Background:
Erectile dysfunction (ED) is a prevalent complication among diabetic men, impacting their quality of life and overall health outcomes. Both glycemic control and body mass index (BMI) have been implicated as potential risk factors for ED in this population, but the evidence remains inconclusive, particularly in the context of Saudi Arabia.
Study Aim:
This meta-analysis aimed to systematically evaluate the association between glycemic control, BMI, and the prevalence of ED among diabetic Saudi men.
Methods:
A comprehensive literature search was conducted in major electronic databases to identify relevant studies published up to 31 December 2023. Eligible studies were cross-sectional or prospective in design, included male participants diagnosed with diabetes mellitus, and reported data on glycemic control, BMI, and ED prevalence. Data were extracted, and a random-effects model was used to calculate pooled odds ratios (ORs) with 95% confidence intervals (CIs). Heterogeneity was assessed using the I2 statistic, and publication bias was evaluated using funnel plots.
Results:
Five studies met the inclusion criteria, comprising a total sample of 1710 diabetic Saudi men. The pooled analysis revealed a significant association between uncontrolled diabetes mellitus and increased risk of ED (OR = 3.01, 95% CI: 0.98–9.26), with substantial heterogeneity (I2 = 92%). However, no significant association was found between high BMI (overweight or obese) and ED prevalence (OR = 0.73, 95% CI: 0.34–1.56), with high heterogeneity (I2 = 85%). Funnel plots suggested minimal publication bias.
Conclusion:
Our findings highlight the critical role of glycemic control in determining ED risk among diabetic Saudi men. While uncontrolled diabetes appears to significantly increase the likelihood of ED, BMI alone may not be a strong predictor in this population. Clinicians should prioritize aggressive management of diabetes to mitigate ED risk, while individualized approaches to weight management may be warranted for overall health optimization.
Introduction
Erectile dysfunction (ED) is a common and distressing condition characterized by the inability to achieve or maintain an erection sufficient for satisfactory sexual performance[1]. While ED can occur in men of all ages, it becomes more prevalent with advancing age and is often associated with various comorbidities, including diabetes mellitus (DM)[2]. The interplay between diabetes and ED is well established, with diabetes being recognized as one of the leading risk factors for ED worldwide[1,3]. The burden of diabetes-related ED is particularly pronounced in Saudi Arabia, where diabetes prevalence rates have reached epidemic proportions, with an estimated prevalence of 32.4% among adults aged 55 years or more[4].
The pathophysiological mechanisms underlying diabetes-related ED are multifactorial and complex. Chronic hyperglycemia, a hallmark feature of diabetes, leads to microvascular damage and endothelial dysfunction, compromising penile blood flow and impairing the erectile response[5,6]. Additionally, diabetes-associated neuropathy and autonomic dysfunction contribute to the development of ED by disrupting the intricate neural pathways involved in erectile physiology[6]. Psychological factors such as depression, anxiety, and diabetes-related distress further exacerbate the burden of ED in diabetic men, contributing to a vicious cycle of sexual dysfunction and impaired quality of life[7].
In addition to glycemic control, obesity has emerged as a significant modifiable risk factor for ED in the general population[8,9]. The adverse effects of obesity on erectile function are thought to result from a complex interplay of metabolic, hormonal, and vascular factors[10]. Excess adiposity is associated with systemic inflammation, insulin resistance, and dyslipidemia, all of which contribute to endothelial dysfunction and impaired penile vascular perfusion[11,12]. Moreover, obesity-related comorbidities such as hypertension, cardiovascular disease, and metabolic syndrome further compound the risk of ED, highlighting the intricate relationship between obesity and erectile health[13].
Despite the well-established individual associations between diabetes, obesity, and ED, the precise interplay between glycemic control, body mass index (BMI), and erectile function in diabetic populations remains incompletely understood, particularly among Saudi men. While some studies have suggested that poor glycemic control and obesity independently increase the risk of ED among diabetic individuals[14–16], others have reported conflicting findings or observed no significant association[14]. This discrepancy underscores the need for a comprehensive synthesis of the existing literature to elucidate the collective impact of glycemic control and BMI on ED prevalence among diabetic Saudi men.
Moreover, the cultural, social, and healthcare context of Saudi Arabia may further influence the relationship between diabetes, obesity, and ED. Cultural norms surrounding sexuality and barriers to seeking healthcare may impact the reporting and management of ED in this population[17]. Additionally, disparities in healthcare access and utilization, as well as variations in diabetes management practices, may contribute to differences in ED prevalence and outcomes among diabetic Saudi men[17].
The primary aim of this meta-analysis is to systematically review and quantitatively synthesize the existing evidence on the relationship between glycemic control and BMI as risk factors for ED among diabetic men in Saudi Arabia. This study seeks to identify the prevalence of ED among diabetic men with different BMI categories (normal weight, overweight, and obese) and compare the prevalence of ED in men with controlled versus uncontrolled DM.
Methodology
Study design
The reporting of this meta-analysis follows the guidelines set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) to enhance transparency and reproducibility. The PRISMA checklist was used to ensure the completeness of reporting throughout the study[18].
Search strategy
The literature search was designed to identify all relevant studies that investigated the association between glycemic control, BMI, and ED in diabetic Saudi men. We conducted a thorough search of electronic databases including PubMed, Scopus, Web of Science, and Embase. The search strategy combined terms related to “erectile dysfunction,” “diabetes mellitus,” “glycaemic control,” “Body Mass Index,” and “Saudi Arabia” without language or publication date restrictions. The search strings were adapted to each database’s syntax and filters. Additionally, the reference lists of included studies and relevant reviews were manually searched to identify further studies not captured by the database searches.
