Article 2 of 18 (This article was originally published on Substack)

“But I’m not fat”

Arjun is thirty-four, an accountant in Hyderabad, vegetarian, a teetotaller, and slim enough that relatives still tell him to eat more. He walks to the bus stop. He has never smoked. For the last year, his erections have been softer, slower to come and quicker to fade. He has noticed, without wanting to, that he rarely wakes up with one anymore.

Arjun assumed the cause was in his head: work stress, or perhaps the masturbation habit of his twenties that a cousin once warned would “weaken” him. He did not mention it to anyone. He went to a doctor for something else entirely, a tiredness that would not lift and a thirst that kept him up at night.

The blood tests told a different story. His three-month average blood sugar sat in the pre-diabetic range. His triglycerides were high and his “good” cholesterol low. His vitamin D and B12 were both deficient. And his waist, measured for the first time in his life, was 94 centimetres, well above the threshold doctors use for Asian men, though his arms and face were thin.

“Your erection problem,” the doctor said carefully, after Arjun finally mentioned it, “may be the first symptom of all this.” Arjun protested: “But I’m not fat.” The doctor’s answer is the subject of this essay. You don’t have to be.

Arjun is a composite, drawn from patterns described in clinical research.

An erection is a blood-vessel test

The first essay in this series argued that India’s sexual-health crisis is above all a crisis of silence and distress. That remains true. But it would be a mistake to conclude that the problem is all in men’s heads. Many Indian bodies are under genuine biological pressure, and that pressure often shows up first in the bedroom.

To see why, it helps to understand what an erection actually is. It is not, at root, an act of will. It is a plumbing event. Arousal signals the lining of the penile arteries to release nitric oxide, a gas that relaxes the smooth muscle in their walls. Blood rushes into spongy chambers, which swell and press shut the veins that would otherwise drain them (physiology review). Everything depends on a healthy inner lining of the blood vessels, the endothelium, and on arteries free to widen.

Here is the crucial detail. The arteries of the penis are narrower than those of the heart. Damage to the vessel lining that barely dents blood flow to the heart can choke the smaller penile arteries much sooner (systematic review). The penis, in other words, is a canary in the coal mine of the circulatory system.

So the question this essay asks is a physical one. Why are so many Indian men, often young and often not visibly overweight, showing the vascular warning signs of erectile dysfunction in their thirties and forties? The answer runs through a peculiar body type, an epidemic of diabetes, early heart disease, hormones, missing vitamins, tobacco and polluted air. It also includes the biology of premature ejaculation, which is not purely psychological either.

The thin-fat Indian

In 2004 The Lancet published a picture that became famous in diabetes research. It showed two doctors, one Indian and one British, with exactly the same body mass index of 22.3, a figure any chart would call healthy. Their body scans told another story. The Indian doctor carried 21.2% body fat; the British doctor, 9.1% (Endotext summary of the Y-Y paradox). The image gave a name to something Indian physicians had long suspected: the “thin-fat” Indian.

The pattern has been confirmed many times. Compared with Europeans, South Asians carry more fat around the abdomen and liver at lower body weights, and less muscle (2026 review). At the same BMI, their body fat runs 3 to 5 percentage points higher, and diabetes tends to arrive earlier and at lower weight (Indian registry study). This is why Indian guidelines set lower thresholds than global ones: overweight from a BMI of 23 rather than 25, and abdominal obesity in men from a waist of 90 centimetres rather than the WHO’s 94 (Data for India). Arjun, at 94 centimetres, was past both.

The fat that matters is the hidden kind, packed around the organs. It is not passive storage. It behaves like an inflamed gland, releasing substances that blunt the body’s response to insulin. Insulin resistance, in turn, damages the vessel lining that erections depend on.

Now scale that up. The national ICMR-INDIAB study estimated that in 2021, 101 million Indians had diabetes and another 136 million had prediabetes, with 351 million carrying abdominal obesity (ICMR-INDIAB, Lancet Diabetes & Endocrinology). Its lead author warned that more than 60% of Indians with prediabetes progress to diabetes within five years (Scroll). The newest national family health survey (NFHS-6, 2023-24) found high blood sugar in 20.9% of men aged 15 and over, up from 15.6% five years earlier, and overweight or obesity in 27.3% of men aged 15 to 49. In Kerala, nearly one man in three had high blood sugar (NFHS-6 summary; The Federal).

