Journal of Diabetes and Its Complications xxx (2016) xxx–xxx

Contents lists available at ScienceDirect

Journal of Diabetes and Its Complications

j o u r n a l h o m e p a g e : W W W. J D C J O U R N A L . C O M

Self-reported sitting time and prevalence of erectile dysfunction in

Japanese patients with type 2 diabetes mellitus: The Dogo Study
Shinya Furukawa a, b,⁎, Takenori Sakai c, Tetsuji Niiya d, Hiroaki Miyaoka e, Teruki Miyake f, Shin Yamamoto g,
Sayaka Kanzaki f, Koutatsu Maruyama h, Keiko Tanaka a, b, Teruhisa Ueda i, Hidenori Senba a,
Masamoto Torisu j, Hisaka Minami k, Takeshi Tanigawa g, Bunzo Matsuura g,
Yoichi Hiasa f, Yoshihiro Miyake a, b
a
Department of Epidemiology and Preventive Medicine, Ehime University Graduate School of Medicine, Ehime, Japan
b
Epidemiology and Medical Statistics Unit, Translational Research Center, Ehime University Hospital, Ehime, Japan
c
Department of Internal Medicine, Yawatahama General City Hospital, Ehime, Japan
d
Department of Internal Medicine, Matsuyama Shimin Hospital, Ehime, Japan
e
Department of Internal Medicine, Saiseikai Matsuyama Hospital, Ehime, Japan
f
Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Ehime, Japan
g
Department of Lifestyle-related Medicine and Endocrinology, Ehime University Graduate School of Medicine, Ehime, Japan
h
Department of Public Health, Juntendo University School of Medicine, Tokyo, Japan
i
Department of Internal Medicine, Ehime Prefectural Central Hospital, Ehime, Japan
j
Department of Internal Medicine, Saiseikai Saijo Hospital, Ehime, Japan
k
Department of Internal Medicine, Ehime Niihama Hospital, Ehime, Japan

a r t i c l e i n f o a b s t r a c t

Article history: Aims: No evidence exists regarding the association between sitting time and erectile dysfunction (ED) among
Received 10 July 2016 patients with type 2 diabetes mellitus. The aim of this study was to evaluate the association between self-reported
Received in revised form 23 September 2016 sitting time and ED among patients with type 2 diabetes mellitus.
Accepted 10 October 2016 Methods: Study subjects were 430 male Japanese patients with type 2 diabetes mellitus (mean age, 60.5 years).
Available online xxxx
A self-administered questionnaire was used to collect information on the variables under study. The study
subjects were asked about time spent sitting during typical 24-hour periods over the past 12 months. Subjects
Keywords:
Sedentary
were divided into four groups according to self-reported sitting time: 1) b5 hours, 2) 5–7 hours, 3) 7–9 hours,
Sexual function and 4) ≥9 hours. ED was defined as present when a subject had a Sexual Health Inventory for Men score b8.
Physical activity Adjustment was made for age, body mass index, duration of type 2 diabetes, current smoking, current drinking,
Erectile dysfunction hypertension, coronary artery disease, stroke, glycated hemoglobin, walking habit, and diabetic neuropathy.
Diabetes Results: The prevalence values of moderate to severe ED and severe ED were 36.1% and 49.8%. At least 9 hours
sitting was independently positively associated with severe ED but not moderate to severe ED; the adjusted OR was
1.84 (95% CI: 1.06–3.33). In the multivariate model, there was a statistically significant inverse exposure–response
relationship between the self-reported sitting time and severe ED (p for trend = 0.029).
Conclusions: Self-reported sitting time may be positively associated with ED in Japanese patients with type 2
diabetes mellitus.
© 2016 Elsevier Inc. All rights reserved.

1. Introduction diabetes mellitus, and cardiovascular diseases, regardless of presence

The opportunities for participating in sedentary lifestyle activities
in modern society, such as watching television (TV), sitting in a car, or
using the computer, are ubiquitous. In the general population, sitting
time is significantly positively associated with all-cause death, type 2
Conflict of Interest: There are no conflicts of interest to declare.
⁎ Corresponding author at: Department of Epidemiology and Preventive Medicine, Ehime
University Graduate School of Medicine, Shitsukawa, Toon, Ehime 791-0295, Japan. Tel.: +81
89 960 5283; fax: +81 89 960 5384.
E-mail addresses: shinya.furukawa@gmail.com, shinfuru@m.ehime-u.ac.jp
(S. Furukawa).
of physical activity (Thorp, Owen, Nauhaus, & Dunstan, 2011; van
Uffelen et al., 2010; Wilmot et al., 2012). Limited evidence exists
regarding the association between a sedentary lifestyle and erectile
dysfunction. In a US study of 31,742 men aged 50 years, TV viewing
time was significantly positively associated with ED (Bacon et al.,
2003). In a US study of 2126 men aged 20 years or older, sedentary
time (TV, video, and computer use) was significantly positively
associated with ED (Selvin, Burnett, & Platz, 2007). Similarly, in a
Brazilian study of 1942 men, a sedentary lifestyle was positively
associated with ED (Martins & Abdo, 2010). On the other hand, TV
viewing hours per week was not associated with self-reported erectile

http://dx.doi.org/10.1016/j.jdiacomp.2016.10.011
1056-8727/$© 2016 Elsevier Inc. All rights reserved.

