The Science of Erectile Dysfunction and Unexpected Ways to Treat It

Mark Hyman, MD

Full Transcript

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Dr. Mark Hyman:
Coming up on this episode of the Doctor's Farmacy, it's all connected, right? It's not just ed, it's heart disease, diabetes, pre-diabetes, insulin resistance. It's all one problem. And one of the major ways that manifests is by damaging the lining of your blood vessels leading to less nitric oxide and hardening the arteries impaired blood flow. This is really a sign that you might have some cardiovascular disease, so you really want to pay attention if you're having erectile dysfunction because it's not just about sex, it's about your overall health.
Have you experienced a loss of libido recently? Are you carrying a little excess belly fat? Are you losing or having a hard time putting on lean muscle? What about an uptick in impotence? If you're a guy listening who's answered yes to any of these questions, then this episode is for you. And if you're a woman who's with a guy who's got these issues, it's also for you. Welcome to another episode of Health Bites, a special episode of the Doctor's Farmacy. I'm Dr. Mark Hyman, and today we're diving deep into a topic that's plagued many but rarely ever openly discussed, and that my friends is male sexual dysfunction, and today we're going to be focusing specifically on recile dysfunction. Now, a decrease in libido or a difficulty in achieving or maintaining an erection during sex are telltale signs of what we call ED or erectile dysfunction, and they can be kind of uncomfortable to talk about cure Aging and performance anxiety are part of the story, but believe it or not, erectile dysfunction is not just about sexual health.
It's intricately linked to your cardiovascular and metabolic health as well, and it's often the first clue of much bigger health issues. In this episode, we're going to explore the root causes of erect dysfunction and we're going to dive into the limitations of conventional approaches, the little blue pill, and how we can utilize the power of functional medicine by making changes to your diet, your lifestyle, and even trying things like supplements, peptides and hormone therapy and more. Now, why does this matter? Well, it's a major, major public health concern. An estimated 30 million American men are affected by ed. Now, people don't like to talk about this and it's uncomfortable to talk about sex. It's kind of a taboo, but you have to talk about it because it's a significant issue that impacts so many aspects of people's life. Now, your physical health and sexual health are totally connected.
Obesity, for example, is independently linked to erectile dysfunction. People have what we call a dad bod. It's becoming normalized among young men where you become a little pudgy around the middle. It's not normal. People with a high body mass index or who are overweight tend to have lower testosterone. I'm going to explain why that is and how you can reverse that. Also, your emotional health and wellbeing are tied to your sexual function. People are stressed, have more trouble with sex, quality of relationships, and intimacy also plays a big role, and it's so common. We're going to talk about how common this problem is. In the Massachusetts male aging study, ED was the most common sexual health problem in 1995. It affected about 150 million men worldwide, and that's projected to reach 300 million next year. The prevalence, in other words, the number of people in the population, men particularly obviously, who have this, is about 52% of men between ages of 40 to 70.
That's a lot of guys. And what does it mean? Well, erectile dysfunction or ED means the inability to have or maintain an erection. Now, as you get older, it's more common. 40% of men are affected at age 40. 70% of men are affected at age 70. A recent study published in the Journal of Sexual Medicine found that one out of every four men under the age of 40 is affected by ed. Now, that's shocking. You're talking about guys under 40 and that's about 25% of men under 40. There's also a strong relationship between testosterone and particularly testosterone deficiency and erectile dysfunction, and was shocking, and I see this in my practice and it kind of blows me away honestly, young guys have very low testosterone. I mean, what you'd see sometimes I see in a 90-year-old I see in a 20 or 30-year-old, and about 30% of men age 40 to 79 according to the American Journal of Medicine article experience low testosterone.
Now, researchers show an increased prevalence that's associated with aging. That's common, but it's also associated with other diseases that are causing the erectile dysfunction. It's not just the penis, it's the problem. It's the rest of your biology and your body that's not operating properly. So obesity, diabetes, high blood pressure are all clues that something's awry with your hormones, your metabolic health, and likely soon with your sexual health. In fact, there's a phenomenon that's called andropause or male menopause, which is sort of a gradual decline in testosterone after the age of 30, about one to one and a half percent drop in testosterone a year. Now, that doesn't mean it's a normal or it has to be. I mean, I have a guy who's like 62, who's got a testosterone like 900, which is what you'd see in a healthy young 20-year-old or 18-year-old rearing to go all the time and promise you he's rearing to go all the time.
It doesn't mean it's normal, right? It means it's common. It doesn't mean it's normal. Normal is just means the average in a population. So it's normal, but it's not optimal. And so you have to understand how you want to get to optimal ranges by addressing the root cause of the problem. And there are a lot of ways you can naturally increase testosterone. Now, there's a strong relationship between low testosterone and erectile dysfunction, and the reason is that low testosterone is a clue for other problems. It's a clue that you have poor metabolic health. And it's so common, and I've talked about this so many times on podcasts, but 93% of Americans have poor metabolic health, and that is what leads to erectile dysfunction. I'm explaining exactly how we're getting into the science, and by the way, all the references, everything I'm saying is in the show notes.
