are less conclusive, but also point toward improvement in sexual dysfunction with reduced weight.

Introduction

At present, 10–30% of all individuals from developed countries are obese. In addition, 1/3–2/3 are considered to be overweight.1 Obesity is on the increase throughout the world, and increasing trends cause concern among health authorities about the associated comorbidities, for example, type 2 diabetes, heart disease, hypertension, certain cancers, reduced life expectancy1 and their cost to society. Other somatic and psychological malfunctions are also known to follow obesity such as fertility problems, osteoarthritis, social disabilities caused by stigmatization, sleeping problems or apnea. Sexual dysfunctions may also relate to obesity, but are rarely mentioned, and may, for both individual and partner, cause concern and constitute a great problem.

Obesity is also rarely mentioned as a cofactor to sexual problems in textbooks on human sexuality, and, if so, with no reference to data in support of a causal relationship.2, 3

The aim of the present review was therefore to evaluate the current evidence from the scientific literature of a possible association between obesity and sexual dysfunction among men and women.

Obesity and sexual dysfunction

There seems to be no available evidence that sexual dysfunction may cause obesity, but there are indicators that obesity may cause sexual dysfunction. However, it may be difficult to single out the independent effects on dysfunction of obesity from other causes, as obesity is a known independent risk factor for vascular risk factors such as dyslipidemia, hypertension, diabetes mellitus and depression, all known to be directly related to sexual dysfunction in both women and men, to some extent. Hence, effects of obesity on sexual dysfunction may be mediated via such vascular risk factors. These issues will be dealt with in the following.

We have identified 11 observational studies on obesity and sexual function.4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 Several factors seem to influence the validity of these studies. First, the diagnostic definition of erectile dysfunction (ED) varies between studies, and only some of them actually indicate the applied definition. The definitions used in this review were based on work by an international expert group, and were developed for epidemiological reasons.3 ED is defined as the consistent or recurrent inability of a man to attain and/or maintain penile erection sufficient for sexual activity. A minimum of 3 months duration is required for this diagnosis.3 ED may be divided into organic (vasculogenic, neurogenic, anatomic and endocrinologic) or psychogenic.15

The definition of female sexual dysfunction (FSD) includes persistent or recurrent disorders of sexual interest/desire, disorders of subjective and genital arousal, orgasmic disorders, pain and difficulty with attempted or incomplete intercourse.3 It has long been debated, whether the term ‘female sexual dysfunction’ should be classified as a dysfunction similar to ED, or whether it should be considered as a pathological condition at all. Therefore, there is no short version of the definition of FSD, but most clinical trials are studying female arousal disorder and female desire disorders. Female arousal disorders have been proposed divided into; genital sexual arousal disorders, subjective sexual dysfunction and the combination of the two.3

The lack of a more specific medical diagnosis of FSD with measurable characteristics, affects the level of evidence from clinical trials, and only few clinical trials are available, despite the fact that some studies support that women seem to be more frequently affected than men. For instance, a study of the US population showed that women reported sexual dysfunction more often than men (43 vs 31%) and 20% of the women, compared to 10% men, were seeking medical consultation for sexual dysfunction.16

Second, the classifications of the subtypes, and the prevalence and the incidence of sexual dysfunctions from the studies where associations with obesity are studied, are generally based on self-reporting, and the duration of the condition is seldom recorded. Third, there are several possibilities for bias, such as selection bias, social desirability bias, interview bias and recall bias.

Methods

A systematic search was carried out using Medline and Embase from 1966 and onwards. Furthermore, relevant books on human sexuality were screened for studies of obesity. The search included different Medical Subject Headings (MeSHs) about obesity in combination with MeSH words on sexual function or dysfunction. Following MeSH words were used: ED or FSD/impotence/masturbation/vaginal lubrication/orgasm/intercourse frequency/dyspareunia/retarded ejaculation/psychological problems, together with MeSH words for obesity such as overweight, body weight, weight loss or weight reduction or obesity surgery.

Comments

Male sexual dysfunction

Recently, a cross-country study on prevalence of ED in five European countries and USA was published.17 Taking the prevalence of ED from this review and correlating it with the prevalence of normal weight, overweight and obesity among men in the same six countries 18 indicates a relationship between weight and male sexual function as seen in Figure 1a–c. The figures show that the prevalence in normal weight men was inversely related to ED, whereas among overweight there was no relation to ED while obesity is directly related, indicating that there is a correlation only among the obese.