Please cite this article as: Furukawa, S., et al., Self-reported sitting time and prevalence of erectile dysfunction in Japanese patients with type
2 diabetes mellitus: The Dogo Stu..., Journal of Diabetes and Its Complications (2016), http://dx.doi.org/10.1016/j.jdiacomp.2016.10.011
2 S. Furukawa et al. / Journal of Diabetes and Its Complications xxx (2016) xxx–xxx
function in a cross-sectional US study of 933 men (Eaton et al., 2007).
In a Brazilian study of 192 men, the percentages of subjects living a
sedentary lifestyle were similar for those with ED and without ED
(Kupelian, Link, Rosen, & Mckinlay, 2008). No evidence exists regarding
the association between sitting time and ED among patients with type 2
diabetes mellitus, although the prevalence of ED among patients with
type 2 diabetes mellitus was higher than without. We aim to evaluate
the association between self-reported sitting time and ED among
Japanese patients with type 2 diabetes mellitus.
2. Subjects
This study is a multicenter prospective cohort study that recruited
1051 Japanese patients with previously diagnosed type 2 diabetes
mellitus from September 2009 to September 2014 (median age at
recruitment, 61.6 years; range, 19–88 years; 60.9% men). Collaborating
physicians from 10 hospitals who specialize in diabetes mellitus was
responsible for the diagnoses of type 2 diabetes mellitus, according to
the Japan Diabetes Society criteria (Seino et al., 2010). Excluded from
our current analysis were 621 patients because of female sex or
incomplete data on the variables under study. Thus the final analysis
sample consisted of 430 patients. The present study protocol received
ethical approval from the institutional review board of Ehime University
Graduate School of Medicine. Written informed consent was obtained
from all patients enrolled in the Dogo Study.
3. Material and method
3.1. Clinical examination and measurements
Each participant completed a self-administered questionnaire,
which collected data on diabetes duration, current smoking habits,
current drinking habits, walking habits, use of antihypertensive
medication, use of anti-hyperlipidemic medication, height, and
weight. Each patient's body mass index (BMI) was calculated as
their weight (kg) divided by the square of their height (m 2). Current
smoking was defined as positive if a study subject reported smoking at
least one cigarette per day. Current drinking was defined as positive if
a study subject reported drinking, regardless of frequency or amount.
Walking habit was defined as positive if a study subject reported
walking or participating in an equivalent physical activity for at least
one hour per day. Blood pressure was measured with a cuff in the
sitting position after a rest period of greater than 5 min. Hypertension
was defined as positive if systolic blood pressure was N140 mmHg,
diastolic blood pressure was N90 mmHg, or both, or if the patient had
received anti-hypertensive medication. Dyslipidemia was defined as
positive if serum low-density lipoprotein cholesterol concentration
was ≥ 140 mg/dL, triglyceride concentration was ≥150 mg/dL, or
high-density lipoprotein cholesterol concentration was b 40 mg/dL, or
if the patients were already being treated with lipid-lowering agents
(Teramoto et al., 2007). Stroke and ischemic heart disease were
assessed based on the self-administered questionnaires, medical
records, and/or admission data. Information on the use of insulin
and oral anti-hyperglycemic agents was based on medical records.
3.2. Assessment of self-reported sitting time
Study subjects were asked about time spent sitting during typical
24-hour periods over the past 12 months. Subjects were divided into
four groups according to self-reported sitting hours: 1) b5 hours,
2) 5–7 hours, 3) 7–9 hours, and 4) ≥ 9 hours.
3.3. Assessment of ED
The Sexual Health Inventory for Men (SHIM) is a validated abridged
five-item version of the 15-item International Index of Erectile Function
Please cite this article as: Furukawa, S., et al., Self-reported sitting time and prevalence of erectile dysfunction in Japanese patients with type
