Erectile Dysfunction – A Bigger Problem Than You Might Think

Erectile dysfunction (ED) is the” inability to get and keep an erection firm enough for sex” (1). Although the origins of ED in older men were once thought to be mostly psychogenic or nerve-generated, the evidence now clearly shows that the predominant causative factor of ED originates in the blood vessels (2,3,4,5). ED is not an uncommon condition with global prevalence determined to be from 3% to 76.5%, depending on many factors (6). A 2006 study found that 49.4% of Canadian men aged 40 to 88 years were suffering from ED (7).

Thank goodness for those little blue pills, right? Unfortunately, the solution is not that easy. Medications like “Viagra” do nothing more than cover up symptoms and, in this case, instead of ignoring the symptoms they should be recognized for what they are, an ominous warning of more serious health problems to come. This is because the roots of ED development are the same as those that lead to catastrophic health events like heart attack and stroke.

ED is caused by clogged and diseased arteries in the penis and, if these blood vessels are struggling to function, you can be sure that other arteries in the same body are also suffering (8). In fact, one study illustrated that, once ED has made its appearance, cardiovascular disease was an average of three years behind in 70% of men (9). A 2008 study showed that presence of undetected coronary artery disease could be predicted with more than 80% accuracy in men with ED (10). A 2011 meta-analysis of twelve previous cohort studies encompassing almost 37,000 participants found that ED accurately predicts a significantly increased risk of cardiovascular disease, coronary heart disease, stroke and death from all causes (11) while another investigation revealed that ED presence forecasts increased risk of future stroke in men (12). A 2018 study corroborated these earlier results when researchers found that those with ED had increased risk for myocardial infarction, cardiac arrest and death from a cardiac event even after adjusting for other cardiovascular disease risk factors, depression, and medication use (13). In short, ED is our early warning system of impending serious health problems. Most health professionals in the fields of cardiology and urology now agree that ED sufferers should be assessed for cardiovascular disease before any symptoms appear so that preventive measures can be put into place (8).

What is happening in the body to produce ED? It all comes down to a gas called nitric oxide (NO) that is produced by endothelial cells, the single layer of cells that line every blood vessel in the human body. NO acts to maintain the health of blood vessels, allowing them to expand when increased blood flow is required and preventing platelets from sticking to blood vessel walls. NO is also necessary to produce enough blood flow through the arteries in the penis to create an erection. Endothelial cell dysfunction and impaired NO production can be caused by many factors including an unhealthy diet, obesity, high cholesterol, high blood sugar, lack of exercise, aging and smoking. When endothelial cell function is compromised, the result is stiffened blood vessels that cannot dilate as needed, increased blood pressure and atherosclerosis, the build-up of plaques on the insides of blood vessels. Adding to the problem is the unstability of the NO compound itself. It contains unbalanced electrons and consequently lasts only a few seconds in body tissues. Its production and stability depend not only on healthy blood vessels but also on extensive antioxidant protection. Inflammation and oxidative stress stemming from the very factors that are damaging the endothelial cells also place extra demands on available antioxidants resulting in decreased antioxidant levels and less protection for the unstable NO compound. Additionally, in ED specifically, because the arteries in the penis have a much smaller diameter than the arteries surrounding the heart or entering the brain, the penile arteries show damage and clogging much earlier. This is why ED often appears before cardiovascular disease (14).

The good news is that there are ways to prevent and treat these vascular problems. Neither ED nor cardiovascular disease are inevitable events. The main pathway to healthy blood vessels throughout the whole body follows a healthy lifestyle. Let’s look at ways to improve the health of the cardiovascular system, for its own sake as well as to prevent and treat ED.



Exercise, both general exercise and sexual activity, appears to be the most important lifestyle factor in ED management and prevention (15). Physical exercise increases NO production because of the mechanical effect of increased blood flow while erections of the penis increase penile blood flow much more even than general exercise (16). One study illustrated that more frequent sexual intercourse was associated with a 50% reduction of ED (17). Even simple pelvic floor exercises can reduce ED, most likely by reducing the draining of blood out of the penis through its veins (18).

Studies have illustrated that the risk of developing ED is less than half in men engaging in high levels of physical activity compared to those who are sedentary (19).