Figure 1
figure1

(a) The correlation between men with normal weight (%) (BMI<24.9) and prevalence of ED (%) in six different countries. (b) The correlation between overweight (%) (BMI 25–29.9) and prevalence of ED (%) in six different countries. (c) The correlation between men with obesity (%) (BMI>30) and prevalence of ED (%) in six different countries.

Observational studies

Four prospective observational studies were identified4, 5, 6, 7 (Table 1). However, two of them involve the same cohort from the Massachusetts Male Aging Study (MMAS) in 1994 from the Boston area.4, 5 The objective in the first of these studies4 was to examine the relationship between baseline coronary risk factors, including obesity, and the 8.9-year incidence of ED. The authors used the definition and classification of ED from the 1993 NIH Consensus Panel.19 From the study population (n=513 without ED at baseline), 154 were classified overweight (body mass index (BMI)28 kg/m2), and among these, 28% had minimal or no ED at follow-up, whereas 41% had moderate or complete ED. This was more than among the leaner subjects (BMI<28 kg/m2), and after controlling for potential confounders such as smoking, hypertension, physical activity, alcohol consumption, serum-cholesterol, age and antihypertensive medication, they found an odds ratio (OR) of 1.96 for developing ED among the more overweight compared to the lean, suggesting that overweight exerts an independent effect on ED.

Table 1 Prospective and cross-sectional observational studies on association between obesity and ED in men

Using the same cohort, Derby et al.5 examined the association between obesity and other potential lifestyle factors and the risk of developing ED. This analysis included 593 men without ED at baseline, and showed that among the men who were obese at baseline (BMI>30 kg/m2) there were higher incidences of ED, regardless of the attained BMI at follow-up. The lowest manifestation of ED was found in the group of men not being obese at baseline or at the follow-up. In another prospective study, Shiri et al.6 included 1130 Finnish non-ED men and followed them for 5 years. They used the same definition of ED as in the above studies. The results showed that the incidence of ED increased among obese (BMI30 kg/m2) compared to men with normal weight (BMI 18.5–24.9 kg/m2) (adjusted RR=1.7). However, only obese, but not the overweight men (BMI 25–29.9 kg/m2), had a higher risk of ED.

Finally, the prospective study by Fung et al.7 examined coronary heart disease risk factors, including obesity, as possible predictors of ED among 570 46-year-old men (average BMI of 25.7 kg/m2, at baseline) followed for 25 years. The erectile function was evaluated from the short five-item ED questionnaire (international index of erectile function (IIEF)-5). The results indicated that obesity (BMI28 kg/m2) at baseline was a significant predictor of subsequent ED, and that this association was independent of age and hypercholesterolemia. In addition, a positive linear trend from no ED to severe/complete ED and no sexual activity was found with increasing BMI (P=0.01) after age-adjustment. However, there was no information about weight change occurring during the period of the study, and hence it is not known if the observed association was independent of the attained BMI.

Seven cross-sectional studies8, 9, 10, 11, 12, 13, 14 on associations between obesity and ED were identified (Table 1).

Feldman et al.8 reported the first cross-sectional results from the MMAS study on the relation between obesity and impotence in 1994. The results indicated that impotence (measured by self-administered questionnaires) was not related to BMI (no P-value given). Chung et al.9 investigated the association between obesity (120% of ideal body weight) and ED, by comparing ED in obese vs others (<120% of ideal body weight). Several functional penile examinations including duplex ultrasonography of the cavernous arteries were carried out to detect ED. The results suggested that the quality of residual erectile function was significantly better in the non-obese than in the obese group (P=0.02), whereas no difference was found in the erectile response to intercavernous injection of prostaglandinE1 (P=0.63). Additionally, the analysis showed that the occurrences of vascular risk factors from medical history or laboratory examinations were higher in the obese group (P=0.048). However, after adjusting for vascular risk factors there were no longer significant differences between the two groups for either residual erectile function or penile vascular impairment (all P>0.05).

Blanker et al.10 investigated the correlates of ED and ejaculatory dysfunction in a population sample (n=1605) of older Dutch men (50–75 years). They defined ED as no erection or erections with severely reduced rigidity. The results showed that ED occurred significantly more often in men with high BMI (>30 kg/m2) than in men with lower BMI (<25 kg/m2) (adjusted OR=3.0 (1.7–5.4)).

The largest and most comprehensive study11 included 31 742 men from The Health Professionals Follow-up Study in US, aged 53–90 years (all without ED at baseline). The study showed an OR of 1.4 of developing ED with obesity (defined as BMI>28.7 kg/m2).

