Erectile dysfunction: signal of your health & what you can do about it

Source: Jeleefstijlalsmedicijn

Authors: dr. Melianthe Nicolai, urologist Antoni van Leeuwenhoek and Link2Care Clinics, and Jaap Versfelt, board member Stichting Je Leefstijl Als Medicijn

Key messages

1. Erectile dysfunction (ED) is the inability to get or maintain an erection that is firm enough for satisfactory sexual activity.
2. ED is a common problem and affects men of all ages. About 14 percent of Dutch men experience ED, and it is more common at older ages.
3. ED is an early warning for cardiovascular disease. Poor blood vessel health often manifests as ED, years before heart attacks or strokes occur.
4. Metabolic dysfunction is a major cause of ED. Metabolic dysfunction, caused by insulin resistance and chronic low-grade inflammation, leads to reduced blood flow and hormonal disruptions, which contributes to ED.
5. Lifestyle changes can address ED. A healthy diet, regular exercise, relaxation, and adequate sleep can significantly reduce ED.
6. Dietary adjustments can help. Various eating habits (such as the Mediterranean diet or low-carb diets) can reduce cardiovascular risk and thereby ED.
7. Patient: seek help in time. Early addressing of ED can improve health and quality of life and even extend life expectancy.
8. Doctor: do not treat ED only symptomatically, but investigate underlying risk factors such as metabolic dysfunction and cardiovascular risk. Encourage lifestyle interventions for sustainable improvement.

Introduction

Erectile dysfunction (ED) affects men of all ages and can have a significant impact on quality of life. Although ED is often seen as a problem that only plays out in the bedroom, it is in reality an important health signal — an early warning for more serious conditions such as heart attacks and strokes.

The good news? ED is not inevitable or untreatable. Through simple changes in your lifestyle, you can address the underlying causes, improve your sexual health, and reduce the risk of cardiovascular disease and strokes. These changes include starting a healthier eating pattern, exercising more, managing stress better, and ensuring adequate sleep.

In this article, we discuss what ED is, what causes it, and — most importantly — how you can address it. Read on and discover how lifestyle changes can improve not only your sex life but also your overall health.

Reading time 18 minutes

1. What erectile dysfunction is and how common it is

Erectile dysfunction (ED) is the persistent inability to get and maintain an erection sufficient for satisfactory sexual contact. ED is a common problem among men of all ages and has a major impact on the quality of life of both the men who suffer from it and their partners.

ED occurs in about 14 percent of men aged 18 and older in the Netherlands. It is more common as age increases: in 5 percent of men in their twenties, up to 42 percent in men in their seventies. Yet only 0.4 percent of men with ED consult their general practitioner. This means that many men with ED do not seek medical help or lifestyle advice for this problem (NHG guideline, 2008).

It is likely that the prevalence of ED is increasing rapidly given the connection that exists with obesity. The number of men with obesity has more than doubled in the past 30 years to 13.4 percent (Vzinfo), and is expected to rise further.

2. How a normal erection works

An erection begins with signals from the brain and spinal cord as a response to sexual arousal. These signals cause the release of nitric oxide (NO), a chemical messenger molecule, in the penis. NO in turn stimulates the production of cGMP, another signaling molecule. The elevated level of cGMP leads to relaxation of the ‘smooth muscle tissue’ in the walls of the blood vessels in the penis.

This relaxation allows the blood vessels in the penis to dilate and blood to flow into the corpora cavernosa. These corpora are two spongy chambers that run along the length of the penis. They absorb blood, similar to how a sponge absorbs water, making the penis firm. At the same time, the veins that normally drain blood from the penis are compressed to maintain the erection.

This process reverses when arousal decreases. NO production decreases and cGMP is broken down. As a result, the smooth muscles in the walls of the blood vessels in the corpora cavernosa contract, reducing blood supply, blood flows away, and the penis returns to a flaccid state.

In addition to erections during sexual arousal, men experience spontaneous erections that occur during sleep. These erections are not related to sexual arousal and are caused by the nervous system relaxing the smooth muscles in the blood vessels of the penis and increasing blood supply.

