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