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\begin{document}

\title{High visceral adiposity index associated with metabolic syndrome impairs
erectile function in sexually active men.}



\author[1]{Mustafa Bolat}%
\author[2]{Mustafa Latif Özbek}%
\author[3]{Bekir Şahin}%
\author[3]{Merve YILMAZ}%
\author[4]{Fatih Kocamanoğlu}%
\author[5]{Recep Büyükalpelli}%
\author[6]{Ahmet Tevfik Sunter}%
\author[5]{Ramazan  Aşçı}%
\affil[1]{Samsun Gazi State Hospital}%
\affil[2]{Private Atasam Hospital}%
\affil[3]{Gazi State Hospital}%
\affil[4]{City Hospital}%
\affil[5]{Ondokuz Mayis University Faculty of Medicine}%
\affil[6]{Ondokuz Mayis University, School of Medicine,}%


\vspace{-1em}



  
  \date{March 13, 2025}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Aims:Erectile dysfunction (ED) is a common condition affected by many
factors. We aimed to show the impact of the metabolic syndrome (MeTS) on
male sexual function based on VAI and the impact of increased levels of
the VAI was investigated in patients with ED among the patients with and
without MeTS. Methods:Participants who met MeTS criteria (Group 1, n=96)
and without MeTS (Group 2, n=189) were included in this cross-sectional
study. The MeTS diagnosis was made in the presence of at least three of
the following criteria: serum glucose level higher than 100 mg/dl, HDL
cholesterol level below 40 mg/dl, triglyceride level greater than 150
mg/dl, waist circumference greater than 102 cm and blood pressure
greater than 130/85 mmHg. Demographic data were recorded; biochemical
and hormonal tests were measured. Erectile and other sexual function
scores were recorded. The VAI was calculated using the
{[}(WC/39.68)+(1.88xMI){]}xTG/1.03x1.31/HDL formula. Results:Mean age,
smoking volume, T and T/E2 ratios of the groups were similar
(p\textgreater{}0.05). Mean VAI was two-fold higher in patients in Group
1 (p\textless{}0.001) and erectile function score was lower in Group 1
than Group 2 (p=0.001). Other sexual function scores were similar
(p\textgreater{}0.05). The METS was associated with an increased risk of
ED (p=0.001). Logistic regression analysis showed that each integer
increase of the VAI was associated with a 1.4-fold increased risk of ED
(p\textless{}0.001). Higher T values were associated with a better
erectile function (p=0.03). For the VAI=4.33, receiver-operating
characteristic analysis showed a sensitivity of 89.6 \% and specificity
of 57.7 \%. Conclusion:Compared to non-MeTS, the presence of MeTS has
emerged as a risk factor for patients with ED with high VAI levels while
the other sexual functions are preserved. Management of ED patients with
MeTS should cover a comprehensive metabolic and endocrinological
evaluation in addition to andrological work up.%
\end{abstract}%



\sloppy


\textbf{Introduction}

In men, sexual function is provided by the central and peripheral
nervous system's harmonious work together with hormonal mechanisms and
vascular systems. The sexual function covers the erectile, orgasmic,
desire, ejaculatory components in addition to sexual and general
satisfaction. Although erectile dysfunction (ED) is managed as a sexual
problem, it can be a messenger of impending significant circumstances
such as coronary artery disease {[}1{]}. Some modifiable and
nonmodifiable risk factors, including increasing age and metabolic
syndrome (MeTS), may negatively affect sexual function {[}2,3{]}. The
current opinion in medicine is to take preventive measures before the
complications develop against diseases that can lead to lifelong
comorbidities {[}4{]}. The MeTS, which is associated with many
conditions, can also cause ED. For men, at least three of the modifiable
criteria are sufficient for the diagnosis of MeTS (Table 1) {[}5{]}.

