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Association of relative fat mass with prevalence of erectile dysfunction in US men: an analysis of NHANES 2001-2004

International Journal of Impotence Research volume 37, pages 645–654 (2025)Cite this article

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Abstract

The high prevalence of erectile dysfunction (ED) underscores the critical importance of interventions and preventive measures targeting potential risk factors, among which obesity stands out. Relative fat mass (RFM) emerges as a superior indicator for quantifying body fat compared to traditional metrics like body mass index (BMI) or waist circumference (WC). However, research on the relationship between RFM and ED is extremely limited. A total of 3627 participants from the National Health and Nutrition Examination Survey 2001-2004 were eligible for analysis. The RFM is calculated using the following formula: RFM = 64-(20×height/WC). Weighted multivariable logistic regression models were utilized to assess the correlation between RFM and ED, supplemented by smooth curve fitting to further explore the linear association. When all potential covariates adjusted, continuous RFM demonstrated a positive association with ED prevalence (odds ratio (OR): 1.11, 95% confidence interval (CI): 1.05-1.18, P = 0.002). When RFM was categorized into tertiles (T1-T3), participants in T3 group exhibited a significantly higher likelihood of ED (OR: 2.19, 95% CI: 1.19, 4.05, P = 0.020) compared to those in T1. Subgroup analyses revealed a stronger correlation among participants aged over 60 years, obese individuals, and those with hypertension, while weaker correlations were observed among those with diabetes and cardiovascular disease (CVD). After sensitivity analysis for severe ED, the aforementioned regression analysis results remained statistically significant. The final ROC analysis demonstrated that the predictive ability of RFM was superior to that of BMI and WC, with an AUC (95% CI) of 0.639 (0.619-0.659). Elevated RFM demonstrated a linear correlation with increased incidence of ED and exhibited strong predictive capability for ED, underscoring the importance of obesity intervention for ED. Future studies with larger clinical samples are necessary to confirm our findings and expand the application value of RFM in assessing ED risk.

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Fig. 1
Fig. 2: Density dose–response relationship between relative fat mass (RFM) and erectile dysfunction (ED) prevalence, with red solid line represents OR and the area between the upper and lower dashed lines representing the 95% CI.
Fig. 3: Subgroup analyses for the relationship continuous relative fat mass (RFM) and erectile dysfunction (ED) prevalence in fully adjusted model 3 except the stratification factor itself, weighted.
Fig. 4: Predictive performance of RFM, WC, and BMI for ED using ROC analysis and corresponding AUC evaluation.

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Data availability

The original NHANES data were accessible on the NHANES public database, and the processed data for this study are included in this published article. Further requests for our data and the corresponding R code can be made by contacting the corresponding author upon reasonable request.

References

  1. Elterman DS, Bhattacharyya SK, Mafilios M, Woodward E, Nitschelm K, Burnett AL. The Quality of Life and Economic Burden of Erectile Dysfunction. Res Rep Urol. 2021;13:79–86.

    PubMed  PubMed Central  Google Scholar 

  2. Herbenick D, Reece M, Schick V, Sanders SA, Dodge B, Fortenberry JD. Sexual behavior in the United States: results from a national probability sample of men and women ages 14-94. J Sex Med. 2010;7:255–65.

    Article  PubMed  Google Scholar 

  3. Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol. 1994;151:54–61.

    Article  CAS  PubMed  Google Scholar 

  4. NIH Consensus Conference. Impotence. NIH Consensus Development Panel on Impotence. JAMA. 1993;270:83–90.

    Article  Google Scholar 

  5. Mark KP, Arenella K, Girard A, Herbenick D, Fu J, Coleman E. Erectile dysfunction prevalence in the United States: report from the 2021 National Survey of Sexual Wellbeing. J Sex Med. 2024;21:296–303.

    Article  PubMed  Google Scholar 

  6. Braun M, Wassmer G, Klotz T, Reifenrath B, Mathers M, Engelmann U. Epidemiology of erectile dysfunction: results of the ‘Cologne Male Survey. Int J Impot Res. 2000;12:305–11.

    Article  CAS  PubMed  Google Scholar 

  7. Nicolosi A, Glasser DB, Kim SC, Marumo K, Laumann EO. Sexual behaviour and dysfunction and help-seeking patterns in adults aged 40-80 years in the urban population of Asian countries. BJU Int. 2005;95:609–14.

    Article  PubMed  Google Scholar 

  8. Nicolosi A, Moreira ED Jr, Shirai M, Bin Mohd Tambi MI, Glasser DB. Epidemiology of erectile dysfunction in four countries: cross-national study of the prevalence and correlates of erectile dysfunction. Urology. 2003;61:201–6.