For sexual health, this is the single most important fact in the series. Among Indian men with type 2 diabetes, a meta-analysis put the prevalence of erectile dysfunction at about 61% (meta-analysis, 2025). And the damage does not wait for a formal diagnosis: blood-vessel complications are already common at the prediabetes stage (Indian Journal of Endocrinology and Metabolism). Many Indian men are losing erectile function on the slope towards diabetes, long before anyone has given their condition a name.

The young Indian heart

If the penis is the canary, the coal mine is the Indian heart. Coronary disease strikes Indians five to ten years earlier than most other populations; the average age at a first heart attack is about 53. In the global INTERHEART study, nearly one in ten first heart attacks among South Asian men occurred before the age of 40, two to three and a half times the Western European rate (premature CAD in Indians). Indians have heart attacks at lower body weights and smaller waists than other groups, including non-smoking vegetarians who exercise (National Lipid Association editorial).

Part of the explanation is a particle most Indians have never heard of: lipoprotein(a), or Lp(a). Its level is set largely by genes rather than lifestyle. About a quarter of Indians and other South Asians have elevated levels, which roughly double or triple the risk of coronary disease, a risk comparable to diabetes (Enas et al.). A man can eat carefully, never smoke, keep his weight down, and still inherit arteries primed for early damage.

The same atherosclerosis that narrows the coronary arteries narrows the penile ones, and because those are smaller, the effect shows earlier. On average, erectile dysfunction appears about three years before a cardiovascular event, and up to five. The men for whom this warning matters most are those aged 30 to 60, and those with diabetes (review of the evidence). That is precisely the age group of Indian men now crowding sexual-health clinics.

High blood pressure belongs here too. The ICMR-INDIAB study estimated that some 315 million Indians have hypertension (ICMR-INDIAB). Raised pressure stiffens and damages arteries, and some older blood-pressure medicines can themselves affect erections. A man who notices this should talk to his doctor about alternatives, not quietly stop his tablets.

Put plainly: for an Indian man in his thirties or forties, a failing erection is not first a question about his masculinity. It is a question about his arteries.

Hormones: the testosterone question

Testosterone is the hormone men most associate with virility, usually wrongly. It matters more for desire than for the mechanics of erection, but low levels sap libido, energy, mood and muscle, and make erections harder to sustain. And Indian men appear to run low surprisingly often.

Globally, male hypogonadism (clinically low testosterone with symptoms) is estimated at 6% to 12%. Indian studies of men aged roughly 40 to 62 report 20% to 29% (Indian expert opinion, 2023). One study of working men found symptomatic low testosterone in 26.1% (Goel et al.). A Delhi hospital study of 745 men found it confirmed by both symptoms and blood tests in 29%, and noted a significant link with vitamin D deficiency (Sir Ganga Ram Hospital study). These are not population surveys, and estimates fall when tests are repeated: one multicentre study of diabetic men found 18.4% at first assessment but 8.5% on repeat testing (observational study). The lesson for any man is to test twice, in the morning, before believing a single number.

The strongest driver is the one we have already met: fat. In a study of young Indian men aged 18 to 30 with severe obesity, 60.4% had low testosterone (bariatric study). Abdominal fat converts testosterone into oestrogen and suppresses the brain signals that tell the testes to produce it. The metabolic story and the hormonal story are one story.

Then there is the gym. A generation of young Indian men has grown up on cinema heroes with sculpted bodies, and some take shortcuts. In one survey of gym-goers in Jammu and Kashmir, 7.1% admitted using anabolic steroids; half of those planned to use them again, and nearly half had already needed hormone injections to restart their own testosterone production (J&K gym study). Indian data are thin, but the pattern abroad is stark. At one large American urology practice, past steroid use was the single most common cause of profoundly low testosterone in young men, accounting for 43% of cases (Coward et al., Journal of Urology). The cruel irony: injected testosterone shuts down the body’s own supply. A man builds muscles to look potent and may end up with shrunken testes, low desire and failing erections once the cycle stops.

A caution runs the other way too. Testosterone has become a wellness product, sold to tired men as a cure-all. Treatment can help men with genuine deficiency, but it is not a remedy for ordinary erectile problems. In young men it can suppress sperm production and fertility, which matters in a culture where a child is expected soon after marriage.