You can go dive deep and you can click through, read the articles yourself, but it's a sort of scary picture in America now with increasing obesity, diabetes, and poor metabolic health. But this leads to what we call endothelial dysfunction. Now, what the heck is that? Your endothelium is a lining of your blood vessels and the health of your blood vessels determines your sexual health and your cardiovascular health and your cognitive health and pretty much everything. In fact, that's one of the problems with C and with long covid, which we've talked about is this massive damage to the lining of our blood vessels. And that is what happens with covid that drives so many of the pathologies. Now, men who have low testosterone are 38% more likely to die of a cardiovascular tent that's like a heart attack or stroke. Now the question is why do we see low testosterone?
Well, it has to do with what we call insulin resistance. Now, I've talked about this for almost God scary now to say 30 years. It is something I paid a lot of attention to. I've written many books on this. Insulin resistance is the scourge of the modern world, like TB was everywhere before, and it wasn't even as prevalent as insulin resistance. We're talking about 93% of Americans having some poor metabolic function and that some degree of insulin resistance somewhere on the spectrum from optimal metabolic health, blood sugar regulation, insulin sensitivity to a slow decline in insulin sensitivity, more insulin resistance, pre-diabetes type two diabetes. It's all a spectrum. And this leads to low libido or low sexual desire, low desire for sex for masturbation. It's influenced by low testosterone and basically, I'll give you the punchline here, but as your belly grows bigger, your testosterone gets lower, big belly low testosterone.
Why do you have a big belly? Because you deposit fat or VAT, visceral adipose tissue. And this visceral adipose tissue is, excuse me, my French here, a storm of hormonal and inflammatory chaos. Essentially, it causes an increase in what we call adipose cytokines, and we'll talk about why inflammation plays a big role in messing up hormones, particularly testosterone, and it also causes an increase in estrogen for men, lower testosterone, and that leads to sexual dysfunction. So it's a big issue. And so this low sex sexual desire, low sexual function is influenced by this low testosterone, but it can be influenced by other things like stress, anxiety, and many other chronic diseases. Now, a 20 study of more than 12,040 5-year-old men found that about one in 20 reported low sexual desire, which is a lot when you think about 45-year-old guys, they should be still rearing to go.
Now, some desire for sex drops naturally with age, but it doesn't go away even in your sixties, seventies, or eighties. I mean, Mick Jagger had a kid at 75. Picasso had a kid. This was in the pre Viagra era at 80 years old. So it's not impossible to keep going for a long time. Now, what's the problem with our conventional approach to dealing with erectile dysfunction? It's not just as simple as giving people Viagra or salis. It's really about taking a deep dive into the why. What's the cause? Now, often your hormones are not tested. It's amazing how many people go to the doctor and never get their hormones tested. Don't get testosterone free testosterone, estrogen, FSH, lh, all the important biomarkers that are critical to understand what's going on with your hormonal health. Also, doctors don't test for insulin resistance. I was recently on a conference call with some of the top scientists and doctors at Quest Laboratories Diagnostics, which is one of the biggest testing laboratories in the country, probably the biggest.
And I said, how many doctors are testing for insulin, fasting insulin? And they're like, well, it's pretty low. Maybe 1% of our lab tests are for fasting insulin that are ordered by doctors. Now, this should be a standard test that everybody gets as part of their annual checkup. It is the most important test, determine your longevity, your risk of heart attacks, cancer, stroke, dementia. It's so critical. The other test that they almost never look at is what we call lipoprotein fractionation. I've talked about this on other podcasts. We'll link to those in terms of how to look at your lipids. But the cholesterol test that doctors do now is really so outdated. It's like looking at things with, I mean, listen to your heart with a stethoscope instead of looking at it with an echocardiogram or an MRI, it's kind of old fashioned and it gives you some indication of what's happening, but it's really not the gold standard.
And I asked, again, I asked these experts in cardiovascular diagnostics at Quest. I said, well, what percent of tests out there are for the lipoprotein fractionation, which means the quality of the cholesterol, the particle number, the particle size, which gives you a much better indication of your insulin resistance and your risk factors? And I said, what percent of your tests are for this 21st century cholesterol panel? And they're like 1% or less than 1%. And so that means 99% of people are not getting the right cholesterol tests, which prevents them from really understand what's going on with their metabolic health. Now, these tests, hormone tests, insulin, lipoprotein fractionation, A1C, many, many other things. We do test at function health. Now, I'm a co-founder of Function Health. I'm the chief medical officer and I believe that people should have access to their data, and it's very empowering to know what's going on.
We found all sorts of things. We've had over 25,000 members to date at the recording of this podcast. We've had over 3 million biomarkers tested, and you can get over 110 biomarkers for less than $500 and you get testing twice a year and you can track what's going on. You can see changes based on your interventions, lifestyle, diet, supplements, and then actually be empowered with the right information and knowledge and education about what to do about these numbers. Anyway, back to the topic at hand. The other thing is most doctors don't really deal with lifestyle, weight, diet, exercise, sleep. It's considered soft medicine, but the truth is, it is the most important thing in determining your risk factor in your health. Now, what do they do if you come in complaining of erectile dysfunction? Well, they give you the little blue pill that was a blockbuster, and that was an accident.