2 diabetes mellitus: The Dogo Stu..., Journal of Diabetes and Its Complications (2016), http://dx.doi.org/10.1016/j.jdiacomp.2016.10.011
questionnaire (Rosen, Cappelleri, Smith, Lipsky, & Peña, 1999). In the
present study, we used two outcomes: 1) moderate to severe ED was
defined as present when a subject had a SHIM score b12, and 2) severe
ED was defined as present when a subject had a SHIM score b 8.
3.4. Assessing the complications of type 2 diabetes mellitus
Retinopathy was diagnosed based on the presence of hemorrhage,
microaneurysm, soft and hard exudates, areas of neovascularization,
or laser coagulation scars in at least one eye. Several ophthalmology
specialists were responsible for evaluating the participants' funduses,
and all ophthalmologists were blinded to the diagnoses of ED and
self-reported sitting time. Estimated glomerular filtration rate (eGFR) was
calculated using serum creatinine (Cr): 194 × serum Cr−1.094 × age−0.287
(Matsuo et al., 2009). Diabetic nephropathy was defined as positive when
the urine albumin-to-creatinine ratio was ≥300 mg/g creatinine and/or
eGFR was b 30 ml/min per 1.73 m 2 (Haneda et al., 2015). Diabetic
neuropathy was diagnosed if the patients showed two or more of the
following three characteristics: neuropathic symptoms, the absence of
the Achilles reflex, or abnormal vibration perception threshold scores
assessed with a 128-Hz tuning fork (Yasuda et al., 2007).
3.5. Statistical analysis
Estimations of crude odds ratios (ORs) and their 95% confidence
intervals (CIs) were generated using logistical regression analyses for
ED in relation to self-reported sitting time. Age, body mass index,
duration of type 2 diabetes, current smoking, current drinking,
hypertension, dyslipidemia, coronary artery disease, glycated hemoglobin,
walking habit, and diabetic neuropathy were selected a priori as
potential confounding factors. Multiple regression logistic analyses
were used to adjust for potential confounding factors. Trend of an
association was assessed using a logistic regression model assigning
consecutive integers to the categories of the sitting hours variables. All
statistical analyses were performed using SAS software package version
9.4 (SAS Institute Inc., Cary, NC, USA). All probability values for statistical
tests were two-tailed, and p b0.05 was considered statistically
significant, using an alpha value of 0.05.
4. Results
Among the 430 patients with type 2 diabetes mellitus, the median
SHIM score was 8.0 and the prevalence values of moderate to severe
ED and severe ED were 36.1% and 49.8%. The percentage of b5 hours
sitting, 5–7 hours sitting, 7–9 hours sitting, and ≥9 hours sitting were
49.1%, 19.5%, 10.7%, and 20.7%, respectively. Table 2 shows diabetic
parameters according to self-reported sitting time. There were
increasing trends in BMI and a decreasing trend in walking habit.
Table 3 shows crude and adjusted ORs and 95% CIs for the prevalence
of ED in relation to self-reported sitting time. In crude analysis,
self-reported sitting time was not associated with ED. However,
among 179 patients aged 65 years or older, self-reported sitting time
was positively associated with moderate to severe ED and severe ED,
respectively. After adjustment for age, BMI, duration of type 2
diabetes, current smoking, current drinking, hypertension, dyslipid-
emia, coronary artery disease, glycated hemoglobin, walking habit,
and diabetic neuropathy, ≥9 hours sitting was independently posi-
tively associated with severe ED but not moderate to severe ED: the
adjusted OR was 1.87 (95% CI 1.06–3.33). In the multivariate model,
there was a statistically significant positive exposure–response
relationship between the self-reported sitting time and ED (p for
trend = 0.029). Among patients aged 65 years or older, ≥9 hours
sitting was independently positively associated with moderate to
severe ED and severe ED: the adjusted ORs were 5.66 (95% CI
1.34–40.81) and 4.57 (95% CI 1.46–18.03), respectively. Among 251
patients aged less than 65 years, self-reported sitting time was not
 S. Furukawa et al. / Journal of Diabetes and Its Complications xxx (2016) xxx–xxx 3