    Article  PubMed  Google Scholar 

  9. Ayta IA, McKinlay JB, Krane RJ. The likely worldwide increase in erectile dysfunction between 1995 and 2025 and some possible policy consequences. BJU Int. 1999;84:50–6.

    Article  CAS  PubMed  Google Scholar 

  10. Yao FJ, Zhang YD, Wan Z, Li W, Lin H, Deng CH, et al. Erectile dysfunction is associated with subclinical carotid vascular disease in young men lacking widely-known risk factors. Asian J Androl. 2018;20:400–4.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Dong JY, Zhang YH, Qin LQ. Erectile dysfunction and risk of cardiovascular disease: meta-analysis of prospective cohort studies. J Am Coll Cardiol. 2011;58:1378–85.

    Article  PubMed  Google Scholar 

  12. Jiang T, Osadchiy V, Mills JN, Eleswarapu SV. Is It All in My Head? Self-reported Psychogenic Erectile Dysfunction and Depression Are Common Among Young Men Seeking Advice on Social Media. Urology. 2020;142:133–40.

    Article  PubMed  Google Scholar 

  13. Wang Y, Zhao L, Gao L, Pan A, Xue H. Health policy and public health implications of obesity in China. Lancet Diabetes Endocrinol. 2021;9:446–61.

    Article  PubMed  Google Scholar 

  14. De Lorenzo A, Gratteri S, Gualtieri P, Cammarano A, Bertucci P, Di Renzo L. Why primary obesity is a disease? J Transl Med. 2019;17:169.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Feeley RJ, Traish AM. Obesity and erectile dysfunction: is androgen deficiency the common link? ScientificWorldJournal. 2009;9:676–84.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017-2018. NCHS Data Brief. 2020;360:1–8.

  17. Ward ZJ, Bleich SN, Cradock AL, Barrett JL, Giles CM, Flax C, et al. Projected U.S. State-Level Prevalence of Adult Obesity and Severe Obesity. N Engl J Med. 2019;381:2440–50.

    Article  PubMed  Google Scholar 

  18. Bacon CG, Mittleman MA, Kawachi I, Giovannucci E, Glasser DB, Rimm EB. A prospective study of risk factors for erectile dysfunction. J Urol. 2006;176:217–21.

    Article  PubMed  Google Scholar 

  19. Derby CA, Mohr BA, Goldstein I, Feldman HA, Johannes CB, McKinlay JB. Modifiable risk factors and erectile dysfunction: can lifestyle changes modify risk? Urology. 2000;56:302–6.

    Article  CAS  PubMed  Google Scholar 

  20. Donini LM, Pinto A, Giusti AM, Lenzi A, Poggiogalle E. Obesity or BMI Paradox? Beneath the Tip of the Iceberg. Front Nutr. 2020;7:53.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Ness-Abramof R, Apovian CM. Waist circumference measurement in clinical practice. Nutr Clin Pract. 2008;23:397–404.

    Article  PubMed  Google Scholar 

  22. Mahmoud I, Al-Wandi AS, Gharaibeh SS, Mohamed SA. Concordances and correlations between anthropometric indices of obesity: a systematic review. Public Health. 2021;198:301–6.

    Article  CAS  PubMed  Google Scholar 

  23. Duren DL, Sherwood RJ, Czerwinski SA, Lee M, Choh AC, Siervogel RM, et al. Body composition methods: comparisons and interpretation. J Diabetes Sci Technol. 2008;2:1139–46.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Woolcott OO, Bergman RN. Relative fat mass (RFM) as a new estimator of whole-body fat percentage ─ A cross-sectional study in American adult individuals. Sci Rep. 2018;8:10980.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Zhu X, Yue Y, Li L, Zhu L, Cai Y, Shu Y. The relationship between depression and relative fat mass (RFM): A population-based study. J Affect Disord. 2024;356:323–8.

    Article  PubMed  Google Scholar 

  26. Shen W, Cai L, Wang B, Wang Y, Wang N, Lu Y. Associations of Relative Fat Mass, a Novel Adiposity Indicator, with Non-Alcoholic Fatty Liver Disease and Cardiovascular Disease: Data from SPECT-China. Diabetes Metab Syndr Obes. 2023;16:2377–87.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Derby CA, Araujo AB, Johannes CB, Feldman HA, McKinlay JB. Measurement of erectile dysfunction in population-based studies: the use of a single question self-assessment in the Massachusetts Male Aging Study. Int J Impot Res. 2000;12:197–204.