That pill was actually designed to treat high blood pressure, but it had a side effect that a lot of the people in this study noticed and they liked the side effect. And so the drug company got very smart and they were like, well, this is a lousy blood pressure pill, but it's a great pill for erectile dysfunction. And before that, it was tough for guys. They were vacuum pumps or were you can have a penile implant. There was sometimes revascularization. You can do a transurethral kind of thing called muse. We used to recommend. It's pretty scary. You put a little pellet in the end of your penis, it's painful. There's injections, which you can use that work, but they're painful. But when Viagra hit the scene in 1998, within six months of approval, they were over 5.3 million prescriptions written, and then the prescriptions have just tripled in the last decade.
So there are a lot of other drugs, s la tendra. They work for different reasons and different people different ways, but then they're not bad to use. In fact, they can be helpful. They may be protective against Alzheimer's, I read recently. So they increased blood flow, they increased circulation, they increased nitric oxide. We're going to talk about all that. And those are not bad things, but more and more people are actually using this. Even younger people are getting it for off-label use. They secretly take it. They're embarrassed. They have performance anxiety. Maybe they have erectile dysfunction when they're younger, but let's talk about how these drugs work and what is the physiology of actually having an erection. When you have sexual arousal, it causes the release of nitric oxide, which is a good thing in those cells that we call that line your blood vessels called the endothelial cells and they're in your penis.
And so basically you get increased blood flow because it helps to activate something called guanylate cyclase, an enzyme you don't remember it, promise no test on this. And that leads to an increase in something called CGMP. Now that particular thing causes the relaxation of smooth muscle cells or it causes your muscles to relax, and that leads to the dilation of the blood vessels in your penis, and that increases blood flow and that leads to an erection and then it gets trapped inside the penis in the corpus cavernosum, which then maintain the erection and have fun. Now, after you ejaculate, there's an enzyme called PDE E five or phosphodiesterase type five, and that degrades the CG MP. So a thing that keeps your erection going, now that causes the smooth muscles to contract again, and that reduces blood flow to the penis and that ends the erection.
Now how Viagra works, sildenafil and Cialis s dil, how they work is they inhibit this PDE five. They inhibit five phosphodiesterase, which is this enzyme that degrades CG MP. Now that prolongs the effect of this particular compound. CG MP keeps the blood vessels constricted in your penis and it helps maintain the erection for longer, which is fun and great and it's no problem. But side effects are common about over one in a hundred people you get mild headaches, dizziness, flushing, congestion, and sinus basically having sex. You're congested, runny nose and have a headache. It's not so much fun. Always can cause back aches, muscle pain, sometimes it can cause low blood pressure. It was designed for a blood pressure pill. It can rarely cause a painful erection to last a long time, like over four hours, and that's called priapism. And that can damage your penis and it can cause all the heart issues.
Rarely it can cause vision or hearing loss, but that's very rare. Now, if you're taking drugs like nitrate drugs, if you have angina, you have heart disease, if you have liver issues, you don't want to take them. So they're not bad. But let's talk about maybe getting to the root cause, which is exactly what functional medicine's about. It's not about treating the symptoms, it's about the cause. So how do we get to the root cause? We have to really understand the full picture. And so we have to look at diagnostics, and I think it's really important to do a proper testing so you understand what's happening with your biology, and that's really why we've created function health, why I'm the co-founder and chief medical officer because all the tests that I'm going to mention right now are all available@functionhealth.com and you can sign up, you can just get in there and get your test done and right, there's a wait list, but we can get you off the wait list if you use the code, Dr.
Hyman. Now the first thing you want to know is something called sex hormone binding globulin or SHBG. Now this is important because it regulates the amount of free hormone free testosterone. It's a protein made by the liver. It binds to testosterone and estrogen and it basically makes them inactive. So it's sort of like a reservoir of extra hormones when you need 'em. Also, albumin can bind to estrogen and testosterone, but not as well, and that's something it's normally in your blood. Now when you have insulin resistance, high insulin, the liver suppresses the sex hormone binding lab and that leads to potentially more free testosterone and that can kind of screw up normal hormone balance. And we often see an increase in prostate cancer and in large prostates in guys who have insulin resistance and big bellies, and that's concern. Inflammation on the other hand, can also increase sex hormone binding globulins.
So why does that matter? If there's inflammation, you get higher binding glot means you get less free testosterone, and that's what matters. That's what does the job. And so when you have less free testosterone from any source of inflammation, you can end up in trouble. So sometimes guys, even with insulin resistance tend to have the high sex hormone binding globulin because of the belly fat, which is basically a factory of inflammatory molecules. Now, what does testosterone do? Well, it increases your sex drive or libido. It is involved in the production of red blood cells, which can sometimes be an issue if you, after you're taking testosterone, it is involved in sperm production mood, so makes you happy, or if you take too much, it can make you angry motivation. So it's very important for motivation in men and women. And by the way, women have a lot of testosterone too.