HIGHLIGHTS
- The meta-analysis includes five studies comprising a total of 1710 diabetic men from Saudi Arabia.
- Uncontrolled diabetes significantly elevates the risk of erectile dysfunction (ED) (odds ratio = 3.01).
- There is no prominent correlation observed between high BMI and the prevalence of ED.
- The study highlights the significance of pre-emptive management of diabetes to mitigate the ED risk.
- Results suggest that body mass index alone might not be a strong predictor of ED in the Saudi population.
- The current findings advocate for a subtler strategy to address ED among male diabetic patients.
Inclusion and exclusion criteria
Studies were included if they met the following criteria: (1) cross-sectional or prospective design, (2) included men diagnosed with DM, (3) reported on the prevalence of ED, (4) assessed the relationship between ED and either glycemic control or BMI, and (5) conducted in Saudi Arabia. We excluded studies that (1) did not report specific data for the Saudi population, (2) were case reports, letters, comments, or reviews, and (3) lacked clear definitions or assessments of ED, glycemic control, or BMI.
Data extraction
Two independent reviewers extracted data from the included studies using a standardized data extraction form. Extracted information included study characteristics (author, year of publication, study design, and setting), population characteristics (sample size, age, and diabetes type), and key findings related to the prevalence of ED among different BMI categories and glycemic control statuses. Any discrepancies between reviewers were resolved through discussion or consultation with a third reviewer.
Statistical analysis
The association between glycemic control (uncontrolled vs. controlled DM) and ED, and the association between BMI (overweight/obese vs. normal weight) and ED were quantified using odds ratios (ORs) with 95% confidence intervals (CIs). A random-effects model was utilized to account for potential heterogeneity across studies. Heterogeneity among the studies was assessed using the I2 statistic, with values of 25%, 50%, and 75% indicating low, moderate, and high heterogeneity, respectively. Publication bias was evaluated through visual inspection of funnel plots. Sensitivity analyses were conducted to explore the impact of individual studies on the overall results. All statistical analyses were performed using Review Manager (RevMan), version 5.4, The Cochrane Collaboration, 2020.
Results
Search results
The initial database search yielded 419 potentially relevant studies. Following the removal of duplicates, title and abstract screening, and full-text assessment, a total of 5 studies were included in the quantitative synthesis[19–23]. The PRISMA flow diagram illustrates the study selection process (Fig. 1).
Figure 1.
PRISMA flow diagram for the study search and selection processes.
Characteristics of included studies
In the review, five studies were included for quantitative data synthesis. These studies, conducted between 2003 and 2020, offer a comprehensive overview of the prevalence of ED among diabetic men in Saudi Arabia, emphasizing the potential impact of BMI and glycemic control (Table 1).
Table 1
Characteristics and findings of the included studies (n = 5)
StudyCityStudy designPopulation typeStudy yearDiagnostic toolNumber of participantsPrevalence of ED among overweight menPrevalence of ED among obese menPrevalence of ED among men with normal BMIPrevalence of ED among men with uncontrolled DMPrevalence of ED among men with controlled DMAlmigbal, 2019[19]RiyadhCross-sectionalMen with T2DM2017IIEF29379.8%78.5%88.2%87.7%71.8%Almogbel, 2014[20]RiyadhCross-sectionalMen with diabetes mellitus registered in primary care clinics2012–2013IIEF37677.9%81.1%97.0%84.7%78.7%Al-Turki, 2007[21]RiyadhCross-sectionalMen with diabetes mellitus attending a primary care clinic2005–2006IIEF18676.9%78.4%71.4%80.0%75.5%Batais et al, 2020[22]RiyadhCross-sectionalMen with T2DM2017IIEF29379.8%78.5%88.2%NRNREl-Sakka and Tayeb, 2003[23]MakkahProspective studyMen with noninsulin-dependent diabetes2001–2002IIEF56281.9%91.9%70.0%95.3%58.6%
The cities of Riyadh and Makkah served as the geographical focal points for this investigation. Notably, all but one study was carried out in Riyadh, highlighting a concentration of research interest in the capital region[19–22]. In contrast, El-Sakka and Tayeb[23] conducted their prospective study in Makkah, offering a broader geographical perspective within the kingdom.
Regarding study design, the majority of the research adopted a cross-sectional approach[19–22], which is instrumental in understanding the prevalence and distribution of ED in specific populations at a given time. The exception was the study by El-Sakka and Tayeb[23], which employed a prospective design, providing insights into the progression and potentially causal relationships over time.
The population type across these studies was consistently men with DM, with a specific focus on those with type 2 DM (T2DM) in three studies[19,22,23], reflecting the global burden of this disease and its implications on sexual health. The participant numbers varied, ranging from 186 in the study by Al-Turki[21] to 562 in the work of El-Sakka and Tayeb[23], indicating a wide range in the scale of research efforts.
The International Index of Erectile Function (IIEF) was universally applied as the diagnostic tool across all studies, ensuring a consistent and reliable measure of ED among participants. This uniformity in assessment methodology enhances the comparability of results across the studies included in this meta-analysis.
The findings revealed a nuanced picture of ED prevalence in relation to BMI and glycemic control. For overweight men, the prevalence of ED ranged from 76.9% to 81.9%, while for obese men, it was slightly higher, with figures between 78.4% and 91.9%. Interestingly, the prevalence of ED among men with a normal BMI was reported in a narrower range, from 70.0% to 97.0%, suggesting that while BMI is a significant factor, other variables also play crucial roles in the development of ED among diabetic men.