A Swedish population-based12 study of 977 younger men (18–49 years) of whom 36% were overweight (BMI 25–29.9 kg/m2) and 8% obese (BMI>30 kg/m2) and 481 older men (50–74 years), where 50% were overweight and 11% obese, found no difference in sexual satisfaction (six-graded questions) between the normal weight and the obese subjects within both age groups. The older men reported a decrease of sexual desire (six-graded questions) during the previous 5 years, but differences were found to be independent of obesity.

Gunduz et al.13 examined 79 patients (aged 31–74 years) with coronary artery disease and lipid metabolism disorders. Twenty-three were obese and all but one had ED (P>0.001). Additionally, among overweight (n=33), 70% had ED, whereas the fraction of the normal weight patients (n=23) with ED was 60%.

Finally, Giugliano et al.14 applied the quantitative scoring system IIEF20 for ED, when studying 40 obese men with ED, 40 obese non-ED and 50 non-obese non-ED men. They demonstrated a significantly decreased reaction to L-arginine infusion and an increased level of C-reactive protein in the obese EDgroup compared with the other two groups (see also section on diabetes mellitus and metabolic syndrome).

Additionally, one study (not included in the table) examined daily-life problems associated with obesity (BMI>30 kg/m2) among men (n=51) and women (n=223) (not couples) seeking treatment of their overweight. The results showed that 31% of the obese men and 31% of the obese women reported problems with their sex life compared to a 10-year older normal weight Italian population study using the same questionnaires, but showing problems among 14% men and 15% women only.21

Female sexual dysfunction

We have identified one cross-sectional study12 only (Table 2), that investigated the association between obesity and female sexual satisfaction.

Table 2 Cross-sectional observational studies on associations between obesity and sexual dysfunctions in women

The study was based on a Swedish population by Adolfsson et al.12 of 840 younger women (18–49 years) of which 18% were overweight and 6% obese, and 426 older women (50–74 years), where 32% were overweight and 11% obese. In both age groups, there was no difference in satisfaction of sexual life between the obese and the normal weight women. However, there was a tendency toward lower sexual satisfaction and sexual desire associated with higher weights in the youngest age group.

Generally, the data on ED were either from questionnaires of sexual activity or interviews. Unfortunately, not all of the studies reviewed describe the used criterion for ED, even if the most commonly used is based on the definition given by NIH Consensus Panel.19 However, this criterion does not quantify the severity of ED, as when the more comprehensive IIEF is applied.20 Some modifications may therefore be present in these studies.

In summary, most of the studies among men suggest a positive association between obesity and sexual dysfunction. In particular, the positive association between obesity and development of ED in all these published prospective cohort studies, is supportive of a relationship. In addition, five out of seven of the cross-sectional studies find a positive association (two of them with significant association), and only two studies did not find any association.

The relationship between obesity and FSD is sparsely investigated with only one cross-sectional and no prospective studies published. There is clearly a need for more studies with prospective information on development of FSD both before and after menopause. Before such studies are performed, a better understanding of the association between obesity and development of FSD cannot be obtained.

Introduction studies on weight reduction and ED/FSD

The weight reduction and ED/FSD studies can be divided into those using lifestyle intervention, such as diet-interventions and those using obesity surgery. In general, the validity of the studies can be discussed, because most studies include few participants, only short follow-up periods, or suffer from selection bias. Table 3 gives the results from published weight reduction studies and sexual function. In total, eight studies22, 23, 24, 25, 26, 27, 28, 29 have been published since 1982.

Table 3 Published studies on influence on weight reduction on ED and FSD (non-surgical and surgical interventions)

Lifestyle intervention

Four studies examined effects of weight loss and sexual difficulties. Kolotkin et al.22 examined the effect of weight loss on quality of life including six questions about sexual life among 37 men and women. However, there was no available information about the intervention or the achieved weight loss from this intervention. Among men, the post-treatment scores of sexual life differed significantly from pre-scores indicating that the weight loss program seemed to have been beneficial. However, among women there was no association between weight changes and changes in sexual life. The pilot among women studies by Werlinger et al.23 demonstrated that weight loss significantly increased the overall perception of sexual functioning (P=0.02) and increased sexual satisfaction (P=0.06) (using Drive subscales, the Satisfaction subscale and the Global Sexual Satisfaction Index of the Derogatis Sexual Functioning Inventory). Kaukua et al.24 measured the effect of weight loss on changes in sex hormones and sexual function among obese men (n=38). The men followed a 10-week very-low-energy-diet and behavior modification and maintenance of weight loss for 8 months. The study did not show significant treatment effect on sexual functioning. However, it should be emphasized that these men still were obese (BMI>30kg/m2) at the end of the study.