associated with ED. Among patients with short duration of diabetes Table 1
(b10 years), ≥9 hours sitting was independently positively associated Clinical characteristics of the 430 study participants.

with severe ED but not moderate to severe ED: adjusted OR was 2.64 Variable n (%)
(95% CI: 1.17–6.19) (p for trend = 0.034). (See Table 1.) Age, years, mean ± SD 60.7 ± 11.5
BMI, kg/m2, mean ± SD 24.8 ± 4.6
5. Discussion HbA1c, %, median [quartiles] 7.53 [6.80–9.09]
Use of insulin (%) 106 (24.7)
Duration of T2DM, years, median [quartiles] 9.0 [3.0–16.0]
In the present study, ≥9 hours sitting was independently positively
Current drinking (%) 240 (55.8)
associated with ED. This is the first study to show the positive association Current smoking (%) 115 (26.7)
between self-reported sitting time and ED among Japanese patients with Walking habit (%) 182 (42.3)
type 2 diabetes mellitus. Hypertension (%) 286 (66.5)
In the general population, evidence exists regarding a sedentary Dyslipidemia (%) 307 (71.4)
Diabetic neuropathy (%) 244 (56.7)
lifestyle and ED. Sedentary lifestyle, including TV, video viewing, and
Diabetic retinopathy (%) 109 (25.4)
computer use, was positively associated with ED in two US studies Diabetic nephropathy (%) 43 (10.0)
(Bacon et al., 2003; Selvin et al., 2007). On the other hand, sedentary Stroke (%) 27 (6.5)
lifestyle was inversely associated with ED in a Brazilian study (Martins Ischemic heart disease (%) 38 (8.8)
SHIM score, median [quartiles] 8.0 [3.0–14.0]
& Abdo, 2010). In a US and a Brazilian study, sedentary lifestyle was
Moderate to severe ED (SHIM score b 12) (%) 275 (36.1)
not associated with ED (Eaton et al., 2007; Kupelian et al., 2008). Severe ED (SHIM score b 8) (%) 214 (49.8)
Several pieces of evidence exist regarding the association between Self-reported sitting hours
physical activity and ED among patients with type 2 diabetes mellitus. b5 hours (%) 211 (49.1)
Physical activity (metabolic equivalents per week) was significantly 5–7 hours (%) 84 (19.5)
7–9 hours (%) 46 (10.7)
inversely associated with ED in an Italian study of 555 men with type
≥9 hours (%) 89 (20.7)
2 diabetes mellitus aged 50 to 70 years (Giugliano et al., 2010).
SD, standard deviation; BMI, body mass index; Hb1Ac, glycated hemoglobin; T2DM, type 2
Similarly, in an Israeli study of 1040 patients with diabetes aged
diabetes mellitus; SHIM, Sexual Health Inventory for Men; ED, erectile dysfunction.
18 years or older, physical activity at work and during leisure time
was significantly inversely associated with ED based on IIEF
(Kalter-Leibovici et al., 2005). In a Korean study of 1312 men with
diabetes, exercise habit (at least once per week) was inversely tation of total sedentary time, particularly in men (Olsen et al., 2008).
associated with ED based on IIEF (Cho et al., 2006). In a Chinese study Third, the assessment of sitting time was a weakness of this analysis.
of 327 men with diabetes mellitus, lower physical activity was In previous epidemiological studies (Bacon et al., 2003; Eaton et al.,
significantly positively associated with ED (Zheng, Fan, Li, & Tam, 2007; Martins & Abdo, 2010; Selvin et al., 2007), however, the
2006). However, to date, no evidence exists regarding the association definitions of sitting time, TV viewing time, and sedentary lifestyle
between TV viewing time or sitting time and ED among patients with were based on self-reported questionnaires or interviews. In other
type 2 diabetes mellitus. epidemiological studies regarding sitting time (Inoue et al., 2008;