Hidden deficiencies in a sunny, vegetarian country

India has abundant sunshine and a proud vegetarian tradition. It also has two of the world’s most widespread vitamin deficiencies, and both touch the blood vessels.

Vitamin D. Studies across the subcontinent find deficiency in 70% to 100% of the general population, despite the sun. Likely contributors include indoor work, covered skin, darker skin (which makes less vitamin D from the same sunlight), air pollution, and dairy that is rarely fortified (review of Indian studies). Vitamin D helps the vessel lining produce nitric oxide. Observational studies find that men with erectile dysfunction tend to have lower levels, and one review reported roughly a 12% rise in its prevalence for every 10 ng/mL fall in vitamin D (mini-review, 2024).

But here honesty matters. A genetic study designed to test cause and effect found no causal link between vitamin D levels and erectile dysfunction, and an earlier meta-analysis also found no strong association (Mendelian randomisation study). Low vitamin D may be less a cause than a marker of an indoor, sedentary, metabolically unhealthy life. Correcting a deficiency is worthwhile for bones and general health. Expecting it to restore erections is not supported by the evidence.

Vitamin B12 and homocysteine. Vitamin B12 comes almost entirely from animal foods, so strict vegetarians are at risk. Among vegetarian Indians, deficiency has been reported in around 70% (study of young vegetarians). Without enough B12 and folate, the body accumulates homocysteine, an amino acid that damages the vessel lining and interferes with nitric oxide. A 2024 meta-analysis of twelve studies found consistently higher homocysteine in men with erectile dysfunction (meta-analysis, 2024). In one study of men around thirty, those with erectile dysfunction had markedly lower B12 and higher homocysteine than their peers (cross-sectional study).

Again, the honest verdict is “plausible, not proven.” Researchers note that confirming homocysteine as a cause would require trials that lower it and measure erectile function, which have not yet been done (Sansone et al.). What can be said is that B12 deficiency is common, easy to test for and cheap to correct, and that it sits on the same vascular pathway as everything else in this essay.

Smoke, air and the shape of a modern day

Tobacco. In the last national tobacco survey (GATS-2, 2016-17), 42.4% of Indian men used tobacco: 19% smoked and 29.6% used smokeless forms such as gutkha, khaini and zarda (GATS-2 fact sheet). Smoking is one of the best-established causes of erectile dysfunction. A dose-response meta-analysis of ten studies and more than 50,000 men found that risk climbs with how much and how long a man smokes (dose-response meta-analysis, Journal of Sexual Medicine). The evidence for chewed tobacco is thinner, but nicotine narrows blood vessels whichever way it enters the body. The paan shop is not innocent.

The air. Indian cities regularly top the world’s rankings for fine-particle pollution (PM2.5), the particles small enough to enter the bloodstream and inflame the vessel lining. Evidence linking this to sexual function is new but growing. A nationwide Chinese study of more than 5,000 men found that higher exposure to PM2.5 and nitrogen dioxide was linked to worse erectile function and more premature ejaculation, even after adjusting for other factors (Shen et al., 2024). A 2025 genetic study went further, finding that genetically predicted PM2.5 exposure raised the odds of erectile dysfunction by about 65% (Aging Male, 2025). Earlier work in older American men found a consistent but not statistically significant link (Environmental Health, 2017). This is not yet settled science. But for a man breathing Delhi’s winter air, it is one more pressure on the same fragile pipes.

The modern day. Much of the rest is the shape of urban Indian life: long commutes, desk jobs, little movement, late nights, poor sleep, more alcohol, and food heavy in refined rice, wheat and sugar. A large synthesis of 92 meta-analyses found that smoking, alcohol and physical inactivity all have dose-dependent links to erectile dysfunction, and that the risk falls as physical activity rises (summary of lifestyle meta-analyses). That last finding is the hopeful one. Of all the forces in this essay, movement is the one a man controls most directly, and it works on every pathway at once: weight, insulin, blood pressure, vessel lining and mood.

The body behind premature ejaculation

Premature ejaculation is usually treated as a problem of nerves in the everyday sense: anxiety, inexperience, excitement. Much of it is, and Part IV of this series examines how Indian patriarchy shapes it. But the body has a part too, and it differs by type.