A more recent study by Esposito et al.25 looked at the effect of weight loss and increased physical activity on ED in 55 obese men with ED, compared to 55 matched-controls, measuring elevated levels of proinflammatory cytokines as a marker of inflammation and endothelial function, and using these markers as an indication of ED. Over a period of 2 years, the weight loss and the increased physical activity improved sexual function in one-third of the men. Those with weight loss all had a lowered serum concentration of the inflammatory markers, and the authors suggested that the improvement in ED was a potential effect of the endothelial function following the improvement in the inflammatory markers.

Surgery

Three studies on surgery induced weight loss and sexual difficulties have been published. The studies generally find that surgery (jejunoileal bypass) for obesity may favorably effect sexual relationships, but to what degree it has an effect is not clear from the studies.26, 27 The study by Rand et al.26 compared sexual functioning among 32 morbidly obese women and 56 morbidly obese men (more than 45 kg overweight), aged 36±8 years before and after surgery. One year after the surgery (Rand et al.,27), 61% (n=88) reported a better sex-life compared to the presurgery condition, whereas 27% reported no change. Fourteen (34%) reported an increased interest in sex, and 56% reported that the partner had attained more interest in sex.

Kinzl et al.28 found a low frequency of sexual activity using 82 semi-structured interviews with morbidly obese (average BMI 42.8 kg/m2) women. Preoperatively, 44% were satisfied with their sexual life, but more than half of the obese women had some kind of sexual problem; low sexual desire (11.2%), sexual avoidance or rare sexual intercourse (23.3%) and difficulty in engaging in sexual intercourse because of physical problems (11%). Postoperatively (1 year later), 63% stated that they enjoyed sexual intercourse more.

The study by Larsen,29 including 66 women and 24 men (average BMI 41.5 kg/m2) undergoing gastric banding and followed for 3 years, found a significant change in satisfaction with sexual life after surgery. The changes were not only apparent among those who got married or went into a stable relationship during the follow-up, but also among those who at baseline lived in a stable relationship.

Other sexual difficulties and obesity

A number of different sexual difficulties may arise with obesity in men and women. For both genders, these include difficulties with lack of orgasm, decreased intercourse frequency, reduced sexual desire and lack of perceived satisfaction. In men, masturbation and premature or retarded ejaculation may be affected. For instance, in a community-based study of older Dutch men, Blanker et al.10 found no significant correlation (P=0.45) between BMI and ED (defined as reduced or absent ejaculate). However, the same study found no correlation between diabetes and ED, which was an unexpected finding, and questions the validity of this data. No published studies have examined the association between obesity and premature ejaculation. In women, dyspareunia and decreased vaginal lubrication may occur. However, only few studies have examined such associations.30

The physiological factor that affects ED in obesity does not necessarily interfere with the psychology of reduced desire for sex or satisfaction. Stress and depression could have an influence on the desire, but a low self-esteem from dissatisfaction of body image may also affect the desire. From retrospective questionnaires among 32 women enrolled in a hospital-based weight management program, Werlinger et al.23 found a significant improvement in perceived body image and sexual function after weight loss. Ray et al.31 found that perceived sexual satisfaction increased significantly (P<0.005) with loss of weight after gastric bypass in 243 previous morbidly obese patients.

In summary, both the lifestyle and the surgery interventions point toward beneficial effects of weight loss among obese on ED. However, considering that the final BMI in a majority of the studies still indicate obesity, it is not clear whether the effect of weight loss is related to the weight loss per se or caused by the complete intervention procedure.

Mechanisms relating ED with obesity

A number of biological mechanisms may link obesity to sexual dysfunction. Potential mechanisms include endothelial dysfunction, metabolic syndrome and diabetes, altered endocrine function, social and psychological problems, obstructive sleep apnea (OSA), as well as ordinary physical disabilities. Lifestyle factors such as smoking, high alcohol intake, poor diet intake and physical inactivity may influence as well. Each of these will be dealt with in the following.

Endothelial dysfunction

A few have examined the relation between obesity, endothelial dysfunction and ED.