3. Erectile dysfunction

There are several ways in which erectile dysfunction can develop. Four important causes are:

• Vascular problems. Erections depend on good blood supply to the penis. Conditions such as clogged arteries (atherosclerosis), damaged blood vessels, or high blood pressure can limit this blood flow. Diseases such as diabetes can worsen damage to blood vessels, making it difficult for the penis to fill with enough blood and stay firm.
• Hormonal imbalance. Testosterone, the hormone responsible for sexual desire, also supports the chemical process needed for an erection. Low testosterone levels (due to aging or health problems such as obesity) can reduce sexual desire and weaken erections. Other hormonal problems such as excess prolactin (a hormone that can lower testosterone levels) and thyroid problems (thyroid glands regulate metabolism) can also cause disruptions.
• Neurological conditions. Nerves send signals from the brain and spinal cord to start the erection process. If these nerves are damaged (by injuries, diseases such as multiple sclerosis, or diabetes), the signals cannot reach the penis, stopping the process before it begins.
• Psychological factors. Erections begin with sexual arousal in the brain, but mental health problems such as stress, anxiety, depression, and relationship problems can disrupt the signals that initiate the erection process. Even if the body is physically healthy, these factors can block an erection. Men with depression, for example, have almost 40 percent more chance of ED than men without depression (Liu, 2018).

4. Erectile dysfunction as early warning for cardiovascular disease

ED affects not only sexual health but can also indicate serious cardiovascular problems. Often ED is the first visible sign of cardiovascular disease, often years before symptoms such as chest pain or shortness of breath occur.

4.1 ED and the heart, what is the connection?

The health of your blood vessels is crucial for both erections and heart function. ED and heart disease share a common underlying cause: poor blood vessel health, also known as vascular dysfunction.

• Smaller arteries, earlier signal The arteries in the penis are smaller (1-2 mm) than those in the heart (3-4 mm) or the brain (5-7 mm). Therefore, they are affected earlier by blockages and plaque formation, making ED a possible early warning for cardiovascular problems (Corona, 2020).
• Damage to blood vessels The inner wall of blood vessels, the endothelium, regulates blood flow by releasing nitric oxide (NO). When this inner wall is damaged — by for example high blood pressure, smoking, or metabolic dysfunction — NO production is disrupted, resulting in poor blood flow. This problem can first manifest as ED before it leads to more serious conditions such as heart attacks or strokes.

4.2 How strong is the link?

Many studies demonstrate the strong connection between ED and heart disease:

• Generally increased risk Men with ED have a 62 percent higher risk of heart attack, a 39 percent higher risk of stroke, and a 25 percent higher risk of dying from heart-related causes compared to men without ED (Vlacopoulos, 2013). Research with the Prostate Cancer Prevention Trial database showed that ED increases a patient’s cardiovascular risk as much as smoking or a family history of heart attacks (Thompson, 2005).
• Higher risk in younger men Younger men with unexplained ED have a very significant increase in their cardiovascular risk at older age, up to 50 times higher (Montorsi, 2003).
• ED as precursor to infarctions Nearly 50 percent of men with known coronary heart disease, demonstrated via cardiac catheterization, also have significant ED. ED often precedes coronary heart disease, heart attacks, and strokes by up to 5 years (Montorsi, 2003).

ED provides a valuable window for early intervention. Because ED often occurs 5 years before symptoms of heart disease, addressing it early can lead to life-saving changes. The most important of these is addressing metabolic dysfunction. In the next chapter, we will see why.

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5. Metabolic dysfunction as a major cause of erectile dysfunction

ED can be a standalone condition, but is often a sign of broader health problems, as we saw in the previous chapter. Why is that? ED and cardiovascular disease share a major risk factor: metabolic dysfunction. By understanding the connection, we can take effective lifestyle measures to counteract ED (and cardiovascular risk).

5.1 What is metabolic dysfunction?

Metabolic dysfunction refers to a disruption of normal metabolism, making the body unable to efficiently produce, store, or use energy. This can manifest as weight gain (especially abdominal fat), elevated blood pressure and blood sugar levels, changes in triglyceride and HDL cholesterol values, and a shift in LDL particle size.