Lifelong premature ejaculation, present from a man’s first sexual experiences, has the strongest biological roots. Twin studies suggest genes account for roughly 30% of the variation in how quickly men ejaculate (Springer reference chapter). Researchers point to differences in serotonin signalling in the brain, a hyper-excitable ejaculatory reflex, and sometimes heightened penile sensitivity (update on pathophysiology). This is why a class of antidepressant-related medicines that boost serotonin can delay ejaculation. It is also why willpower alone rarely fixes lifelong cases.

Acquired premature ejaculation, which appears after years of normal function, more often has a trigger. The most common are performance anxiety, relationship problems and erectile dysfunction itself, but two physical causes deserve attention (McMahon, pathophysiology review):

  • An overactive thyroid. In one multicentre study, half the men with hyperthyroidism had premature ejaculation; after their thyroid levels were brought to normal, the figure fell to 15%, close to the general population (endocrine disorders review).
  • Inflammation of the prostate. In a cohort of 153 men with premature ejaculation, 64% had prostatic inflammation and 52% chronic bacterial prostatitis, far more than in healthy controls (El-Nashaar & Shamloul). A meta-analysis of men with chronic prostatitis found premature ejaculation in about 40% (meta-analysis). Many of these studies have design weaknesses, so the link is suggestive rather than proven.

The metabolic story reaches here too. Researchers have proposed that the low-grade inflammation of obesity and metabolic syndrome may contribute to premature ejaculation, partly through the prostate (endocrine disorders review), and the Chinese air-pollution study above linked pollutants to worse ejaculatory control as well as erections.

The practical lesson is simple. A man whose ejaculation has recently become much faster deserves a thyroid test and, if he has pelvic or urinary symptoms, a prostate examination, before anyone tells him it is all in his head.

Where body meets mind

The division between “physical” and “psychological” erectile dysfunction is useful for doctors and misleading for patients. In real bedrooms, the two almost always arrive together.

It usually begins in the body. Narrowing arteries or rising blood sugar do not switch erections off overnight; they make them a little softer, a little slower, a little less reliable. A man notices. The next time, part of his attention is on his penis rather than on his partner. That watchfulness triggers the body’s alarm system, and the stress hormones it releases tighten exactly the blood vessels an erection needs to relax. A modest physical problem becomes a large one, now held in place by fear. The next essay in this series examines that loop in detail.

Clinicians look for clues to which came first. Problems that develop gradually, that occur in every situation including masturbation, and that come with fewer morning erections point towards the body. Problems that arrive suddenly, with one partner or in one setting, while morning erections continue normally, point more towards the mind. Most Indian men in their thirties and forties will have some of both.

Here is where Indian culture turns a medical problem into a moral one. A man like Arjun, raised on warnings that semen is precious and masturbation weakening, will not read a softening erection as a sign of insulin resistance. He will read it as a punishment for his past, confirmation of what the roadside clinics have always said. Guilt feeds the anxiety; the anxiety worsens the erection; and the real cause, his blood sugar, goes untreated for years. The body supplied the first crack. The culture made sure he looked for its cause in the wrong place.

There is a second, subtler risk. Pills that improve blood flow, bought online or from a chemist without a prescription, can restore erections while doing nothing for the arteries behind the problem. A man may feel cured just as his heart disease progresses unnoticed. The pill is not the danger; skipping the check-up is.

What cannot be claimed

A biological account is powerful, and that is exactly why it needs limits.

Most of the evidence is association, not proof. Studies of vitamin D, homocysteine and air pollution show that these factors travel with erectile dysfunction. Only some, like smoking, diabetes and vascular disease, have the weight of evidence to be called causes with confidence. Where a careful genetic study found no causal link, as with vitamin D, that deserves as much attention as the studies that found one.

Not every young man’s problem is metabolic. In men under thirty with no risk factors, sudden or situational erectile difficulty is more often driven by anxiety than by arteries. Sending every such man for a battery of tests can feed the very health anxiety that keeps him stuck.

“The Indian body” is an average, not a destiny. The thin-fat pattern describes populations, not every individual, and South Asia is genetically and culturally diverse. Science about “racial” differences in sexuality has an ugly history; observations that Asian men ejaculate faster were once used to rank “races” by their supposed sexual restraint (Indian Journal of Urology). What the modern evidence shows is a higher-risk metabolism shaped by genes, early nutrition and modern lifestyle, not a fixed racial trait.