Increased fat accumulation without the diagnosis of MeTS also causes
sexual dysfunction in men by decreasing the quality of life and damaging
the vascular endothelial mechanism via increased amounts of inflammatory
products, including cytokines, adipokine, and fatty acids cause nitric
oxide insufficiency {[}6{]}. Although cavernous arteries are slowly
affected by the atherosclerotic process, early diagnosis of ED remains
important before irreversible damage develops {[}7{]}. Due to the body
mass index (BMI) and waist circumference (WC) cannot homogenously
compute the fat distribution {[}8{]}, a decade ago, the gender-specific
visceral adiposity index (VAI) was first introduced by Amato et al. as
an indicator of adipose tissue dysfunction, which combines HDL
cholesterol, triglyceride, BMI and WC in a formula {[}9{]}. Based on the
limited number of studies investigating the relationship between VAI and
ED, we recently demonstrated a 1.3-fold increased risk of ED in response
to each integer increase of VAI {[}10{]}. However, a debate is still
open whether male sexual dysfunction could be recovered when the
correctable risk factors are adequately managed and when the VAI level
is decreased.

In this study, we aimed to show the impact of the MeTS on male sexual
functions based on VAI. We also aimed to highlight the importance of
seeking the urologists to receive comprehensive support from different
disciplines and professional partners to manage life-long or correctable
comorbidities that negatively affect erectile dysfunction.

\textbf{Materials and Methods}

After obtaining the Institutional Board approval of the XXX Local Ethics
Committee, this prospective study was conducted among patients at
outpatient urology clinics at four centers (A Hospital, B University, C
Hospital and D City Hospital). Written informed consent was obtained.
After a power analysis, a total of 285 sexually active men with complete
data from 298 participants were included in the study. Patients with
incomplete data (n = 3), active neurological disorders (n = 4),
unwilling to participate (n = 1), end-stage renal failure (n = 1), those
with a history of total thyroidectomy (n = 2) and patients with
urogenital cancer surgery (n = 2) were excluded from the study. Patients
with sexual dysfunction who met or did not meet the MeTS criteria, those
who applied to the urology clinic with complaints of sexual dysfunction
and those who were referred from Internal Medicine and Endocrinology
clinics were included in the study. Participants were given the
Turkish-validated 15-items long-form of the International Index of
Erectile Dysfunction (IIEF) questionnaire to fill under a urologist's
supervision. Erectile function was assessed using the IIEF 1-5 and 15th
items; sexual satisfaction, orgasmic function, sexual desire and general
satisfaction were assessed using the IIEF 6-8th, 9-10th, 11-12th 13-14th
items, respectively. Participants with IIEF 1--5 and 15 scores [?]26 were
defined as non-ED patients, those with IIEF 1--5 and 15 score = 22--25
were mild ED, IIEF 1--5 and 15 scores = 17--21 were mild-to-moderate ED,
IIEF 1--5 and 15 scores = 11--16 were moderate ED, and IIEF 1--5 and 15
scores = 0--10 were defined as severe ED. The BMI was calculated using
the kg/m2 formula. Waist circumference measurement was performed at the
level of the umbilicus. The mean age of the patients and comorbidities,
including hypertension and diabetes mellitus, medications, smoking and
alcohol habits, and ED duration, were recorded. The VAI was calculated
using {[}(WC / 39.68) + (1.88 x BMI){]} x TG / 1.03 x 1.31 / HDL male
sex-specific formula {[}9{]}. The mean sexual satisfaction, orgasm,
desire and general satisfaction scores were calculated. Among the
participants, 96 patients with MeTS criteria were defined as Group 1 and
189 with no MeTS criteria were defined as Group 2. Using the
enzyme-linked immunosorbent assay (ELISA), single hormonal analysis for
total testosterone (T), prolactin (PRL), estradiol (E2) tests were
performed from morning fasting venous blood samples when needed.
Aromatase activity was calculated using the T/E2 formula where available
{[}11{]}. The mean VAI, erectile function score, sexual satisfaction,
orgasm, desire and overall satisfaction scores were statistically
compared between the groups.

Statistical Analysis

The Statistical Package for the Social Sciences (version 21.0.; IBM,
Armonk, NY) was used to evaluate the data. The results were given as
mean \selectlanguage{ngerman}± standard deviation for normally distributed data and frequencies
(percentages) for categorical variables. Student-t, Mann-Whitney U test
was used to assess the differences between the groups. Multivariate
logistic regression analysis was performed to determine the VAI's impact
and the MeTS on sexual function. A p-value smaller than 0.05 was
accepted as statistically significant.