Metabolic dysfunction is largely caused by insulin resistance and low-grade inflammation.

• Insulin resistance is a reduced sensitivity of body cells to the hormone insulin, requiring increasingly higher insulin levels to maintain normal blood sugar levels. This can eventually lead to type 2 diabetes. Elevated insulin levels can have negative effects (including sodium retention) and over time it becomes increasingly difficult to regulate blood sugar levels.
• Chronic low-grade inflammation occurs when the immune system is persistently mildly activated without noticeable symptoms. Low-grade inflammation and insulin resistance reinforce each other, creating a vicious cycle.

5.2 Evidence for the connection between ED and metabolic dysfunction

Research demonstrates a strong connection between ED and metabolic dysfunction and the associated conditions diabetes and obesity:

• Metabolic syndrome and ED Men with metabolic syndrome have up to four times higher risk of ED (Corona, 2023).
• Obesity and ED Men with obesity have 50 percent higher risk of ED than men with normal weight (Janiszewski, 2009).
• Type 2 diabetes and ED: Men with type 2 diabetes have 3.5 times higher risk of ED than men without diabetes. Up to 75 percent of men with type 2 diabetes report some degree of ED, and for some, it is the first noticeable symptom of diabetes (Defeudis, 2021). Clinical studies show that men treated with metformin (a medication for type 2 diabetes) show significant improvements in both metabolic markers and ED symptoms (Rey-Valzacchi, 2012).

What ED and cardiovascular risk have in common is that both are strongly connected to metabolic dysfunction. The risk of heart attack is greatly increased by high blood pressure, obesity, type 2 diabetes, and other characteristics of metabolic dysfunction (Dugani, 2021).

5.3 How metabolic dysfunction causes ED

The connection between metabolic dysfunction and ED lies in the consequences of metabolic dysfunction for blood flow and hormone balance:

• Nitric oxide (NO) deficiency A healthy blood supply is essential for an erection, and NO plays a key role in relaxing blood vessels to allow blood to flow into the penis. Metabolic dysfunction reduces NO production through damaged blood vessels and disrupted insulin signaling, making it difficult to get and maintain an erection.
• Damage to blood vessels Metabolic dysfunction causes chronic inflammation, oxidative stress, and endothelial dysfunction, leading to plaque formation in blood vessels (atherosclerosis). This limits blood flow to the penis, impairing the ability to get and maintain an erection.
• Low testosterone Insulin resistance and obesity often lower testosterone levels, which reduces sexual desire and weakens the biochemical processes that support erections (Jalali, 2024). Visceral obesity and metabolic dysfunction are considered major causes of low testosterone levels (Defeudis, 2021).

In-depth: Metabolic dysfunction

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6. Limitations of medicinal treatment of erectile dysfunction

Medicinal treatments for erectile dysfunction, such as Viagra (a so-called PDE5 inhibitor), effectively dilate blood vessels and improve blood flow to the penis, resulting in harder and longer-lasting erections. Although medication continues to make penetrative sex possible, despite naturally reduced penile blood flow, they often mask the underlying problem that is therefore not recognized or addressed. This leads to temporary relief of the symptoms without addressing the actual medical cause of ED and poor lifestyle choices.

Over time, as overall health further declines, the effectiveness of PDE5 inhibitors will also decline. Doses can be increased to some extent, but higher costs and more side effects accompany this. The literature also shows that 35 percent of PDE5 inhibitor users stop using them within six months due to side effects or reduced effectiveness (Son, 2004).

This emphasizes the need for a holistic treatment of erectile dysfunction, where symptoms are relieved alongside the identification and treatment of underlying causes. Lifestyle interventions are essential to prevent further deterioration of erectile function and reduce the risk of future cardiovascular disease. Patients should be guided in making better lifestyle choices to help them improve health and prevent new diseases.