It's really critical to build lean muscle mass, which we'll talk about and why that's important for sexual function. It helps energy or cognition recovery from exercise or injury, and it improves insulin sensitivity, so it's good. Now, free testosterone is the act of kind. It's not bound to the sex hormone binding globulin. It's the active form of testosterone and it's about less than 2% of the total amount. Now the optimal range, and these are all going to be in the show notes, you have to memorize them now, but you can check it out in the show notes. The optimal range is over 30 picograms per deciliter. Now you want to look also at the total and the free, so you want to look at both. Now, if you look at the total testosterone, the ranges are kind of screwy because how we develop reference ranges in America is based on the average or normal in a population.
So if you're a martian, you land in America, it's normal to be overweight because 75% are overweight. It doesn't mean it's optimal. So the ranges that we see are not the really optimal levels, but you see ranges of 200 or 300 nanograms per deciliter, but the range should really be over 500 and you have to look at the combination free and total, but it can be up to a thousand or more. And I think it's important to sort of look at what the symptoms are, what the person's overall health is, and look at the free and total and you get a sense of how much is going on there. Now, even if your total can be normal, you can still have issues of low testosterone because your sex hormone binding globulin is high. In other words, there's not enough free testosterone. So I see that very often in my patients.
Also, the other hormone that guys have, which you probably may not know, is estrogen or particularly estradiol. Now, men and women both have estrogen and it has a lot of important functions. It does affect the libido, it affects erectile dysfunction and sperm production. It's also important for bone health or brain function and also for nitric oxide production. You don't want it too high or too low. And often guys who have big bellies have basically something called aromatase in their fat, which turns testosterone into estrogen. You don't want that. You don't want testosterone turning into estrogen. It's not nice. The other hormone you want to look at is the pituitary hormones and the hypothalamic hormones. Your pituitary hormones are really important. We call LH and FSH luteinizing hormone and follicle stimulating hormone. Now, it's kind of a weird thing because follicle stimulating hormone sounds like it's for women's follicles that produce eggs, but it's also active in men.
So in men, the way this works is your hypothalamus, which is kind of way in the top at your brain. It's kind of the master control center creates a hormone called gonadotropin releasing hormones. So gonadotropins essentially are the hormones that make gonadal hormones. So it's like stimulates the pituitary to produce the gonadotropic hormones, which are hormones that stimulate the testicles or the ovaries, which may be the case in women to produce more hormones. So lh, our luteinizing hormone, which again, it's kind of a weird name because it basically luteal phase of the menstrual cycle. It's named after women's hormones, but it really affects men too. So LH affects a cells in the testicles called the lighting cells. Now these cells produce testosterone, so higher LH will increase testosterone. FSH affects different cells in the testicles called the oli cells, and they lead to sperm production.
So lh, testosterone, FSH, sperm really important and it's important to assess fertility, what's going on with somebody. It's really important. You may not know what's going on and you might have low testosterone, but you could have a pituitary tumor for some reason. So you got to check all these things. Also, we look at prolactin, another hormone we check with function health. Again, not usually checked. Prolactin is another pituitary hormone that is involved in many things including lactation. That's what I call it, pro prolactin. But it can be high in certain benign tumors that grow in the pituitary, which are not that uncommon. And the treatment usually is surgery. Sometimes there's drugs that can be treated. We also need to look at inflammation and we look at something called H-S-C-R-P or high sensitivity C-reactive protein. Inflammation is such an important factor in our overall health and aging and longevity.
High inflammation is a root cause of sexual dysfunction, whatever's causing it. Now many things can cause it, including our diet. That's the number one cause, really, sugar, starch, processed foods, all that's driving inflammation, our gut microbiome, environmental chemicals, heavy metals, toxins. There's also endocrine disrupting hormones, which are really concerning to me, and I see a change in the population in the birth rates of men and women. We see changes. Fertility, we're going to talk about that on another podcast, and I think a lot of it has to do with these forever chemicals that are petrochemicals that are in the environment that don't go away. We used to have dioxin and PCBs and DDT, they're still around, and now we have other plastics and other pesticides and herbicides. These are highly dangerous and they're toxic at very small levels. So oh, you're like, ah, I'm so out.
I'm not getting that much this or that, but you are cumulatively you are over your lifetime. And then they've done fat biopsies of people and they found pretty much every human is a toxic waste tub and we probably wouldn't be safe to eat if we were food. Other hormones are important as well. Leptin, again, something we check on function health that mostly doctors don't check, but leptin is the appetite suppressing hormone. But sometimes when you have insulin resistance, you also get leptin resistance, so you see high levels of lectin and that leads to low testosterone and suppressed lh. So that's concerning. In one study in the Journal of Clinical Endocrinology, they looked at three groups of men and they found that those with higher leptin levels, mostly due to leptin resistance had a higher body mass index, so they were heavier and they had lower levels of testosterone.