In an Italian study of 499 patients with recently diagnosed type 2 Katzmarzyk, Church, Craig, & Bouchard, 2009; Manson et al., 2002;
diabetes mellitus, physical activity was not associated with ED Patel et al., 2010; Weller & Corey, 1998), the definition of sitting time
(Corona et al., 2014). The present results were partially inconsistent was based on self-reported questionnaire. Fourth, self-reported long
with those of the Italian study. The majority of participants had been sitting time might be a marker of lower physical activity. We collected
treated for diabetes for several years, and half of this cohort had information on physical activity behaviors: walking habit was defined
received anti-hypoglycemic agents; this could affect the association as a study subject reporting that they walked or participated in an
between sitting time and ED.
The mechanism linking the association of sitting time and ED has
yet to be fully clarified. Regardless of physical activity, prolonged Table 2
sitting time might have important metabolic consequences that may Clinical characteristics of the 430 study participants according to self-reported sitting
influence specific biomarkers (such as triglycerides (Jakes et al., 2003; time.
Healy et al., 2008), HDL-cholesterol C, resting blood pressure (Jakes et Variable b5 hours 5–7 hours 7–9 hours ≥9 hours p for
al., 2003), leptin (Fung et al., 2000), lipoprotein lipase activity (Olsen, (n = 211) (n = 84) (n = 46) (n = 89) trend
Krogh-Madsen, Thomsen, Booth, & Pedersen, 2008), and testosterone Age, years 61.8 61.4 58.0 58.7 0.06
(Patel et al., 2010)). Prolonged sedentary time might lead to ED via BMI 24.2 25.3 25.6 25.5 0.04
several metabolic dysfunctions. Alternatively, unmeasured factors HbA1c, % 8.20 8.04 8.15 8.24 0.91
related to sitting time might have confounded the observed Insulin (%) 28.9 20.2 19.6 21.4 0.11
Duration of 11.7 10.8 8.7 9.6 0.15
association.
diabetes mellitus, years
Lifestyle modification, including increased physical activity and Current drinking (%) 51.2 60.7 54.4 49.4 0.13
weight loss, might be associated with improvement in sexual Current smoking (%) 26.1 25.0 30.4 28.1 0.61
function. In a systematic review and meta-analysis, weight loss was Walking habit (%) 49.8 47.6 32.6 24.7 0.001
associated with increasing testosterone level (Corona et al., 2013; Hypertension (%) 69.7 67.9 54.4 64.0 0.15
Dyslipidemia (%) 34.9 38.1 35.8 43.0 0.32
Gupta et al., 2011). Reducing the amount of time spent sitting, Diabetes neuropathy (%) 58.8 60.7 54.4 49.4 0.13
regardless of the physical activity, might improve erection function Diabetes retinopathy (%) 29.9 16.7 26.1 22.5 0.18
via elevated testosterone level. In the future, an interventional study Diabetes nephropathy (%) 11.9 10.7 2.2 9.0 0.21
on long sitting time is needed to prove the protective effect for ED. Stroke (%) 5.7 9.5 8.7 4.5 0.89
Ischemic heart disease (%) 9.5 13.1 2.2 6.7 0.25
Our study has several limitations. First, because this was a
SHIM score 8.7 9.3 9.2 8.9 0.90
cross-sectional study, we cannot conclude that there is a causal Moderate to severe ED (%) 64.5 63.1 60.9 65.2 0.98
relationship between self-reported sitting time and ED. Second, in this Severe ED (%) 49.8 46.4 47.8 53.9 0.60
study, TV viewing time was not available. However, in a previous BMI, body mass index; SHIM, Sexual Health Inventory for Men; ED, erectile dysfunction.
study, although TV viewing is a common sedentary behavior during For continuous variables, a linear trend test was used; for categorical variables, a Mantel–
leisure time, evidence suggests that it may not be a good represen- Haenszel χ2-test was used.