7. Addressing erectile dysfunction with lifestyle

As we have seen, ED is often a sign of broader metabolic health problems. Metabolic dysfunction can be addressed with lifestyle changes, which can both improve ED and reduce cardiovascular risk. The changes are in the areas of nutrition, exercise, stress, and sleep, among others. Below we discuss these factors. Because diet is one of the most easily adjustable components, we will discuss that in more detail.

7.1 Addressing metabolic dysfunction through lifestyle

The main areas to address are:

• Diet Nutrition plays a central role in managing metabolic dysfunction and improving vascular health. More on this in the rest of this chapter.
• Exercise Regular physical activity improves blood flow, reduces oxidative stress, and increases nitric oxide (NO) production. Research shows that regular exercise stimulates NO production and improves blood vessel function, which reduces the risk of ED. Studies show that men who exercise moderately have 33 percent lower risk of ED, and intensive athletes even 58 percent lower risk (Cheng, 2007).
• Sleep Adequate sleep improves hormone balance and reduces inflammation, supporting both metabolic and sexual health.
• Stress management Chronic stress increases cortisol, which can worsen insulin resistance and suppress testosterone. Mindfulness and relaxation techniques can help with this.

Cycling and erectile dysfunction

Cycling and the relationship with ED is a topic of discussion. Traditional racing bike saddles can exert a lot of pressure on sensitive nerves and blood vessels in the groin area, which can raise concerns about potential problems for cyclists. Research among more than 3,300 cyclists compared to about 1,500 non-cyclists showed that cyclists had a higher risk of developing ED (Gan, 2021).

7.2 Research demonstrates the effect of lifestyle change on erectile dysfunction

Just like the amount of exercise, diet can also be relatively easily adjusted (unlike sleep and stress, which are less easily influenced). Some studies on diet and ED show that weight loss and a Mediterranean diet can help:

• Weight loss Men with obesity who achieved weight loss through diet and exercise showed significant improvements in erectile function scores. In one study, 55 obese men increased their scores from 13.6 to 17 over two years, with 31 percent of these men achieving normal erectile function (Esposito, 2004).
• Mediterranean diet A randomized controlled study showed that men with metabolic syndrome who followed a Mediterranean diet were six times more likely to restore normal erectile function than men on a standard Western diet. The Mediterranean diet emphasizes fresh vegetables and fruit, whole grains, nuts, olive oil, fish, and lean proteins, with minimal processed foods and moderate amounts of red wine (Esposito, 2006).

7.3 More studies point to the potential of a low-carb diet

There are only a few studies available on diet and ED. However, there are many more studies available on diet and cardiovascular risk. Given the close connection between ED and cardiovascular risk (as discussed in chapters 4 and 5), it is likely that the diet that works best for reducing cardiovascular risk also works well for ED.

That diet is the low-carb diet. A recent umbrella review (Chatzi, 2024) concluded that this diet had an even stronger effect on reducing risk factors for cardiovascular disease than the Mediterranean diet (and other diets in the list).

Table 2: Effect of diets on cardiovascular risk (source: Chatzi, 2024)**

A low-carb diet focuses on significantly reducing carbohydrate intake, particularly refined carbohydrates, and emphasizes proteins, healthy fats, and non-starchy vegetables.

More specifically, the diet advises:

• Reduce intake of ultra-processed food. The first step is to stop drinking sugary drinks (such as soft drinks), reducing consumption of products with added sugars and refined starch (such as cereals, cookies, candy, and sauces), and avoiding inflammatory seed oils (sunflower oil, rapeseed oil, soybean oil, etc.).
• Choose foods with low glycemic load. Some foods cause high insulin spikes and thereby increase insulin resistance. These are foods with high ‘glycemic load,’ meaning the food contains many carbohydrates that are quickly released. Think of mashed potatoes, white bread, cookies, and fruit juices. Whole, natural food causes fewer insulin spikes. Think of animal products (such as meat, fish, milk, and eggs), certain fruit (such as apples, blueberries, olives, and avocados), certain vegetables (such as broccoli, lettuce, and carrots), and nuts (such as walnuts). In this table, you can find the glycemic load of more than one hundred foods.
• Limit the amount of carbohydrates. Depending on how insulin resistant someone is, there is more or less room for whole grain products, starchy vegetables, fruit, and honey. To determine how many (or few) carbohydrates someone can handle, a continuous glucose monitor is useful. For many diabetes patients, this means they limit the amount of carbohydrates to less than 50 grams per day.