So it's an important thing to check adiponectin. Another important hormone, it's an anti-diabetic hormone. It's an anti-inflammatory hormone. It prevents heart disease, and it's often low in insulin resistance and inflammation, obesity. So you want to check a ab bendectin again, and we check that as part of our panel with function health. Again, it's not usually checked, but it's important because if it's high, it's good, and if it's low, it's bad. We also check your fasting insulin and he mingled one A, one C because insulin resistance is really, I would say the majority of the causes of erectile dysfunction as we get older. And at leads to, like I said, low testosterone, higher belly fat, more estrogen, abnormal cholesterol, more inflammation, low sex drive, it's just not a good thing. And your insulin, you really want between two and five. Now most reference ranges are 15 again, because the average American is unhealthy and overweight.
So the reference range is wrong, basically, is what I'm saying. So in functionality, we talk about what are the current reference ranges and what are the optimal ranges. Also, you want to look at stress hormones like cortisol and DHA, and you also look at cardiovascular testing and not just a regular cholesterol panel as I mentioned, but looking at, we call lipoprotein fractionation. And this really looks at cardiovascular risk, insulin resistance, really important. And I think if you don't look at the right cholesterol panel, you're basically just living in the 20th century and not the 21st century in terms of cardiovascular health. Thyroid also really important and we have to look at thyroid properly, not just the way doctors do it on their traditional panel or the TSH, you have to look at the TSH, the free T three, free T four, even thyroid antibodies, which we all check on function health.
And they're really important because thyroid function, if it's low, will cause a low libido, a low sex drive, a low mood, and may be as simple as taking thyroid and also will influence sex hormone binding allotment. Now, none of these tests are hard to get or expensive, but unfortunately your doctor's probably not doing most of them or doing them properly. So that's why again, I co-founded Function Health and encourage you to check out your own tests so you can see what's going on and be empowered with your own health data and be the CEO of your own health. Alright, so what are the root causes of sexual dysfunction? Well, aging, that's a big one. Age basically is the strongest variable associated with every age-related disease, including erectile dysfunction. As you get older, you lose muscle, you don't exercise as much, you get more insulin resistant, and so you get lower testosterone, you get lower free testosterone, you get higher LH because your body's trying to make more, but you're just not doing it.
So you get lower testicular function. And in a study published in JAMA, about 1400 men, they looked at men between 18 and 59 and they found that it was an increase in erectile dysfunction with age, not surprising, it was an older study, it was published in 99. They also reported a decrease in sexual desire with increasing age men in the oldest cohort who were basically 50 to 59, which is young to me because I'm 64. They were three times as likely to experience erection problems and to AB report low sex desire compared with men who were 18 to 20. So it's common as we get older and it was likely among men in poor health, poor physical health and poor emotional health. It's important. And as you get older, you get more in these what we call comorbidities, which I hate that term. Comorbidities essentially it means you got a bunch of different diseases altogether like high blood pressure, high cholesterol, heart disease, diabetes, but they're all connected, they're all the same thing.
And we're seeing just massive rates of obesity in this country. 75% of us are overweight. Basically 40 plus percent have obesity, not just being overweight. And this all leads to cardiovascular disease. And what is going on in cardiovascular disease is an endothelial problem. It's endothelial dysfunction and it's basically hardening of the arteries. And guess what? The arteries that are affected first are the small blood vessels and guess where they live in your penis. So it's kind of the first telltale sign that something's wrong and it can often be the first sign of heart disease and people are not really aware of that. And by the way, smoking is a massive disruptor of endothelial function, and you might remember those ads. Well, you probably don't because most people, listeners are younger maybe, but I'm old. And there were those Marlborough ads where they showed basically the Marvin man with a cigarette in his mouth that was kind of limp and falling over, and that's sort of how they basically got people to stop smoking, but it's a big factor of smoke.
Now what endothelial dysfunction, let's talk about it a little bit. Basically these cells, if they don't work properly, stop producing this important molecule called nitric oxide. Now, what is nitric oxide? It's not nitrous oxide, which is laughing gas, but it's essentially gaseous molecule that is made inside your body, in your endothelial cells, in your blood vessel cells, and it's a signaling molecule. It's a vasodilator, it's an antioxidant, it's an anti-inflammatory. It increases blood flow, it helps lower blood pressure, and I had a scientist, Dr. Louis Iro on the podcast who won the Nobel Prize in 1998 for his discovery of the role of nitric oxide in the cardiovascular system, and he's amazing. He was 80 years old, he was going strong and he's great, so I would encourage you to listen to that if you want to learn more about this. But these endothelial cells line every inch of your body, including your penis and the corpus caper, noosa muscles, and they're very active in that lining.