Please cite this article as: Furukawa, S., et al., Self-reported sitting time and prevalence of erectile dysfunction in Japanese patients with type
2 diabetes mellitus: The Dogo Stu..., Journal of Diabetes and Its Complications (2016), http://dx.doi.org/10.1016/j.jdiacomp.2016.10.011
4 S. Furukawa et al. / Journal of Diabetes and Its Complications xxx (2016) xxx–xxx

Table 3
Crude and adjusted odds ratios and 95% confidence intervals for severity of ED in relation to self-reported sitting time.

Variable Prevalence (%) Crude OR (95% CI) Adjusted OR (95% CI)

All 430 patients

Associated with moderate to severe ED
b5 hours 136/211 (64.5) 1.00 1.00
5–7 hours 53/84 (63.1) 0.94 (0.56–1.60) 1.09 (0.61–1.97)
7–9 hours 28/46 (60.9) 0.86 (0.45–1.68) 1.32 (0.63–2.84)
≥9 hours 58/89 (65.2) 1.03 (0.62–1.75) 1.57 (0.88–2.85)
p for trend 0.12
Associated with severe ED
b5 hours 106/201 (49.8) 1.00 1.00
5–7 hours 39/84 (46.4) 0.88 (0.53–1.45) 1.04 (0.59–1.84)
7–9 hours 22/46 (47.8) 0.93 (0.49–1.75) 1.46 (0.70–3.04)
≥9 hours 48/89 (53.9) 1.18 (0.72–1.95) 1.87 (1.06–3.33)
p for trend 0.029
179 patients aged 65 years or older
Associated with moderate to severe ED
b5 hours 72/96 (75.0) 1.00 1.00
5–7 hours 31/38 (81.6) 1.48 (0.60–4.03) 1.91 (0.69–5.83)
7–9 hours 12/16 (75.0) 1.00 (0.31–3.84) 1.39 (0.38–6.08)
≥9 hours 27/29 (93.1) 4.50 (1.22–29.18) 5.66 (1.34–40.81)
p for trend 0.036
Associated with severe ED
b5 hours 59/96 (61.5) 1.00 1.00
5–7 hours 24/38 (63.2) 1.08 (0.50–2.38) 1.33 (0.55–3.28)
7–9 hours 10/16 (62.5) 1.05 (0.36–3.29) 1.37 (0.42–4.78)
≥9 hours 25/29 (86.2) 3.92 (1.39–14.10) 4.57 (1.46–18.03)
p for trend 0.019
251 patients aged less than 65 years
Associated with moderate to severe ED
b5 hours 64/115 (55.7) 1.00 1.00
5–7 hours 22/46 (47.8) 0.73 (0.37–1.45) 0.76 (0.35–1.63)
7–9 hours 16/30 (53.3) 0.91 (0.41–2.06) 1.11 (0.45–2.80)
≥9 hours 31/60 (51.7) 0.85 (0.46–1.60) 0.99 (0.50–1.98)
p for trend 0.93
Associated with severe ED
b5 hours 46/115 (40.0) 1.00 1.00
5–7 hours 15/46 (32.6) 0.73 (0.35–1.48) 0.83 (0.37–1.81)
7–9 hours 12/30 (40.0) 1.00 (0.43–2.25) 1.29 (0.50–3.26)
≥9 hours 23/60 (38.3) 0.93 (0.48–1.76) 1.18 (0.58–2.39)
p for trend 0.56
221 patients with short duration of diabetes (b10 years)
Associated with moderate to severe ED
b5 hours 56/100 (56.0) 1.00 1.00
5–7 hours 26/42 (61.9) 1.28 (0.62–2.71) 2.05 (0.87–4.99)
7–9 hours 13/26 (50.0) 0.79 (0.33–1.88) 1.22 (0.43–3.52)
≥9 hours 32/53 (60.4) 1.20 (0.61–2.38) 2.05 (0.93–4.70)
p for trend 0.12
Associated with severe ED
b5 hours 42/100 (42.0) 1.00 1.00
5–7 hours 19/42 (45.2) 1.14 (0.55–2.36) 1.95 (0.82–4.67)
7–9 hours 10/26 (38.4) 0.86 (0.35–2.07) 1.29 (0.43–3.84)
≥9 hours 26/53(49.1) 1.33 (0.68–2.60) 2.64 (1.17–6.19)
p for trend 0.034
209 patients with long duration of diabetes (≥10 years)
Associated with moderate to severe ED
b5 hours 80/111 (72.1) 1.00 1.00
5–7 hours 27/42 (64.3) 0.70 (0.33–1.51) 0.56 (0.24–1.31)
7–9 hours 15/20 (75.0) 1.16 (0.41–3.82) 1.79 (0.55–6.70)
≥9 hours 26/36 (72.2) 1.01 (0.44–2.41) 1.24 (0.50–3.25)
p for trend 0.53
Associated with severe ED
b5 hours 63/111 (56.8) 1.00 1.00
5–7 hours 20/42 (47.6) 0.69 (0.34–1.41) 0.57 (0.25–1.29)
7–9 hours 12/20 (60.0) 1.14 (0.44–3.12) 2.03 (0.68–6.48)
≥9 hours 22/36 (61.1) 1.20 (0.56–2.63) 1.39 (0.60–3.33)
p for trend 0.32

Odds ratios were adjusted for age, body mass index, duration of type 2 diabetes, current smoking, current drinking, hypertension, dyslipidemia, coronary artery disease, glycated
hemoglobin, walking habit, and diabetic neuropathy. ED, erectile dysfunction; OR, odds ratio; CI, confidence interval.

equivalent physical activity for at least 1 hour per day. Answering simple
question with a standard questionnaire was validated to estimate
physical activity using tri-axial accelerometers; the daily step count and
the amount of physical activity at 3 metabolic equivalents or more
among subjects who answered yes to this question regarding walking
habit were higher than those who answered no (Kawakami & Miyachi,
2010). In the present study, the positive association between
self-reported long sitting time and ED remained statistically significant
after adjustment for walking habits. Fifth, we did not measure
testosterone level in this study. The testosterone among patients with