Even in the short term, food affects erections

The effects of unhealthy food choices affect erections not only in the longer term:

Fat Immediately after consuming a fatty meal, a temporary increase in arterial stiffness and erectile dysfunction can be measured. A fatty meal during a romantic evening can cause disappointments in the bedroom in the hours directly after eating due to diminishing erections (Murray, 2015).

Sugar A sugar-rich meal will immediately affect nerve conduction. A meal with a high glycemic index, rich in quickly absorbable sugars, leads to a significant decrease in nerve conduction in the hours after. A sweet dessert during the same romantic dinner can reduce the ease of reaching orgasm that same evening (Kikkawa, 2005).

7.4 Supplements

It receives little attention in Western medicine, but there are a number of supplements that have proven effective in treating erectile dysfunction. The most researched phytotherapeutic options are L-arginine, tribulus terrestris, and red ginseng.

• L-arginine is an amino acid that helps produce nitric oxide (NO) and therefore has vasodilating properties. By supplementing L-arginine, NO is also better available and erections can occur more easily. Especially in combination with citrulline and/or yohimbine, it seems to have a positive effect. For mild ED, L-arginine can replace PDE5 inhibitors; in more severe cases, it supports by enhancing the effect of PDE5 inhibitors (Chang Rhim, 2019).
• Tribulus terrestris is a plant that, among other things, increases the biological availability of testosterone. The main active substances in tribulus terrestris are saponins, especially protodioscin. Protodioscin can promote the production of nitric oxide (NO). A number of prospective placebo-controlled studies have shown that tribulus terrestris can improve erections and sexual satisfaction in men with mild erectile dysfunction (Kamenov, 2017, Santos Jr, 2014).
• Red ginseng is a root of a plant. Various RCTs demonstrate a positive effect of ginseng in treating both hypertension (Lee, 2017) and erectile dysfunction (Manafra, 2022). Ginseng contains ginsenosides, which promote NO resulting in vasodilation. Although ginseng does not work as powerfully as PDE5 inhibitors, the substance, like L-arginine, can be a natural alternative or provide support in the treatment of erectile dysfunction while simultaneously reducing cardiovascular risks.

All these supplements are easily available online.

8. Conclusion: what can you do with this knowledge?

8.1 For the patient

The erection is the antenna of your health. If erections deteriorate or morning erections stay away without a known condition or mental cause, do not let the problem persist. Although medication like Viagra can work for years, it does not treat the cause of erectile dysfunction. To treat the cause, it is important to examine lifestyle and especially the risks for cardiovascular disease.

Men with erectile dysfunction on a physical basis have 62 percent higher risk of heart attack, 39 percent higher risk of stroke, and 25 percent higher risk of death from cardiovascular problems. These risks are especially increased in younger men, smokers, and men with an unfavorable cholesterol profile. Erectile dysfunction should therefore be seen as an early warning signal for underlying cardiovascular problems. And these cardiovascular problems are often based on poor lifestyle choices.

If you have erectile dysfunction, put your shame aside and go to the general practitioner.

The general practitioner has a duty of confidentiality and will assess the risk factors for cardiovascular disease. The doctor can advise on how these risks can be reduced. You will not be immediately sent to the gym; small lifestyle adjustments can achieve a lot to both increase (healthy) life expectancy and address erectile dysfunction.

Having pleasurable sex with an erection is possible until old age, provided you take good care of your heart and blood vessels.

8.2. For the general practitioner

When presenting with erectile dysfunction, cardiovascular screening can be life-saving; in men with (mildly) elevated risk of cardiovascular disease, ED appears to be an important warning signal.