\textbf{Results}

Mean age, smoking volume, T and T / E2 ratios of the groups were similar
(p\textgreater{} 0.05). The mean BMI and WC were significantly higher in
Group 1 than Group 2 (p\textless{}0.05). Proportions of obesity and
morbid obesity were much higher in Group 1 than Group 2. The majority of
Group 1 patients had at least four or five MeTS criteria (50\% + 11.5)
(Table 2). The majority of Group 2 patients had one or two criteria of
MeTS (37.6\% + 43.9 \%). Mean VAI was two-fold higher in patients in
Group 1 than Group 2 (p \textless{}0.001). Mean sexual satisfaction,
desire, orgasm, and general satisfaction rates were similar between
groups (p\textgreater{} 0.05). Group 1 had higher diabetes, hypertension
and coronary artery disease rates than Group 2 (p = 0.001). The mean
erectile function score was 13.6±7.7 in Group 1 compared to 18.8±7.9 in
Group 2 (p = 0.001). Severe and moderate ED scores were observed in
61.5\% of the cases in Group 1, while this rate was 39.1\% in Group 2.
(Table 2). Multivariate logistic regression analysis showed that the VAI
was associated with a 1.4-fold increased risk of ED (p \textless{}0.01,
OR = 1.4 (95\% CI 1.4-1.7) and higher T values were associated with a
better erectile function (p = 0.03, OR = 0.7, 95\% CI 0.5-1). Regarding
the VAI, the receiver-operating characteristic (ROC) analysis showed for
the VAI=4.33 value, the area under the curve (AUC) was 0.835 (95\% CI:
0.786-0.884) with a sensitivity of 89.6 \% and specificity of 57.7 \%
(Figure 1).

\textbf{Discussion}

According to the American Association of Clinical Endocrinologists
Medical Guidelines for Clinical Practice, the prevalence of obesity
increased sharply. It continues to be a global problem over the past
three decades. Not only adults but also children and adolescents are at
risk of overweight or obesity {[}12{]}. To date, many reports have been
published showing the association between MetS and cardiovascular
diseases and ED and cardiovascular diseases. Still, only several
analyses showed the associations between ED and MeTS. The common feature
of the coronary and genital arteries' destructive process is that these
arteries have similar structures and are easily affected by risk factors
such as MeTS. Cavernosal arteries tend to be involved at first glance
due to their smaller diameters than coronary counterparts, and the
presence of MeTS often worsens the ED {[}1{]}. The presence of the MeTS
has been linked with a two-fold increased risk of ten years of
cardiovascular events {[}13{]}. Liu et al. sought whether MetS was an
independent risk factor for ED or just a silent marker of ED, and they
showed in a meta-analytical study that MeTS significantly increased the
risk for ED {[}14{]}. Smoking causes a decrease in endothelial
elasticity over time through a direct toxic effect on the endothelium.
{[}15{]}. Previous reports have reported that smoking has a
dose-dependent impact on ED, and more than 20 years/pack smoking
accelerates the ED process. In our study, smoking volumes were less than
20 packs/year for groups {[}16{]}. This finding could explain that the
ED progressed similarly. However, in particular populations such as in
patients with MeTS, it would not be misleading to think that a lower
smoking volume could accelerate the ED process where complex risk
factors coexistent. Smoking is an independent but preventable risk
factor. Creamer et al. reported that three out of five smokers succeed
in quitting in 2018 {[}17{]}.

MeTS may predispose to ED by decreasing the circulating androgen level
{[}18{]}. High blood lipid profile and high systolic blood pressure are
associated with a decrease in endothelial elasticity {[}19{]}, increased
amounts of cytokines, adipokines, and fatty acids and their interactions
with the endothelium cause decreased nitric oxide release, and
subsequently, ED manifests. Increased cytokines, adipokines, fatty acids
and their interactions with the endothelium cause decreased nitric oxide
release, and later, ED embodies {[}6{]}. Patients with MeTS prone to
have moderate to severe ED than those without MeTS {[}20{]}. The
complexity of pathophysiological changes could be a challenging factor
in patients with MeTS. In patients with MeTS, we observed a proportional
increase in the severity of ED as the number of MeTS components
increased. Indeed, in Group 1, the sum of severe and moderate ED rate
was significantly higher than Group 2 (61.5\% vs 39.1\%). Although the
decrease of total testosterone was similar in groups, the conversion of
some circulating androgen levels upon the peripheric aromatase activity
may accelerate the ED process {[}21{]}.