Genes load the gun; life pulls the trigger. Even inherited risks like Lp(a) interact with blood pressure, sugar, cholesterol and smoking. A higher starting risk is a reason for earlier checks, not for fatalism.

Biology and culture are not rivals. The body explains why so many Indian men’s erections falter early. It does not explain why those men wait years to seek help, buy capsules from roadside clinics, or blame their own past for a problem in their blood vessels. For that, the rest of this series turns to the mind, the family and the culture.

What this means in practice

Measure what matters. Take a tape measure to your waist, at the level of your navel. For Indian men, 90 centimetres or more signals abdominal obesity, whatever your weight or BMI.

Ask for the right tests. If your erections have weakened, the useful first tests are inexpensive and widely available:

  • Blood sugar: HbA1c or fasting glucose, to catch diabetes and prediabetes.
  • Lipid profile and blood pressure; and once in your life, Lp(a), since it is inherited and does not change much.
  • Morning testosterone, if you also have low desire, fatigue or low mood, repeated before any conclusion is drawn.
  • Thyroid function (TSH), especially if ejaculation has recently become much faster.
  • Vitamin B12, if you are vegetarian.

Move. A 2023 meta-analysis of 11 randomised trials involving 1,147 men found that regular aerobic exercise, usually 30 to 60 minutes three to five times a week for around six months, improved erectile function, with the largest gains in men with the worst problems (Khera et al., 2023). The average benefit was modest, and its greatest value may lie in prevention (commentary). But in a landmark two-year lifestyle trial in obese men, 31% recovered full erectile function (review of exercise trials). Few pills can claim that.

Stop tobacco in every form, smoked or chewed.

Leave steroids alone, and be wary of testosterone sold as a lifestyle product. Treatment is for confirmed deficiency, under a doctor, with fertility in mind.

Use medicines wisely. Erection-supporting tablets prescribed by a doctor are effective and generally safe. They must never be combined with nitrate heart medicines, and they are not a substitute for treating what lies underneath.

For doctors and health planners. India already screens adults over thirty for diabetes and high blood pressure. A single question about erections would turn sexual health into a cardiometabolic early-warning system, and give men a reason to come in years before their first heart attack.

When to see a doctor: if erections have been weakening for more than a few weeks; if you have stopped waking with erections; if you are over 30 with a waist of 90 cm or more, diabetes, high blood pressure or a family history of early heart disease; if ejaculation has suddenly become much faster; or if you have chest pain, breathlessness, excessive thirst or frequent urination. Seek emergency care for chest pain.

Key takeaways

  1. An erection is a blood-vessel event, and the penile arteries are smaller than the heart’s, so erectile dysfunction often appears about three years before heart disease.
  2. Many Indian men are “thin-fat”: more abdominal fat and less muscle at a normal-looking weight. For Indian men, a waist of 90 cm or more signals risk.
  3. Diabetes is the biggest single driver. India has about 101 million people with diabetes and 136 million with prediabetes; around 61% of Indian men with type 2 diabetes have erectile dysfunction.
  4. Heart disease arrives early in Indians, helped by inherited Lp(a), elevated in about a quarter of South Asians.
  5. Low testosterone is common and fat-driven, and anabolic steroids can cause it in young men chasing a cinematic body.
  6. Vitamin D, B12, homocysteine and air pollution are plausible contributors, but the evidence is weaker than for diabetes, smoking and vascular disease.
  7. Premature ejaculation has biological sides too: genes in lifelong cases, and thyroid or prostate problems in some acquired ones.
  8. Body and mind combine. A small physical problem plus fear and guilt becomes a large one. The first step is a check-up, and regular exercise helps every pathway.

Sources and further reading

Erection physiology and the heart

The thin-fat phenotype and diabetes

Hormones

Vitamins and homocysteine

Tobacco, air and lifestyle

Premature ejaculation

Disclaimer: This content is for general information only and does not replace professional medical advice. Asmidev is not responsible for any diagnosis made based on this content, nor does it endorse or take responsibility for external websites or products mentioned. Always consult a qualified healthcare professional for health-related concerns. This article was created through a human–AI collaboration. The ideas and direction come from the author’s research, with AI used only to assist in organizing information and refining expression, while cross-checking against established scientific literature.

 

Posted by Asmidev Herbals