Hussein Ghanem, M.D.Professor of Andrology, Sexology
& STDsCairo University
Course: Optimization of response to ED pharmacotherapy
Sidney Glina, Hussein Ghanem & Eusebio Rubio
Modification of lifestyle to improve erectile function
Presentation Objectives
Outline the link between Lifestyle factors and Cardiac & Sexual Health.
Clarify if lifestyle modifications can really enhance sexual function.
Discuss if our guidance is effective in changing patients’ lifestyles?
Al Suwaidi J, et al. Clin Card 8/01
How much sooner does obesity give you a heart attack?
56
58
60
62
64
66
68
70
72
74
Normal Overweight Obese
Age
Mittleman MA et al, N Engl J Med 1993;329:1677 Rodriquez BL et al, Circulation 1994;89:2540 Hakim AA et al, Circulation 1999;100:9
Effects of Exercise on CHD Risk
-100%
-90%
-80%
-70%
-60%
-50%
-40%
-30%
-20%
-10%
0%
Daily Walking Midde-Aged
Daily Walking Elderly
Heavy Exertion 1-2/week
Heavy Exertion 5-7/Week
Age
Exertion
Frequency
Red
uct
ion
CH
D R
isk
Hu FB et al, JAMA 2003;289:1785
Daily Activities, Obesity & Diabetes
per 1 hour/day
Comparison of Exercise & Antidepressants Blumenthal JA et al, Arch Intern Med 1999;159:2349
0
5
10
15
20
25
Medication Exercise
Baseline
16 Weeks
Bec
k’s
Dep
ress
ion
In
dex
156 with MDD (age, > or = 50 years) were assigned randomly to a program of aerobic exercise, antidepressants (sertraline hydrochloride)
ICSM-5 step management algorithm – Paris 2009
The second Princeton consensus on sexual dysfunction and cardiac risk: new guidelines for sexual medicine. Jackson G, Rosen RC, Kloner RA, and Kostis JB. J Sex Med 2006;3:28–36.
The recognition of ED as a warning sign of silent vascular disease has led to the concept that a man with ED and no cardiac symptoms is a cardiac (or vascular) patient until proven otherwise.
Men with ED and other cardiovascular risk factors (e.g., obesity, sedentary lifestyle) should be counseled in lifestyle modification.
Cardiometabolic risk and female sexual health: The Princeton III summaryMiner M, Esposito K, Guay A, Montorsi P, and Goldstein I. J Sex Med 2012;9:641–651.
Promotion of healthful lifestyles, including healthy diet and exercise, for prevention and treatment of women of all ages yields benefits and reduces the burden of chronic diseases beyond the specific effects on sexual dysfunctions (Mainly arousal).
Lifestyle & Medical Risk Factors associated with EDLifestyle
factors• Physical inactivity• Unhealthy diet• Obesity• Smoking, Alcohol abuse & drug abuse
Medical factors• DM• Hypertension• Dyslipidemia• Hypogonadism
• Insufficient Sleep•Work stress
Hatzichristou, Rosen, Derogatis, et al. Recommendations for the clinical evaluation of men and women with sexual dysfunction.J Sex Med 2010;7:337–348.
Effect of Medical & Lifestyle factors on ED Risk
1. Martin-Morales A et al. J Urol. 2001;166:569-575. 2. Braun M et al. Int J Impot Res. 2000;12:305-311. 3. Goldstein I. Am J Cardiol. 2000;86(suppl):41F-45F. 4. Feldman HA et al. J Urol. 1994;151:54-61.
1.8Depression3,4
1.6Hypertension1,2
1.6Hyperlipidemia1
1.8Cardiac problems1
2.0Smoking4
2.6Peripheral vascular disease1
4.1Diabetes1,2
Increased ED Risks*Increased ED Risks*Chronic Chronic Disease/LifestyleDisease/Lifestyle
Obesity x 2.0
*Age-adjusted odds ratio.
How can we maintain / restore Erectile Function?