Please cite this article as: Furukawa, S., et al., Self-reported sitting time and prevalence of erectile dysfunction in Japanese patients with type
2 diabetes mellitus: The Dogo Stu..., Journal of Diabetes and Its Complications (2016), http://dx.doi.org/10.1016/j.jdiacomp.2016.10.011
 S. Furukawa et al. / Journal of Diabetes and Its Complications xxx (2016) xxx–xxx
diabetes was lower than those without (Brand et al., 2014). Lower
testosterone level might affect sexual desire and ED. Finally, we could
not control for subjects' partner or socioeconomic status.
In conclusion, self-reported sitting time may be positively associated
with ED in Japanese patients with type 2 diabetes mellitus, regardless of
walking habits.
Acknowledgements
We thank Eriko Kawamoto from University of the Ryukyus, Keiko Kikuchi
and Tomo Kogama from Ehime University, and Eri Furukawa from the
Furukawa Clinic. This study was supported by the Japan Society for the
Promotion of Science (JSPS) KAKENHI Grants (21790583 and 23790697).
The authors declare that they have no duality of interest.
References
Bacon, C. G., Mittleman., M. A., Kawachi., I., Giovannucci, E., Glasser, D. B., & Rimm, E. B.
(2003). Sexual function in men older than 50 years of age: Results from the health
professionals follow-up study. Annals of Internal Medicine, 139, 161–168.
Brand, J. S., Rovers, M. M., Yeap, M. M., Schneider, H. J., Tuomainen, T. P., Haring, R., ... van
der Schouw, Y. T. (2014). Testosterone, sex hormone-binding globulin and the
metabolic syndrome in men: An individual participant data meta-analysis of
observational studies. PLoS ONE, 9, e100409.
Cho, N. H., Ahn, C. W., Park, J. Y., Lee, H. W., Park, T. S., Kim, I. J., ... Choi, D. S. (2006).
Prevalence of erectile dysfunction in Korean men with type 2 diabetes mellitus.
Diabetic Medicine, 23, 198–203.
Corona, G., Giorda, C. B., Cucinotta, D., Guida, P., Nada, E., & Gruppo di studio SUBITO-DE
(2014). Sexual dysfunction at the onset of type 2 diabetes: The interplay of
depression, hormonal and cardiovascular factors. The Journal of Sexual Medicine, 11,
2065–2073.
Corona, G., Rastrelli, G., Monami, M., Saad, F., Luconi, M., Lucchese, M., ... Maggi, M.
(2013). Body weight loss reverts obesity-associated hypogonadotropic hypogo-
nadism: A systematic review and meta-analysis. European Journal of Endocrinology,
168, 829–843.
Eaton, C. B., Liu, Y. L., Mittleman, M. A., Miner, M., Glasser, D. B., & Rimm, E. B. (2007). A
retrospective study of the relationship between biomarkers of atherosclerosis and
erectile dysfunction in 988 men. International Journal of Impotence Research, 19,
218–225.
Fung, T. T., Hu, F. B., Chu, N. F., Yu, J., Spiegeleman, D., Tofler, G. H., ... Rimm, E. B. (2000).
Leisure-time physical activity, television watching, and plasma biomarkers of
obesity and cardiovascular disease risk. American Journal of Epidemiology, 152,
1171–1178.
Giugliano, F., Maiorino, M., Bellastella, G., Gicchino, N., Giugliano, D., & Esposito, K.
(2010). Determinants of erectile dysfunction in type 2 diabetes. International
Journal of Impotence Research, 22, 204–209.
Gupta, B. P., Murad, M. H., Clifton, M. M., Prokop, L., Nehra, A., & Kopecky, S. L. (2011).
The effect of lifestyle modification and cardiovascular risk factor reduction on
erectile dysfunction a systematic review and meta-analysis. Archives of Internal
Medicine, 171, 1797–1803.
Haneda, M., Utsunomiya, K., Koya, D., Babazono, T., Moriya, T., Makino, H., ... Shide, K.
(2015). A new classification of diabetic nephropathy 2014: A report from joint
committee on diabetic nephropathy. Clinical and Experimental Nephrology, 19, 1–5.
Healy, G. N., Wijndaele, K., Dunstan, D. W., Shaw, J. E., Salmpm, J., Zimmet, P. Z., & Owen,
N. (2008). Objectively measured sedentary time, physical activity, and metabolic
risk: The Australian Diabetes, Obesity and Lifestyle study (AusDiab). Diabetes Care,
31, 369–371.
Inoue, M., Yamamoto, S., Kurahashi, N., Iwasaki, M., Sasazuki, S., Tsugane, S., & Japan Public
Health Center-based Prospective Study Group (2008). Daily total physical activity
level and total cancer risk in men and women: Results from large-scale population-based
cohort study Japan. American Journal of Epidemiology, 168, 391–403.
Please cite this article as: Furukawa, S., et al., Self-reported sitting time and prevalence of erectile dysfunction in Japanese patients with type
2 diabetes mellitus: The Dogo Stu..., Journal of Diabetes and Its Complications (2016), http://dx.doi.org/10.1016/j.jdiacomp.2016.10.011
5
