Dear Dr G,

I understand from your previous articles, you have been dealing with New Year resolutions to improve sexual performance since the beginning of the year.

I am somewhat surprised you have not mentioned the motivation to lose weight for a better sex life.

I am a 45-year-old married man who has been having trouble with my weight since my youth.

Owing to lack of exercise and excessive eating, especially after the recent festivities, my BMI (body mass index) has gone from overweight to obese.

Apart from not getting any morning wood, I am unable to obtain or maintain an erection during intercourse.

Besides, I am also losing my libido and getting breathless during sex.

My wife also hates having sex with me as I am getting too heavy to be on top.

I went to the doctor for some blue pills and was somewhat disappointed he recommended I lose weight instead for better overall health.

Don’t get me wrong – I fully agree I should be in better shape. Before I begin my weight loss programme, I would like to put Dr G on the spot for an opinion on weight and sexual health management.

Firstly, am I having erectile dysfunction at the young age of 45?

Is there robust evidence associating obesity with erectile dysfunction?

Can weight loss really improve the erection and libido?

I am really weighed down by my poor erection and looking forward to your opinion.

Yours truly,

Wilting William

Erectile dysfunction (ED), also known as impotence, is defined as the persistent inability to attain and maintain a penile erection sufficient for satisfactory sexual intercourse. A previous Massachusetts Male Aging Study (MMAS) report noted that ED is the most common sexual health issue, affecting over 150 million men worldwide in 1995 and is estimated to affect over 300 million this year.

The Health and Morbidity Survey 2019 in Malaysia also revealed ED affected nearly a third of young men aged 18 to 29. ED is also associated with substantial adverse effects on physical and psychological health in these men facing a high incidence of non-communicable diseases such as diabetes, hypertension, dyslipidemia and obesity.

Being overweight or obese is having abnormal or excessive fat accumulation, causing an impaired quality of life. For adults, the World Health Organization (WHO) defines “overweight” as a BMI greater than or equal to 25, and “obesity” as a BMI greater than or equal to 30.

With its rapidly increasing prevalence, obesity has become a global public health concern. Sexual dysfunction, especially ED, is common among obese males. One study found that obesity increases the risk of ED by approximately 1.3 times. This risk is compounded with other additional risk factors such as diabetes, smoking, high cholesterol and blood pressure. Other studies also demonstrated that the incidence of ED was directly attributed to the growing prevalence of obesity.

A regional study found that the prevalence of ED was as high as 42.1% in higher BMI and larger waist circumference in young non-diabetic men. The association of obesity with ED is not completely clear.

However, there is an association with metabolic syndrome, inducing a high risk of pathophysiologic processes, including oxidative stress, inflammation and insulin resistance. This might partly explain the elevated prevalence of chronic diseases (hypertension, hyperlipidemia and diabetes) in the men facing ED. Moreover, the efficacy of medications such as the blue pill on erectile function is reduced in obese men as their weight problems worsen.

Many randomised controlled trials have been performed to evaluate weight reduction in ED in obese men. The results showed that lifestyle changes are associated with improvements in erectile function. In addition, weight loss by bariatric surgery has been reported to improve erectile function in obese men. Weight loss from exercise, diet, or surgery could reverse ED and provide a cost-effectiveness analysis for its treatment.

A 15% weight loss in obese men can significantly improve their erectile function, as measured by the international index of erectile function (IIEF) score. The association between obesity and the increasing risk of sexual dysfunction is well documented in scientific literature. Although medications such as phosphodiesterase-5 (PDE5) inhibitors (that blue pill and others in its class) are effective in the treatment of ED, they are not a long-term solution for overall health.

Given the increasing prevalence of ED in obese men, clinicians are paying more attention to getting them to maintain a healthy body weight for overall health, instead of quick solutions. US comedian and actor Ralphie May once declared: “I’m obese, but I’m not obtuse!”

When obese men troubled by ED put Dr G on the spot, his response is: don’t be obtuse – understand how obesity can damage your sexual and overall health. The key is to not get weighed down when it comes to erectile rigidity.