Several reports have shown that mean VAI levels tend to rise in ED
patients compared to non-ED patients {[}22,23{]}. Some authors have also
reported an increase of VAI from different disciplines {[}24{]}. Our
previous study showed that VAI increased in men with moderate and severe
ED might be a reliable, independent risk factor for ED, especially at
values above 4.33. We also concluded that researchers could use the VAI
for monitoring the ED before it manifests or clinically manifested at a
very early stage. However, as far as we know, the present study is the
first to show that the mean VAI level in the MeTS arm increased by at
least twice, reached 9.3 ±4.4. A significant increase of the VAI is
suspected to increase ED upon several complex pathways. A decrease of
endothelial nitric oxide release, low T / E2 secondary to circulating
peripheral aromatase activity, increased circulating leptin, and
diminished self-esteem may cause a potential increase in MeTS {[}10{]}.
Still, any combination of multiple risk factors, including MeTS, could
incredibly likely accelerate ED severity. As far as we know, this study
is the first to show that the VAI level doubled in patients with MeTS.
Our opinion is that researchers should take into account the rapid
increase of the VAI in patients with MeTS. Contrary to previous reports,
high VAI levels in patients with MeTS may challenge ED management.
Therefore, management of such cases should cover a comprehensive
metabolic and endocrinological evaluation in addition to andrological
work up.

Contrary to current reports, some studies conflicting results that MeTS
was not associated with an increased risk of ED. In one of them, the
authors stated no difference in the prevalence of ED between men with or
without MetS but, age, presence of depressive symptoms and lower
education were significant predictors of ED {[}25{]}. Plata et al. also
reported no relationship between MetS and ED among urological patients,
probably due to the low prevalence of MetS {[}26{]}. The methodological
settings of these studies due to the low number of MeTS patients might
have been insufficient to explain the relationship between MeTS and ED.

\textbf{Strengths \& Limitations:} This study's main strength is the
first to investigate very high VAI levels in men with ED in a specific
risk group such as METS. Lack of assessment of the penile vascular
system using penile duplex ultrasonography, lack of measurement of
cytotoxic end-products that may interfere with endothelial function and
only a single testosterone measurement using the enzyme-linked
immunosorbent assay are the limiting factors.

\textbf{Conclusions}

The increased combination of multiple risk factors in patients with MeTS
can dramatically accelerate ED severity with doubling VAI levels. Our
findings suggested that investigators should consider the rapid increase
in VAI in patients with MeTS, which may challenge ED management, and the
management of such cases should include a comprehensive metabolic and
endocrinological evaluation in addition to andrological examination.