Avoid smoking, excess alcohol & drugs
Sleep well & control work stress
PrimaryMetabolic
Disturbance
PrimaryMetabolic
Disturbance
Intermediate Intermediate Vascular Disease Vascular Disease
Risk Factor Risk Factor
Intermediate Intermediate Vascular Disease Vascular Disease
Risk Factor Risk Factor Intravascular
PathologyIntravascular
PathologyClinicalEvent
ClinicalEvent
Atherosclerosis
• Penile / Int pudendal• Coronary arteries• Carotid arteries• Cerebral arteries• Aorta• Peripheral arteries
Hyperinsulinemia
Hyperglycemia
Hypertension
Dyslipidemia
Inflammation
ImpairedFibrinolysis
Endothelial Dysfunction
Insulin Resistance
CVD& ED
Despres JP, et al. Abdominal obesity and metabolic syndrome. Nature. 2006;444:881-887.
Multiple Factors Associated With Obesity Give Rise to Increased Risk of CVD
Unhealthy diet, Obesity & Physical inactivity
How can Obesity & Sedentary Lifestyle cause ED or CVD
Esposito K, Giugliano F, Maiorino MI, and Giugliano D. Dietary factors, Mediterranean diet and erectile dysfunction. J Sex Med 2010
Acute variations of plasma glucose &lipid levels may cause early injury in endothelial cells.
2010
Obesity & Testosterone deficiency
Cause or effect?Visceral obesity seems to be both the cause & the consequence of TD.
Third International Consultation of Sexual Medicine (Paris 2009). Buvat, Maggi, Gooren et al, Endocrine Aspects of Male Sexual Dysfunctions. J Sex Med 2010;7:1627–1656.
Measuring waist circumference
Between the lowest rib and the top of the iliac crest
Tape should be snug & parallel to the floor without causing compression
NHLBI. www.nhlbi.nih.gov.
Iliac crest
Ethnic specific values for waist circumference: The International Diabetes Foundation consensus
Exercise may reduce CVD and all-cause mortality
Fang J et al. Am J Hypertens. 2005;18:751-8.
N = 9791; moderate physical activity vs little or no physical activity
0.75 (0.53–1.05)0.76 (0.39–1.49)
0.79 (0.65–0.97)
All-cause deathCV death
All-cause deathPrehypertension
CV deathHypertension
Hazard ratio1.51.00.5
Normal BP
0 2.0
All-cause deathCV death
0.79 (0.58–1.09)
0.88 (0.80–0.98)0.84 (0.73–0.97)
Adjusted HR (95% CI)Favorsexercise
Favorsno exercise
NHANES 1 Epidemiological Follow-up Survey (1971–1992)
Practical advise about physical activity
30 ms of moderate-intensity physical activity preferably daily.
Incorporate exercise into your daily routine Take stairsWalk, cycle Park further awayGo down on an earlier bus stop.
A pedometer (10,000 steps)
30 ms of moderate-intensity physical activity preferably daily.
Incorporate exercise into your daily routine Take stairsWalk, cycle Park further awayGo down on an earlier bus stop.
A pedometer (10,000 steps)
Surgeon General’s Report on Physical Activity and Health
American Diabetes Association. Diabetes Care. 2007;30:S4-41.
Why is vascular ED
an early warning sign for CVD?
clinical symptoms
silent ischemiastabil/non-
anginaAMI
ED TIAstroke
intermittent
claudication
Size ofarteries(mm)
obstruction of the Artery
O (%)
penile artery(1-2)
proximal LAD(3-4)
internal carotid(5-7)
femoralartery(6-8)
plaque: only ED plaque: clinical CAD
ED CAD CVD PAD
50 % obstruction
Montorsi et al., Eur Urol 2003
Number of Patients
Patients +ve for IHD on treadmill
PSV < 25 cm/s 22 11
(50%)
P= 0.003
PSV 25 – 35 cm/s 2 1PSV > 35 cm/s 16 0 (0%)
Is obesity a further cardiovascular risk factor in patients with ED?Corona et al, J Sex Med. 2010 Jul;7(7):2538-46
Observational prospective cohort study of 1,687 patients (mean follow-up of 4.3 ± 2.6 years).
Relationship between ObesityArteriogenic EDMajor adverse cardiovascular events
(MACE).
Corona 2010
Is obesity a further cardiovascular risk factor in patients with ED?Corona et al, J Sex Med. 2010 Jul;7(7):2538-46
1% fatal
Severe ED predicted MACE (hazard ratio [HR] 1.75; 95% confidence interval 1.10–2.78; P < 0.05)
Obesity & risk of major adverse cardiovascular events
Arteriogenic ED ( PSV<25 cm/sec) predicted MACE
Is obesity a further cardiovascular risk factor in patients with erectile dysfunction?Corona et al , J Sex Med. 2010 Jul;7(7):2538-46.