Esposito et al.25 suggested that in obese men endothelial dysfunction might contribute to ED because of a reduced blood flow and an abnormal platelet aggregation response. Furthermore, they suggested that the explanation of the relation between ED, obesity and endothelial dysfunction could depend on a decreased ability to relax the vascular smooth muscle cells, possibly because of alterations in the nitric oxide activity.32

Diabetes mellitus and metabolic syndrome

Several studies have suggested an increased risk of ED or FSD as a complication to diabetes mellitus. The risk of ED or FSD is further related to age, duration of the diabetes mellitus, poor metabolic control, smoking and to the presence of diabetic complications. Additionally, some studies suggest that also men with type 1 diabetes mellitus and a high BMI are at increased risk of ED.33, 34

A recent published study by Kupelian et al.35 assessed the association between ED and metabolic syndrome with data from the MMAS. The results indicated that ED may predict the metabolic syndrome and be more common among men with BMI less than 25 kg/m2 (adjusted RR 0.008). However, the authors question these findings, as there was a difference between subject sample used in the analysis and the original baseline sample.

The etiology of ED and the metabolic syndrome has been reviewed by Matfin et al.36 The review concluded that several of the conditions related to the metabolic syndrome, such as diabetes, obesity, endothelial dysfunction, lipids, as well as the related therapies may exacerbate ED. In addition, the review suggested that endothelial dysfunction, as a cause of the metabolic syndrome, might be an underlying reason for the observed difficulties in treatment of ED.

Esposito et al.25 also examined if the metabolic syndrome could act as a cause for sexual dysfunction in premenopausal women. One-hundred and twenty (aged 20–48 years) women with metabolic syndrome were compared to 80 controls without the syndrome. All were recruited from an outpatient department for metabolic disease. Sexual function was assessed using the Female Sexual Function Index.20 The results indicated that women with the metabolic syndrome had an increased prevalence of sexual dysfunction compared to controls (P<0.001). Giugliano et al.14 applied the quantitative scoring system IIEF20 for assessing ED, and studied 40 obese men with ED, 40 obese non-ED and 50 non-obese, non-ED men. They demonstrated a significant decreased reaction to L-arginine infusion and an increased level of C-reactive protein in the obese ED group compared to the other two groups. However, they did not have an age-matched group of non-obese ED men to serve as a control group. On the other hand, another study,25 published simultaneously and by the same clinic, among men who had been treated and had undergone weight loss, could not demonstrate any differences in CRP values between men with and without ED at baseline, despite the fact that several of the other metabolic characteristics for these groups were similar to those from the above mentioned publication.14

Altered endocrine function

Obesity has been found to be associated with increased androgen production among women, whereas studies in men show a low androgen production.37, 38

Kaukua et al.24 studied the association between weight loss, sex hormones and sexual functioning among 38 obese men (BMI>35 kg/m2) and showed that testosterone increased, but the sexual function scores were unaffected after weight loss (see also the section about weight loss).

Dyslipidemia and related drugs

Obesity is often accompanied by hyperlipidemia, and ED has been linked to serum lipid levels.39, 40 For instance, Wei et al.41 described hyperlipidemia as a common condition in ED patients. However, conflicting results on associations between use of hypolipidemic drugs and ED exist. Recent published studies by Taneva et al.,42 Strey et al.43 and Guven et al.44 suggest that statin therapy improves endothelial function, especially among patients with pre-existing endothelium dysfunction44 and therefore found a potential positive effect from these compounds.

On the other hand, it has also been debated if ED may be a side effect of the lipid-lowering drugs.45 One case–control study46 showed that among 339 age-matched men, those treated with hypolipidemic drugs (especially fibrates and/or statins), more often complained about ED compared to a control group (OR=1.46). Additionally, a systematic review45 from 2002 of the effect of lipid-lowering drugs on ED concluded that statins and fibrates might cause ED.

It should be noted that the results from the larger studies, such as the MMAS, indicated no correlations between use of lipid-lowering drugs and impotence10 and also data from a large Scandinavian study (n=4444) suggested that simvastatin did not seem to be the likely cause of sexual dysfunction.47

In an attempt to explain these conflicting results, four mechanisms have been mentioned in the literature. First, there is no true association and previous results are dependent on confounders or other common diseases. Second, there is a direct effect of lipid-lowering drug on ED as statins may lower blood pressure. Third, idiosyncratic side effects of the drug itself may be operating.47 And finally, the statins may inhibit the rate of cholesterol synthesis and may thereby inhibit the synthesis of steroid hormones (e.g. testosterone) eventually leading to ED.45

Psychological problems

There may be a strong relationship between psychological problems and the occurrence of both sexual dysfunction and obesity. However, neither the order in which they occur, nor the way they occur are fully understood but an interrelation seems likely.48 There is surprisingly little research on the association between sexual activity and body image. One of the few studies published on body image and women's sexual behavior found that women who were satisfied with their body image reported more sexual activity (P<0.0001), more frequent orgasm (P<0.0001), comfort with having sex with lights on (P<0.0001) and with pleasing their partner sexually (P<0.0001), compared to those not being satisfied with their body image.49

Weight loss studies also support a generally improved sexual satisfaction with weight loss (see section on weight reduction and ED/FSD).