It's the main site of nitric oside production. It essentially acts on the corpus cavernosum, as we mentioned, to increase the CG MP, and that leads to erections. When that endothelial lining is damaged, it leads to male sexual dysfunction or ed. Now it's all connected. It's not just ed, it's heart disease, diabetes, pre-diabetes, insulin resistance. It's all one problem. And one of the major ways that manifests is by damaging the lining of your blood vessels leading to less nitric oxide and hardening the arteries impaired blood flow. And this is really a sign that you might have some cardiovascular disease, so you really want to pay attention if you're having erectile dysfunction because it's not just about sex, it's about your overall health, particularly your cardiovascular health and metabolic health and your risk of stroke, heart attack, dementia, all of it. It's not really a local problem.
It seems local, but it's not local. It's systemic and it's a telltale sign of basically endothelial dysfunction. If you're having erectile problems, it's like the canary in the coal mine for more life-threatening conditions, the canary the miners had in the coal mine, and when the air was bad, the canary would die. They need to get out. Well, if you got this, it's time to get out and change your lifestyle. We're going to talk about what to do to fix endothelial dysfunction. Now, what's the biggest cause? As I've been saying, it's insulin resistance. It's our crappy diet, it's our processed food diet. I mean, I watched the Super Bowl recently and there was 11 commercials for junk food in the first half. I didn't watch the second half. I just got so disgusted and anyone, Ben anyway, but basically in insulin resistance is really the big driver and that leads to bad cholesterol.
We call atherogenic dyslipidemia, which is the type of cholesterol that causes heart disease, it causes metabolic dysfunction, prediabetes, diabetes, obesity. It's basically what we're all suffering from and dying from. When you're having insulin resistance, you have more oxidative stress, more inflammation that leads to more damage to the blood vessel walls, more endothelial dysfunction and more heart disease and all of it. So obesity, basically, you've got this big belly fat and that even if it's not that big, by the way, it doesn't have to be a lot. It leads to the development of inflammatory cytokines, which are called adipose cytokines or adipokines cytokines you probably remember from covid, and that leads to vascular information and that lowers testosterone. So what is driving this? Well, if you know me, the answer, our diet, right? 65% of our diet is ultra processed food. We eat about 133 pounds of flour and 152 pounds of sugar per person per year.
I mean, the average American consumes about 22 teaspoons of sugar per day, the average kid about 34 teaspoons, which is ridiculous. I mean, there's no biological requirement at all for sugar, none and none for carbohydrates. By the way. What's really scary is that according to the CDC, about one in three Americans have pre-diabetes. I think it's way more. If you look at the data on the metabolic health stuff, I always talk about the 93% of people who are metabolically healthy. That means they're somewhere in the continuum, might not meet the strict criteria for pre-diabetes, but they have some metabolic dysfunction. So it's probably more like two even maybe 300 million people who at some level have an issue. Even if you're not overweight, there's 75% overweight, but if you have belly fat and you're not overweight, it can still be an issue. If you're under lean or under muscle, it's an issue. So it's really a big problem. And then about almost 40 million Americans have type two diabetes. Now, people who have ed, I mean it's really common to have pre-diabetes. 40% of patients with erectile dysfunction have metabolic syndrome is probably more. I think again, how it's defined.
I think obesity is an independent risk factor for erectile dysfunction. About 80% of men have a higher BMI, meaning they're overweight. If your BMI is 25 to 30, which is sort of mildly overweight, you have a one and a half times risk of having it. If you're over 30 BMI, you have three times higher risk of sexual dysfunction than the general population. That's 300% increased risk of having erectile dysfunction. If your body mass index is over 30, and by the way that accounts for 42% of the population, it's a lot of people, and if you have poor glycemic control, poor blood sugar control, you're about two to five times more likely to have a risk of erectile dysfunction. So what do we see? Often we see low testosterone and we see high estrogen in these men. And what are the symptoms of low testosterone? You might be listening carefully because you want to know if this is you, but it's a big deal and it really affects quality of life significantly.
It leads to low libido or sex drive, erectile dysfunction, as we mentioned, it can lead to loss of body hair and even facial hair. The loss of muscle and fatigue, it can lead to weight gain, depression, anxiety, and this is commonly what happens. We get higher estrogen and lower testosterone in men. It happens as we get older a little bit, but it doesn't have to, but it really has reversible causes like insulin resistance, obesity, stress, too much alcohol, pot or cannabis. It can be a pituitary issue, a hypothalamic issue. It can be leaky gut. Now, it can be a lot of gut. By the way, your microbiome biome plays a big role in your hormones. You don't have time to get into that today, but it's a big factor. Now also, you can have too much estrogen and as men age, testosterone goes down a little bit and estrogen increases, but not at the level we're seeing.
And often we see high estrogen in men, and that's concerning when we see, I've seen men with breast cancer. It's a big issue. And so low testosterone and high estrogen increases the risk of erectile dysfunction, even unrelated to age. It can be caused by alcohol. By the way, alcohol number of beer bellies, that's the same thing, and particularly beer and particularly because it's very high in carbohydrates and sugar, a diet, he starts with sugar will cause this. And so if you have it, you just look down, look down and look at your belly. I always say use the mirror test. It's very cheap. You just look in the mirror, jump up and down. If your belly jiggles, you probably have it right? You can use a waist to hip ratio. You can measure your waist if you're a man, your waist divided by your hips, basically around your belly button.