Lifestyle factors in relation to ED
Obesity to ED
Study YearStudy design
Patient number
Major findings
Esposito 2004Randomized controlled
110Decrease in BMI is independently associated with increase in IIEF score
Fung 2004 Cohort 570Obesity at baseline is not independently associated to ED 25 years later
Bacon 2003Cross-sectional
31,742BMI > 28.7 kg/m2 is independently associated to ED
Blanker 2001Cross-sectional
1,688Obesity is independently associate to ED
Janiszewski
2009Cross-sectional
3,941Abdominal Obesity 50% higher odds of having ED
Andersen 2008Cross-sectional
3,300ED was more prevalent among younger and older Danish men with higher BMIUpdated from: Obesity, dyslipidemias and erectile dysfunction: A report of a subcommittee of the
sexual medicine society of North America. Mulhall J, Teloken P, Brock G, and Kim E. J Sex Med 2006;3:778–786.
Population-based cross-sectional study of 1,580 participants.
The IIEF-5 was used to assess erectile function.
Compared with never smokers, the odds of ED, adjusted for age, square of age, and CVD, were significantly higher among current smokers (odds ratio [OR] = 1.40; 95% confidence interval [CI] 1.02, 1.92).
2008
Chew K-K, Bremner A, Stuckey B, Earle C, and Jamrozik K. Is the relationship between cigarette smoking and male erectile dysfunction independent of cardiovascular disease? Findings from a population-based cross-sectional study. J Sex Med 2009;6:222–231.
Smoking
Rats has a constant influx of smoke using a specially constructed device. 24 Sprague Dawley (SD) rats were randomly into two groups: an experimental group and a control group. 36rats for the chronic cigarette smoke exposure were randomly divided into three groups: a control group and two experimental groups.
Electrical field stimulation of the cavernosal nerve to assess the erectile function,.
Vasoconstrictor effects & the decrease in testosterone levels after chronic smoking had some effects on erectile function in rats. Park MG, Ko KW, Oh MM, Bae JH, Kim JJ, and Moon DG. Effects of smoking on plasma testosterone level and erectile function in rats. J Sex Med 2012;9:472–481.
Park et al, 2012
Smoking
5,552 men and women aged 16-97 years Sexual dysfunctions were associated with
Increased waist circumferencePhysical inactivity >21 alcoholic beverages/weekTobacco smokingHard drugs
(ORs between 1.71 and 22.0)
Associations of unhealthy lifestyle factors with sexual inactivity and sexual dysfunctions in DenmarkChristensen et al, J Sex Med. 2011 Apr;8(4):971-5.
2011
Lifestye
Associations of unhealthy lifestyle factors with sexual inactivity and sexual dysfunctions in DenmarkChristensen et al, J Sex Med. 2011 Apr;8(4):971-5.
Conditions associated with sexual inactivity:Both underweight (BMI <20 kg/m(2) )
& obesity. Obesity (body mass index [BMI]≥30 kg/m(2) ) or a substantially increased waist circumference (men ≥102 cm; women ≥88 cm),
physical inactivityTobacco smoking in women
Lifestyle
Mediterranean diet & ED with type 2 diabetes. Giugliano et al. J Sex Med 2010
555 (90.8%) of 611 diabetic men followed for at least 6 months.Age 35–70 years(BMI) of 24 or higherHbA1c of 6.5% or higher or treatment with diet or oral drugs.
Food-frequency questionnaire and self-report measures of sexual function.
2010
Diet
Diet based on plenty of vegetables (excluding potatoes), fruits, nuts, whole grains, legumes, fish, monounsaturated fatty acids.
Low-fat dairy productsLow consumption of
saturated fat, red and processed meats.
No excess alcohol
Diet characteristics
Mediterranean diet & ED with type 2 diabetes. Giugliano et al. J Sex Med 2010
Mediterranean diet & ED . J Sex Med 2010
Men more adherent to a healthy diet were:
Sexually active Lower prevalence
of ED & severe ED (P=0.01)
Diet
Beneficial impact of exercise and obesity interventions on erectile function and its risk factors.Hannan et al, J Sex Med. 2009
2009
Animal Studies
% body weight change & Erectile response
Beneficial impact of exercise and obesity interventions on erectile function and its risk factors.Hannan et al, J Sex Med. 2009
Animal Studies
Visceral adipose tissue & Erectile response
A urologist examined 674 men aged 45-60 yr at their place of work. Physical examinationMedical history(T) and SHBG
IIEF-5 Paffenbarger score (PhA) was assessed
in kilojoules per week (4.2 kJ=1 kcal).