    Article  CAS  PubMed  Google Scholar 

  28. Wu X, Zhang Y, Liu G, Jiang H, Zhang X. Association between severe headache or migraine and erectile dysfunction in American adults: a cross-sectional of data study from the NHANES. Int J Impot Res. 2024. https://doi.org/10.1038/s41443-024-00867-w.

  29. Macdonald EJ, Gaines JM, Kim JI, Paduch DA. Exploring the relationship between socioeconomic status and erectile dysfunction: an analysis of the National Health and Nutrition Examination Survey. Int J Impot Res. 2023;35:478–83.

    Article  PubMed  Google Scholar 

  30. Youcheng L, Xun W, Zhufeng C. Association between nonalcoholic fatty liver disease and erectile dysfunction among American Adults from the National Health and Nutrition Examination Survey: a cross-sectional study. Int J Impot Res. 2024. https://doi.org/10.1038/s41443-024-00914-6.

  31. Riedner CE, Rhoden EL, Ribeiro EP, Fuchs SC. Central obesity is an independent predictor of erectile dysfunction in older men. J Urol. 2006;176:1519–23.

    Article  PubMed  Google Scholar 

  32. Liu Y, Hu X, Xiong M, Li J, Jiang X, Wan Y, et al. Association of BMI with erectile dysfunction: A cross-sectional study of men from an andrology clinic. Front Endocrinol. 2023;14:1135024.

    Article  Google Scholar 

  33. Janiszewski PM, Janssen I, Ross R. Abdominal obesity and physical inactivity are associated with erectile dysfunction independent of body mass index. J Sex Med. 2009;6:1990–8.

    Article  PubMed  Google Scholar 

  34. Yassin AA, Nettleship JE, Salman M, Almehmadi Y. Waist circumference is superior to weight and BMI in predicting sexual symptoms, voiding symptoms and psychosomatic symptoms in men with hypogonadism and erectile dysfunction. Andrologia. 2017;49:1–6.

  35. Lin W, Lin ME. Novel anthropometric measures are positively associated with erectile dysfunction: a cross-sectional study. Int Urol Nephrol. 2024;56:855–65.

    Article  PubMed  Google Scholar 

  36. Eknoyan G. Adolphe Quetelet (1796-1874)-the average man and indices of obesity. Nephrol Dial Transplant. 2008;23:47–51.

    Article  PubMed  Google Scholar 

  37. Humphreys S. The unethical use of BMI in contemporary general practice. Br J Gen Pract. 2010;60:696–7.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Grier T, Canham-Chervak M, Sharp M, Jones BH. Does body mass index misclassify physically active young men. Prev Med Rep. 2015;2:483–7.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Batsis JA, Villareal DT. Sarcopenic obesity in older adults: aetiology, epidemiology and treatment strategies. Nat Rev Endocrinol. 2018;14:513–37.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Ross R, Neeland IJ, Yamashita S, Shai I, Seidell J, Magni P, et al. Waist circumference as a vital sign in clinical practice: a Consensus Statement from the IAS and ICCR Working Group on Visceral Obesity. Nat Rev Endocrinol. 2020;16:177–89.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Rimm EB, Stampfer MJ, Giovannucci E, Ascherio A, Spiegelman D, Colditz GA, et al. Body size and fat distribution as predictors of coronary heart disease among middle-aged and older US men. Am J Epidemiol. 1995;141:1117–27.

    Article  CAS  PubMed  Google Scholar 

  42. Vazquez G, Duval S, Jacobs DR Jr, Silventoinen K. Comparison of body mass index, waist circumference, and waist/hip ratio in predicting incident diabetes: a meta-analysis. Epidemiol Rev. 2007;29:115–28.

    Article  PubMed  Google Scholar 

  43. Wang J, Guan J, Huang L, Li X, Huang B, Feng J, et al. Sex differences in the associations between relative fat mass and all-cause and cardiovascular mortality: A population-based prospective cohort study. Nutr Metab Cardiovasc Dis. 2024;34:738–54.

    Article  PubMed  Google Scholar 

  44. Guzmán-León AE, Velarde AG, Vidal-Salas M, Urquijo-Ruiz LG, Caraveo-Gutiérrez LA, Valencia ME. External validation of the relative fat mass (RFM) index in adults from north-west Mexico using different reference methods. PLoS One. 2019;14:e0226767.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Yu P, Huang T, Hu S, Yu X. Predictive value of relative fat mass algorithm for incident hypertension: a 6-year prospective study in Chinese population. BMJ Open. 2020;10:e038420.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Suthahar N, Wang K, Zwartkruis VW, Bakker SJL, Inzucchi SE, Meems LMG, et al. Associations of relative fat mass, a new index of adiposity, with type-2 diabetes in the general population. Eur J Intern Med. 2023;109:73–8.