In 2015 scientists placed patients who had suffered a recent myocardial infarction into two groups: one group was asked to participate in a home-based walking program and the other group became the control group who received usual care with no suggested exercise. 84% of all participants reported suffering from ED at the time of their hospital discharge. The vascular function of each participant was determined through a 6-minute walk test and a questionnaire provided by the International Index of Erectile Function. Both of these tests were performed at the time of hospital discharge and again 30 days later. After 30 days, symptoms of ED had increased by 9% in the control group but had decreased by 71% in the home-based walking group. In addition, the distance attained during a 6-minute walk was significantly higher in the home-based walking group compared with the control group. Researchers concluded that walking decreases ED and that there is a strong link between exercise capacity and sexual function (20).

Another study enrolled men with ED into an 8 week exercise program consisting of 45 to 60 minute daily exercise sessions. Results showed that exercise is an effective and non-invasive treatment promoting a significant and prolonged improvement in ED (21).

The effects of daily exercise of 45 to 60 minutes in overweight men was also explored in a 2002 investigation. Results showed a significant increase in NO availability along with lowered blood pressure and improved lipid levels (22).



Obesity is a risk factor for ED, increasing its risk of development by 40% (23).

Excess fat contributes to ED development in several ways. Visceral fat (that extra fat around the waistline that is packed in around many major body organs) is metabolically active. It can release free fatty acids, contributing to insulin resistance and the resulting high levels of sugar in the blood. High blood sugar causes lower production of NO by endothelial cells (24). Obesity is also associated with inflammation, another cause of increased insulin resistance and impairment of NO production (25).



The standard diet eaten in North America contributes to inflammation, dysfunction of endothelial cells and reduction in the production of NO by endothelial cells (26). Such diets are low in beneficial nutrients such as antioxidants and fiber and high in inflammation-producing foods such as animal-sourced foods. Studies have found that adherence to diets higher in fruits and vegetables improves NO production and is associated with lower incidence of ED (27,28). The Massachusetts Male Aging Study illustrated that eating a diet rich in whole foods such as fruits, vegetables, and whole grains with fewer red and processed meats and refined grains decreased the risk of ED (29). In fact, other studies have discovered that each additional daily serving of fruits or vegetables results in a 10% decrease in risk of ED (27). Such plant-strong diets result in improvements in endothelial function with increased NO production and a decrease in inflammation (30).

A systematic review of six randomized controlled trials including over 25,000 men showed that increased intake of foods rich in flavonoids, especially flavones, flavanones and anthocyanins, was associated with reduced ED incidence. Flavonoids are present in many plant-based foods including fruit, vegetables, tea, herbs, and wine. Foods highest in flavones, flavanones and anthocyanins include strawberries, blueberries, red wine, apples, pears, and citrus products. In addition, the study discovered that a higher total intake of fruit was associated with a 14% reduction in risk of ED and found a 19% reduction in risk of ED predominantly due to intake of citrus products and blueberries (31). Other antioxidant-containing foods shown to improve NO production are cocoa and dark chocolate, tea, cranberries, blackberries and some spices (14).



Cigarette smoking almost doubles the likelihood of moderate or complete ED. Cigar smoking and second-hand smoke also significantly predict ED (5). This is due to the oxidative stress produced by smoking and the resulting reduced production of NO (14).



Animal studies suggest that keeping alcohol intake low will boost production of NO in arteries (14).



If you are suffering with ED, there is much that you can do to improve your situation. The combination of a healthy diet, sufficient physical activity, weight loss and smoking cessation have shown their effectiveness for the treatment of ED.

Putting many of these lifestyle factors together, a randomized controlled trial of 110 obese men with erectile dysfunction found that, after two years of moderate lifestyle changes, ED disappeared and normal sexual function returned in almost one-third of the participants in the intervention group. The modifications in lifestyle that these men achieved were not huge. Supported by intensive intervention, they increased their fiber by an average of 18 grams per day by eating more plant foods; they kept their fat under 30% of total calories and their saturated fat under 10% by consuming a greater percentage of their calories from whole complex carbohydrates (fruits and vegetables); they lowered their cholesterol by eating fewer animal-sourced foods and they increased their exercise from an average of 48 minutes per week to 195 minutes per week. Their results speak for themselves. Besides improvements in ED these men decreased their body weight, blood pressure, blood sugar levels, blood lipid levels and insulin levels. There were no improvements among participants in the control group (32).

Understanding the influence of lifestyle factors on the health of your blood vessels opens up a new level of control over your own health. If you look after the health of your blood vessels, whether for improvement in erectile function or for prevention of other vascular events like heart attacks and strokes, you will likely find yourself enjoying a healthier, longer and more satisfying life.




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My name is Debra Harley (BScPhm) and I welcome you to my retirement project, this website. Over the course of a life many lessons are learned, altering deeply-rooted ideas and creating new passions.

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