Biggest point around your hip's, biggest point with a tape measure, and if it's less than 0.9, you're good. If it's over 0.9, you're in trouble for a woman. If it's over 0.8, you're in trouble. If it's less than 0.8, you're probably okay, but it depends on where that fat is too. So it's not always just about the tape measure and the clues are there. I mean we've talked about it. It's all this insulin resistance, diabetes, and what happens when you have high insulin, which is an epidemic in this country, is it stimulates this enzyme that I mentioned earlier called aromatase, and that increases the conversion of testosterone to estrogen. You're basically making estrogen in your body. Even if you don't have ovaries, you're making it in your fat tissue, and that's concerning. A few other things to mention before we get into the treatment. Sleep issues, sleep apnea is a big factor, very underdiagnosed, very common, and that will lead you to lead to produce less nitric oxide, low testosterone and erectile dysfunction, people basically don't breathe at night.
They stop breathing, they get CO2, it screws up their sleep, it increases cortisol. That decreases testosterone. It's a mess. If insomnia is an issue for you, it also might be a factor in sexual function. So you got to get that sorted. And I have a sleep master class. We'll link to it in the show notes. Psychological factors also play a big role, even independent of the insulin resistance, depression, anxiety, chronic stress. I mean, you don't want to be making babies when life's stressful, right? Basically disrupt your whole hypothalamic pituitary gona axis. Lifestyle factors play a big role being sedentary, not exercising. Big factor. Substance abuse, alcohol, particularly opiates. I think Andrew Huberman Hass talked a lot about this on his podcast. Alcohol use is a big factor. Alcohol increases. Aromatase makes you have more estrogen. It increases desire, but decrease the ability, particularly when you're drunk and you get a beer belly, you get hair loss.
So tobacco, we mentioned smoking. Just forget about it. It's not even worth talking about. Everybody knows it's bad. Certain medications, by the way, can mess up your libido like a lot of the antidepressants that'll make you more depressed, right? The SSRIs like Prozac, Zoloft, they lead to lower sex drive. They can kind of make you numb to life. Insects. Long-term use of steroids may do it. Opioids also a drug that's used commonly for male baldness called Finasteride Propecia. It inhibits an enzyme called five alpha reductase, which reduces a form of testosterone called DHT, and that's a problem. So a lot's a lot, and you might be depressed and I get it, but the good news is this is super treatable and super fixable, and if you're systematic about it, you can actually get your sex drive back and your sexual function back. And with functional medicine, it's really about dealing with the root causes and you start with lifestyle, diet, lifestyle and basic supplements.
So what should we do? Well, basically we should be focusing on our lifestyle, what we're eating, our sleep stress, exercise, getting our weight under control and taking the right supplements. Now, if you do all that stuff, and we're going to get into the specifics of those, if you do all that stuff and it doesn't get better, then you would digitally consider some alternative therapies that are being used out there. And there's a lot of good therapies that are around. Peptides are actually being used and can be very helpful. You probably may not know what peptides are, but you've heard of ozempic, I'm sure you've heard of insulin. I'm sure those are peptides. Those are little tiny mini proteins the body uses to regulate everything, including hormones, so you can actually take them. There's shockwave therapy, which is using ultrasound and shockwaves to damage the penis a little bit and increase blood flow, circulation repair, recruit stem cells.
That can be helpful. The testosterone placement therapy can be helpful or hormone optimization therapy in select patients', stem cells have been used and they're expensive, but they can really work. Also, pelvic floor dysfunction, we haven't talked much about that, but a lot of guys and women have dysfunctional muscles in their pelvic floor that can lead to erectile dysfunction. And physical therapy can be very helpful, and that can be exercises, it can be internal massage that can help relieve some of that. So it can be something to explore if you're having trouble. So what should you be eating to optimize your sexual health? Well, guess what? It's you eat for everything else, right? Whole foods and anti-inflammatory diet should be high in antioxidants, high in phytochemicals, polyphenols, lots of fiber. Like one study in young men, aged 18 to 40 found that men with ed consumed a lot less vegetables and flavonoids, basically phytochemicals compared to the control group that didn't have ed.
Even after adjusting for age and body mass index, it was found that consuming flavonoids, which are basically from these phytochemicals from colorful plant foods, about 50 milligrams a day, reduce the risk of ED by 32%. Pretty good just from eating vegetables. So eat your vegetables, flavones or your class of flavonoids, they're especially linked to he erectile dysfunction. So where do you get them? Partially celery, onions, oranges, thyme, oregano, basil. You basically eat your way to better health and sexual health. Actually men without Ed tended to eat more of these things and they eat more fruits and vegetables. They eat less dairy, they drank less, they smoke less compared to men who have erectile dysfunction. No surprise. The study that was then suggested that increasing the consumption of fruits and vegetables and flavonoids can lower the risk of ED and young men. So basically eating fruits and vegetables can lower your risk.