    Article  PubMed  Google Scholar 

  47. Efe S, Karagoz A, Dogan C, Bayram Z, Kalkan S, Altıntas MS, et al. Relative Fat Mass Index can be solution for obesity paradox in coronary artery disease severity prediction calculated by SYNTAX Score. Postgrad Med J. 2021;97:434–41.

    Article  PubMed  Google Scholar 

  48. Caiano LM, Costanzo S, Panzera T, Di Castelnuovo A, de Gaetano G, Donati MB, et al. Association between body mass index, waist circumference, and relative fat mass with the risk of first unprovoked venous thromboembolism. Nutr Metab Cardiovasc Dis. 2021;31:3122–30.

    Article  CAS  PubMed  Google Scholar 

  49. Zhang M, Wang Z, Liu W, Wang M, Wu H, An R. Association between the recommended volume of leisure-time physical activity and erectile dysfunction: A cross-sectional analysis of the national health and nutrition examination survey, 2001-2004. Heliyon. 2024;10:e32884.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Zhou H, Xu M, Xu Z, Li M, Ren C, Chen X, et al. The association of various physical activities with erectile dysfunction: NHANES 2001-2004. Sex Med. 2023;11:qfad036.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Huangfu Z, Gan X, Yang Y, Pang Q, Zhu B, Zhang X, et al. A Mendelian randomization study on causal effects of leisure sedentary behavior on the risk of erectile dysfunction. Andrology. 2024;12:1841–50.

  52. Xi YJ, Feng YG, Bai YQ, Wen R, Zhang HY, Su QY, et al. Genetic prediction of modifiable lifestyle factors for erectile dysfunction. Sex Med. 2024;12:qfae010.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Tucker J, Salas J, Secrest S, Scherrer JF. Erectile dysfunction associated with undiagnosed prediabetes and type 2 diabetes in young adult males: A retrospective cohort study. Prev Med. 2023;174:107646.

    Article  PubMed  Google Scholar 

  54. Liu Q, Zhang Y, Wang J, Li S, Cheng Y, Guo J, et al. Erectile Dysfunction and Depression: A Systematic Review and Meta-Analysis. J Sex Med. 2018;15:1073–82.

    Article  PubMed  Google Scholar 

  55. Chen G, Huang L, Lai M, Ran J. Association between erectile dysfunction and the prevalence and prognosis of hyperglycemia in adults in the USA based on NHANES 2001-2004. Sci Rep. 2024;14:17663.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

We extend our gratitude to all NHANES participants and staff for their outstanding work and substantial data contributions. We also thank the Third Affiliated Hospital of Soochow University for their support.

Funding

This work received support from the Changzhou Health Commission’s Youth Talent Science and Technology Project (Grant No. QN202109).

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  1. These authors contributed equally: Xingliang Feng, Nuo Ji

Authors and Affiliations

  1. Department of Urology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China

    Xingliang Feng, Nuo Ji, Bo Zhang, Wei Xia & Yiming Chen

  2. Department of Urology, The First People’s Hospital of Changzhou, Changzhou, Jiangsu, China

    Xingliang Feng, Nuo Ji, Bo Zhang, Wei Xia & Yiming Chen

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Xingliang Feng, Nuo Ji, Bo Zhang, Yiming Chen: conceptualization, methodology, writing—original draft preparation, writing—review & editing; Xingliang Feng, Nuo Ji and Wei Xia: data curation, formal analysis, writing- original draft preparation; Xingliang Feng, Nuo Ji, Yiming Chen: validation, supervision, writing—review & editing, funding acquisition. All authors read and approved the final manuscript.

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Correspondence to Yiming Chen.

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The study protocols were reviewed and approved by the Institutional Review Board of the National Center for Health Statistics (NCHS) (Protocol #98-12), and all participants provided written informed consent. The NHANES database is publicly accessible; therefore, a second ethical review of this study by our institution was exempt. Additionally, all methods were performed in accordance with the relevant guidelines and regulations.

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Feng, X., Ji, N., Zhang, B. et al. Association of relative fat mass with prevalence of erectile dysfunction in US men: an analysis of NHANES 2001-2004. Int J Impot Res 37, 645–654 (2025). https://doi.org/10.1038/s41443-024-01003-4

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