European Urology
ResultsA positive correlation between the IIEF-
5 and the Paffenbarger score (r=0.164, p<0.001)
The risk of severe ED was decreased by 82.9% for males with PhA of at least 3000 kcal/wk (OR=0.171, p=0.018).
How much physical activity is needed to maintain erectile function? Vienna Municipality Study. Kratzik et al, Eur Urol. 2009 Feb;55(2):509-16
European Urology
Do lifestyle modifications improve
sexual function?
The Effect of Lifestyle Modification and Cardiovascular Risk Factor Reduction on EDA Systematic Review and Meta-analysisBhanu et al Arch Intern Med. 2011;171(20):1797-1803
740 participants from 6 clinical trials in 4 countries
How effective is our guidance in changing patients’ lifestyles?
Overweight diabetic men subjected to either: Intensive lifestyle intervention versus Conventional Diabetes support & education
Sexual function was assessed after 1 year
Look AHEAD: Action for Health in Diabetes
Wing et al, J Sex Med. 2010 Jan;7(1 Pt 1):156-65
Weight LossIntervention
Diabetes support and education (DSE)Intensive lifestyle intervention (ILI)
Weight LossIntervention & SF
Diabetes Support & Education (DSE)?
Oral & written information about Healthy food choices
Physical activity. Effects of weight loss intervention on erectile function in older men with type 2 diabetes in the look AHEAD trial. J Sex Med 2010;7:156–165.
Intensive lifestyle intervention (ILI)?Body Weight :Detailed advice about
how to reduce body weightDiet:
7 sessions with a nutritionistPersonal goal-settingSelf-monitoring (food diaries) through a
series of monthly small-group sessions.Exercise: Individual guidanceBehavioral and psychological
counseling was offered
Changes in weight and fitness from baseline to 1 year
VariableILI DSE
Comparison of ILI vs. DSE
NMean
SD N Mean SD F P
Weight loss (kg)
153−11.1
9.4 150 −0.7 4.5 153.2 <0.001
HbA1c change
148 −0.7 1.0 144 −0.3 1.1 11.8 0.001
BP change 153 −7.5 16.3 150 −1.5 14.9 11.4 0.001
HDL change 148 3.7 6.6 144 1.0 5.8 13.3 <0.001
Intensive lifestyle intervention (ILI)Diabetes support and education (DSE)
Greater improvement in EF (17.3 +/- 7.6 at baseline; 18.6 +/- 8.1 at 1 year) than in DSE (18.3 +/- 7.6 at baseline; 18.4 +/- 8.0 at 1 year); P = 0.06
Cardiorespiratory fitness was found to be protective of ED in a multivariable analysis (OR = 0.61; P < 0.001)
Physical Fitness & SF
Effects of intensive lifestyle changes on erectile dysfunction in men.Esposito et al, J Sex Med. 2009 Jan;6(1):243-50.
Changes in the IIEF-5 were assessed up to 2 years.
Goal
Intervention group
Control group P valu
e%
Weight reduction >5% 50 15
0.001
Monounsaturated-fat intake ≥10% of energy intake
57 260.001
Saturated-fat intake <10% of energy intake
86 410.001
Fiber intake ≥15 g/1,000 kcal 29 12
0.001
Exercise >4 h/week 76 410.001
Goals & Success of lifestyle interventionEsposito K,et al
Patients without ED
Effects of intensive lifestyle changes on erectile dysfunction in men.Esposito et al, J Sex Med. 2009 Jan;6(1):243-50.
(P = 0.015).
EF could be improved non-pharmacologicaly through intensive lifestyle changes.
Effects of intensive lifestyle changes on erectile dysfunction in men.Esposito et al, J Sex Med. 2009 Jan;6(1):243-50.
ConclusionsA healthy lifestyle improves Sexual function.
Sexual health professionals should guide their patients: Appropriate lifestyle counseling
& control of co-morbidities Follow-up to reinforce
educational messages