Treating ED without knowing and addressing the underlying cause is a procedural error since men with erectile dysfunction (for which there is no neurological, psychogenic, or surgical/oncological explanation) have 62 percent higher risk of heart attack, 39 percent higher risk of stroke, and 25 percent higher risk of death due to a cardiovascular event. The risks are especially increased in younger men, smokers, and men with an unfavorable cholesterol profile. Erectile dysfunction should be seen as an early warning signal for underlying cardiovascular problems. Addressing underlying poor lifestyle choices cannot be missing as part of the treatment.

A useful tool for having the conversation about lifestyle is the Lifestyle Wheel, available through the Dutch Association of Lifestyle Medicine. While typing the anamnesis, have the patient complete the lifestyle wheel, then jointly choose one or two points that the patient would like to work on.

A referral to a dietitian, physio-fitness, practice nurse, or Combined Lifestyle Intervention program or to one of the support groups of Je Leefstijl Als Medicijn can be an important next step. Little appears more motivating for men for a lifestyle change than the prospect of a future-proof and healthy sex life.

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Veelgestelde vragen

What are the main causes of erectile dysfunction?

There are four main causes of erectile dysfunction: 1) Vascular problems (poor blood flow to the penis), 2) Hormonal imbalance (such as low testosterone levels), 3) Neurological conditions (damaged nerves that send signals), and 4) Psychological factors (such as stress, anxiety, or depression). Metabolic dysfunction, characterized by insulin resistance and chronic inflammation, is an underlying factor that can cause vascular problems and hormonal imbalance.

Is there a connection between erectile dysfunction and cardiovascular disease?

Yes, there is a strong connection between erectile dysfunction (ED) and cardiovascular disease. Men with ED have a 62% higher risk of heart attack, 39% higher risk of stroke, and 25% higher risk of dying from heart-related causes. ED is often an early warning signal that occurs 3-5 years before other symptoms of heart disease. This is because the arteries in the penis are smaller (1-2 mm) than those in the heart (3-4 mm) and therefore show signs of damage earlier. Nearly 50% of men

How does metabolic dysfunction affect erectile problems?

Metabolic dysfunction causes ED in several ways: 1) It reduces the production of nitric oxide (NO), which is essential for relaxing blood vessels and enabling an erection, 2) It causes damage to blood vessels through chronic inflammation and oxidative stress, which limits blood flow to the penis, and 3) It lowers testosterone levels, which reduces sexual desire and weakens erections. Research shows that men with metabolic syndrome up to

What lifestyle changes can improve erectile dysfunction?

Effective lifestyle changes include: 1) Diet adjustment (reducing ultra-processed food, choosing foods with low glycemic load, limiting carbohydrates), 2) Regular exercise (moderate exercise reduces ED risk by 33%, intensive sports by 58%), 3) Adequate sleep for hormone balance, and 4) Stress management. In men with obesity, weight loss through diet and exercise can lead to significant improvements in erectile function, with 31

What natural alternatives to Viagra are there?

There are several proven natural supplements for ED: 1) L-Arginine: an amino acid that helps produce NO and promotes vasodilation, effective for mild ED or as a supplement to PDE5 inhibitors, 2) Tribulus terrestris: increases the bioavailability of testosterone and promotes NO production, 3) Red Ginseng: contains ginsenosides that promote NO and can improve both ED and hypertension. These supplements are available online and may be a natural

Which dietary pattern is best for reducing erectile dysfunction?

A low-carb diet appears most effective for improving cardiovascular risk factors associated with ED. This diet reduces insulin spikes that cause metabolic dysfunction. Specific recommendations are: 1) Reduce ultra-processed food, sugary drinks, and inflammatory seed oils, 2) Choose foods with low glycemic load (such as meat, fish, certain vegetables, nuts), and 3) Limit the amount of carbohydrates, especially for people with insu

How does low testosterone affect erectile dysfunction and what can I do about it?

Low testosterone levels reduce sexual desire and weaken the biochemical processes that support erections. Insulin resistance and obesity (especially abdominal fat) are major causes of low testosterone levels. To improve this naturally: 1) Lower your body weight, especially abdominal fat, through a healthy diet and regular exercise, 2) Reduce your consumption of ultra-processed food and foods with high glycemic index, 3) Ensure adequate sleep, since