Obstructive sleep apnea

OSA is characterized by repetitive episodes of upper airway obstruction often seen in relation to obesity. A review50 of the evidence on associations between OSA and ED suggested that the pathological processes, which cause OSA, could be the same as those predisposing for ED. The potential mechanisms are suggested to be both neural, hormonal and endothelial. However, there is a need for further investigation in this area, especially on the role of obesity as a common risk factor.

Lifestyle factors

ED shares several modifiable risk factors with vascular diseases, including lifestyle factors such as smoking, alcohol intake, physical inactivity and diet. Second, these risk factors are themselves associated with obesity.

Smoking

Associations between smoking and the penile erection seem complex, but associations have been proposed to be mediated via toxic effects of nitric oxide, decreasing the smooth muscle relaxation on the endothelium.51 Blanker et al.10 found ED to be more frequent among current smokers (OR=1.6) and Bacon et al.11 found smoking associated with increased prevalence of ED (RR 1.3). Similar findings among current smokers (RR=1.3, 95% CI: 0.8–2.1) were found by Shiri et al.6 However, not all studies find an association between smoking and ED. Derby et al.5 for instance, did not find that changes in smoking were related to ED (P=0.28). Gunduz et al.13 found no statistical difference in ED between cigarette smokers and non-smokers (P=0.28), although the prevalence of ED was higher in cigarette smokers. However, some may use smoking as a way of reducing body weight and smoking may in this way be related both to weight loss and at the same time ED.

Alcohol

The effect of alcohol and ED also remains controversial. Alcohol is inconsistently related to obesity in men; one review suggests that alcohol intake may be related to leanness in women.52, 53

Physical activity

Both ED and obesity may be related to physical inactivity. However, whereas many studies find that obese are less physically active than lean, there are only few studies on the association between physical activity and ED, and there are no studies available investigating the association between physical activity and FSD.

It is hypothesized that physical activity may increase blood flow and improve lipid profile, thereby affecting penile vasculature.5, 54 In agreement, one study examined the effect of 9 months exercise on sexuality among 78 healthy, sedentary men, and showed that sedentary behaviors were associated with ED risk.54 Similarly, the US Health Professionals Follow-up Study11 found that men who were the most physically active (measured by time spent doing different activities) had a lower risk of ED (RR=0.7) compared to those men doing less or no physical activity (RR=0.9). In addition, watching television for more than 20 h per week was significantly associated with ED (RR=1.2) also after control for leisure physical activity and other health-related factors. Finally, the MMAS study by Derby et al.5 concluded that men with sedentary behaviors would be able to reduce their risk of ED with physical activity.

Diet

Whereas many studies show that obese have different diet intakes than lean, there are currently no available studies of the association between diet and ED or FSD (see above for dyslipidemia).

Conclusion

The general worldwide increase in obesity among most populations may result in more individuals with sexual dysfunction. The present review found support from both cross-sectional and prospective observational studies that obesity may have a direct relationship to ED, and seems of importance for the development of ED. The results are sparse regarding associations between obesity and FSD in women, and conclusions regarding potential influence of obesity on FSD cannot be made before more studies have been performed. However, most weight loss intervention studies suggest that weight loss improves sexual functioning in women as well as in men. However, it is not known whether this effect is related to the weight loss per se or caused by the complete intervention procedure, including the lifestyle interaction, as the patients were obese in most intervention studies.

Indeed, it is possible that endothelial dysfunction, dyslipidemia, altered endocrine function, OSA or psychological problems are the biological mediators of the negative impact on erectile function reported among obese men or on sexual function among obese women. Likewise, medication or adverse lifestyles are common risk factors for both obesity and ED and may be the real causes behind both. Further research is needed in this area to clarify if obesity itself is an underlying factor for, or a passive cofactor to ED.

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Correspondence to B L Heitmann.

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Keywords

  • body mass index
  • sexual function
  • sexual dysfunction
  • weight loss
  • metabolic syndrome
  • erectile dysfunction

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