Jakes, R. W., Day, N. E., Khaw, K. T., Luben, R., Oakes, S., Welch, A., ... Wareham, N. J.
(2003). Television viewing and low participation in vigorous recreation are
independently associated with obesity and markers of cardiovascular disease risk:
EPIC-Norfolk population-based study. European Journal of Clinical Nutrition, 57,
1089–1096.
Kalter-Leibovici, O., Wainstein, J., Harman-Bohem, I., Murad, H., Raz, I., & Israel Diabetes
Research Group (IDRG) Investigators (2005). Clinical, socioeconomic, and lifestyle
parameters associated with erectile dysfunction among diabetic men. Diabetes
Care, 28, 1739–1744.
Katzmarzyk, P. T., Church, T. S., Craig, C. L., & Bouchard, C. (2009). Sitting time and
mortality from all causes, cardiovascular disease, and cancer. Medicine and Science
in Sports and Exercise, 41, 998–1005.
Kawakami, R., & Miyachi, M. (2010). Validity of a standard questionnaire to assess
physical activity for specific medical checkups and health guidance. Nihon Koshu
Eisei Zasshi, 57, 891–899 (In Japanese).
Kupelian, V., Link, C. L., Rosen, R. C., & Mckinlay, J. B. (2008). Socioeconomic status, not
race/ethnicity, contributes to variation in the prevalence of erectile dysfunction:
Results from the Boston Area Community Health (BACH) survey. The Journal of
Sexual Medicine, 5, 1325–1333.
Manson, J. E., Greenland, P., LaCroix, A. Z., Stefanick, M. L., Mouton, C. P., Oberman, A., ...
Siscovick, D. S. (2002). Walking compared with vigorous exercise for prevention of
cardiovascular events in women. The New England Journal of Medicine, 347,
716–725.
Martins, F. G., & Abdo, C. H. (2010). Erection dysfunction and correlated factors in
Brazilian men aged 18–40 years. The Journal of Sexual Medicine, 7, 2166–2173.
Matsuo, S., Imai, E., Horio, M., Yasuda, Y., Tomita, K., Nitta, K., ... Hishisa, A. (2009).
Revised equations for estimated GFR from serum creatinine in Japan. American
Journal of Kidney Diseases, 53, 982–992.
Olsen, R. H., Krogh-Madsen, R., Thomsen, C., Booth, F. W., & Pedersen, B. K. (2008).
Metabolic responses to reduced daily steps in healthy nonexercising men. JAMA,
299, 1261–1263.
Patel, A. V., Bernstein, L., Deka, A., Feigelson, H. S., Campbell, P. T., Gapstur, S. M., ... Thun,
M. J. (2010). Leisure time spent sitting in relation to total mortality in a prospective
cohort of US adults. American Journal of Epidemiology, 172, 419–429.
Rosen, R. C., Cappelleri, J. C., Smith, M. D., Lipsky, J., & Peña, B. M. (1999). 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. International Journal of
Impotence Research, 11, 319–326.
Seino, Y., Tajima, N., Kadowaki, T., Kashiwagi, A., Araki, E., ... Uekim, K. (2010). Report of
the committee on the classification and diagnostic criteria of diabetes mellitus.
Journal of Diabetes Investigation, 1, 212–218.
Selvin, E., Burnett, A. L., & Platz, E. A. (2007). Prevalence and risk factors for erectile
dysfunction in the US. The American Journal of Medicine, 120, 151–157.
Teramoto, T., Sasaki, J., Ueshima, H., Egusa, G., Kinoshita, M., Shimamoto, K., ... Yokode,
M. (2007). Executive summary of Japan Atherosclerosis Society (JAS) guideline for
diagnosis and prevention of atherosclerotic cardiovascular diseases for Japanese.
Journal of Atherosclerosis and Thrombosis, 14, 45–50.
Thorp, A. A., Owen, N., Nauhaus, M., & Dunstan, D. W. (2011). Sedentary behaviors and
subsequent health outcomes in adults a systematic review of longitudinal studies,
1996–2011. American Journal of Preventive Medicine, 41, 207–215.
van Uffelen, J. G., Wong, J., Chau, J. Y., van der Ploeg, H. P., Riphagen, I., Gilson, N. D., ...
Brown, W. J. (2010). Occupational sitting and health risks: A systematic review.
American Journal of Preventive Medicine, 39, 379–388.
Weller, I., & Corey, P. (1998). The impact of excluding non-leisure energy expenditure
on the relation between physical activity and mortality in women. Epidemiology, 9,
632–635.
Wilmot, E. G., Edwardson, C. L., Achana, F. A., Davies, M. J., Gorely, T., Gray, L. J., ... Biddle,
S. J. (2012). Sedentary time in adults and the association with diabetes,
cardiovascular disease and death: Systematic review and meta-analysis.
Diabetologia, 55, 2895–2905.
Yasuda, H., Sanada, M., Kitada, K., Terashima, T., Kim, H., Sakaue, Y., ... Kashiwagi, A.
(2007). Rationale and usefulness of newly devised abbreviated diagnostic criteria
and staging for diabetic polyneuropathy. Diabetes Research and Clinical Practice,
77(Suppl. 1), S99–103.
Zheng, H., Fan, W., Li, K., & Tam, T. (2006). Predictors for erectile dysfunction among
diabetics. Diabetes Research and Clinical Practice, 71, 313–319.