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\begin{longtable}[]{@{}l@{}}
\toprule
\textbf{Table 1. MeTS* criteria according to the National Cholesterol
Education Program} \textbf{(NCEP ATP3, 2005).}\tabularnewline
\midrule
\endhead
A waist circumference of greater than 102 cm Triglyceride level higher
than 150 mg/dL, or receiving treatment for hypertriglyceridemia
HDL-cholesterol of less than 40 mg/dL Systolic blood pressure higher
than 130 mm Hg, or diastolic blood pressure higher than 85 mm Hg, or
receiving antihypertensive treatment Fasting glucose level greater than
100 mg/dL, or receiving treatment for hyperglycemia\tabularnewline
\textbf{*MeTS, metabolic syndrome}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 2. Demographic and clinical results of the groups.}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Variable} \selectlanguage{ngerman}\textbf{(mean ± standard deviation)}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Group 1} \textbf{Patients with MeTS*} \textbf{(n=96)}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{Group 2} \textbf{Patients with no MeTS (n=189)}\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{p}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Age (years)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
54.1\selectlanguage{ngerman}±8.5\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
53.1\selectlanguage{ngerman}±8.4\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.334\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Smoking volume (pack/year)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
16.6\selectlanguage{ngerman}±20.5\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
13.4\selectlanguage{ngerman}±16.5\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.158\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
BMI (Kg/m\textsuperscript{2})*** Waist circumference (cm) Patients
according to BMI (n, \%) Normal ([?]24.9) Overweight (25.00-29.9) Obese
(30.0-39.9) Morbid obese ([?]40.0)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
30.7\selectlanguage{ngerman}±4.2 110.6±19.3 7 (7.3) 37 (38.5) 46 (47.9) 6 (6.3)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
27.4\selectlanguage{ngerman}±4.0 99.8±10.4 43 (22.8) 108 (57.1) 37 (19.6) 1 (0.5)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.001 0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Presence of MeTS with None o the components Only a component Two
components Three components 4\textsuperscript{th} component
5\textsuperscript{th} component\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
- - - 37 (38.5) 48 (50.0) 11 (11.5)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
35 (18.5) 71 (37.6) 83 (43.9) - - -\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
-\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Comorbidity (n, \%) Diabetes Mellitus Hypertension Coronary artery
disease\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
26 (27.1) 32 (33.3) 16 (16.7)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
8 (4.2) 11 (5.8) 7 (3.7)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.001 0.001 0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Serum Testosterone (ng/mL)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3.9\selectlanguage{ngerman}±4.4\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4.1\selectlanguage{ngerman}±1.6\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.158\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
T / E\textsubscript{2} ratio\textsuperscript{\textbf{\#}}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.18\selectlanguage{ngerman}±0.19\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.21\selectlanguage{ngerman}±0.21\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.361\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
VAI**\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
9.3\selectlanguage{ngerman}±4.4\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
4.6\selectlanguage{ngerman}±2.9\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
IIEF score\textsuperscript{\textbf{\&}} Patients according to Erectile
function (n, \%) Severe (IIEF score = 0--10) Moderate (IIEF score =
11--16) Mild-to-moderate (IIEF score = 17--21) Mild (IIEF score =
22--25) No-erectile dysfunction\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
13.6\selectlanguage{ngerman}±7.7 33 (34.4) 26 (27.1) 23 (23.9) 10 (10.4) 4 (4.2)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
18.8\selectlanguage{ngerman}±7.9 34 (17.9) 40 (21.2) 34 (17.9) 42 (22.2) 39 (20.6)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.001 -\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Sexual satisfaction\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
7.4\selectlanguage{ngerman}±4.3\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
7.1\selectlanguage{ngerman}±4.2\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.568\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Orgasm\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
6.2\selectlanguage{ngerman}±3.5\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
6.2\selectlanguage{ngerman}±3.4\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.872\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Desire\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
6.3\selectlanguage{ngerman}±2.7\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
5.7\selectlanguage{ngerman}±2.7\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.468\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
General satisfaction\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
5.6\selectlanguage{ngerman}±2.7\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
5.7\selectlanguage{ngerman}±2.7\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.925\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{*MeTS, metabolic syndrome; **VAI, visceral adiposity index;
***BMI, body mass index; \textsuperscript{\#}T / E\textsubscript{2},
testosterone to estradiol ratio; \textsuperscript{\&}IIEF, International
Index of Erectile Function.}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{*MeTS, metabolic syndrome; **VAI, visceral adiposity index;
***BMI, body mass index; \textsuperscript{\#}T / E\textsubscript{2},
testosterone to estradiol ratio; \textsuperscript{\&}IIEF, International
Index of Erectile Function.}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{*MeTS, metabolic syndrome; **VAI, visceral adiposity index;
***BMI, body mass index; \textsuperscript{\#}T / E\textsubscript{2},
testosterone to estradiol ratio; \textsuperscript{\&}IIEF, International
Index of Erectile Function.}\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{*MeTS, metabolic syndrome; **VAI, visceral adiposity index;
***BMI, body mass index; \textsuperscript{\#}T / E\textsubscript{2},
testosterone to estradiol ratio; \textsuperscript{\&}IIEF, International
Index of Erectile Function.}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Figure Legend

Fig. 1. Receiver operator characteristics (ROC) curve for visceral
adiposity index for VAI=4.33, Sensitivity=89.6\%, Specificity=57.7\%.

\selectlanguage{english}
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\end{document}