In 2020, a study in JAMA of 21,500 men from the health professionals follow-up study, they found a significantly important link between adherence to a healthy diet as measured by basically a higher Mediterranean diet score and a risk of ed. So the healthier diet overall, good olive oil, nuts and seeds, lots of fruits and vegetables, whole grains, all can be helpful. And that's whole grains. Not whole grain bread, but whole grains. Men who were younger than 60 with the highest Mediterranean diet score had a 22% relative risk reduction, meaning they were 22% less likely to have erectile dysfunction. And those between 16 and 70 actually saw an 80% reduction. So even as you're older, you eat more fruits and vegetables, it works. Also, you want to eat fat because guess what? How do you make testosterone? You make it from fat, particularly cholesterol. Ooh, cholesterol, that's bad.
No, not necessarily. You need cholesterol for everything in your body, particularly your cell membranes, your brain function and your sex hormones and many other hormones. Also, mono and saturated fats are great. Olive oil, avocados, olives, all great. Lots of omega threes are anti-inflammatory. The smash fish, I call 'em sardines, macro anchovies, herring salmon, eating, lots of even plant-based omega threes like walnuts, chia seeds, hemp seeds are fine, saturated fat. Now, saturated is not for everybody, but for particularly for people with insulin resistance, it can be very good, particularly from generally raised meats from grass fed butter, ghee, eggs, coconut oil, and actually you can increase your testosterone levels by eating fat. Now you have to keep an eye on your lipids. Everybody's different. Some people can tolerate them, but we can. So keep an eye on it and you can use function to track it and see what happens.
But it could be an experiment like change your diet, add more saturated fat, see what happens in your testosterone. I noticed when I started eating more saturated fat, my testosterone levels went way up. So you can change it by your diet, getting quality protein, really important. Regeneratively raised grassfed meats well called seafood. Past raised chicken. I mean, I've written a lot about this. My peak diet book, you can check out food. What the heck should I eat? Also, I don't eat so much sugar star, eat low glycemic carbs, vegetables, things that help blood flow, circulation, vascular health, berries, nice starchy veggies, leafy greens, beets, dark chocolate, that's good. Mackerel, salmon, sardines, walnuts, chia seeds, watermelon, pomegranate, garlic, citrus foods, tomatoes, lycopene, great for the prostate, ginger, turmeric, all these are really awesome foods that help to improve your overall phytochemical content and that help in blood flow and circulation.
So the ones I mentioned are particularly around blood flow and circulation. So you can eat your way to better sex is basically what I'm saying. Also, of course, avoid all the bad stuff, right? Ultra processed foods. Sugar. Sugar sweetened beverage is the worst. High fructose corn syrup, all the conventional dairy products, conventional meats have lots of hormones. Antibiotics don't eat a low fat diet. It's bad news for most people. It significantly decreases the total and free testosterone. Avoid toxins like big fish, mercury containing big fish like tuna, swordfish, halibut and so forth. And sea bass are bad. And also alcohol, not great. I think we're coming more and more to understand that alcohol even a little bit is harmful. And so you can have it occasionally I do, but I probably wouldn't have it more than once or twice a week. Definitely there's no health benefits.
So just get that out of your mind. It's basically a poison. As Paracelsus said, the dose makes the poison while I have a glass of wine occasionally when I go out for sure, but it's definitely not a habit. Also, recreational drugs do contribute to erectile dysfunction. Things like opioids, cigarettes, marijuana concern. And of course we mentioned the toxins. You want to try to reduce your exposures. All the endocrine disrupting chemicals, the plastics, deodorants with aluminum fragrances, basically everything. There's a great website. I'm on the board of the environmental working group. It's ewg. You can go to ewg.com and they have great ways to reduce your exposure through skincare products, household cleaning products through foods, really, really well. Researched databases, so you can choose products that aren't going to kill you and pollute you basically. Obviously lifestyle, really important exercise is key. Exercise helps with insulin resistance, it helps with improving muscle mass, reducing body fat, helping inflammation.
It's just all around the best thing. So about 150 minutes a week, three or four times a week, you can do aerobic exercise, walking, biking, running, rucking, swimming, whatever you love tennis, I just do something, right? Also hit training. That's when you do high intensity exercise and do that at least once a week. So like sprinting, weightlifting, really important, at least three times a week, 20 minutes, 30 minutes. You can use bands, you can use weights. It's critical. Why? Because when you do strength training, you're actually building muscle. And that will improve insulin sensitivity. It will increase testosterone, particularly loading large muscles like your glutes and your thighs, your hamstrings. It increases testosterone and also growth hormone. If you have sleep issues, fix those. Sleep apnea is important to fix. Very common. When you lose weight, it'll help. But using the dietary things we talked about in the lifestyle, things that should help.
But basically you want to fix sleep apnea and you might need a C pap, you might need testing. You might see a doctor, but get that checked out. Mouth taping can be helpful. People are really into it. You can use 3M micro report tape for sleep taping, mouth taping at night or there's mouth tape. Also pay attention that you're a biological creature, right? You're not a machine and you should follow a circulating rhythm. Wake and sleep at the same time, at least seven hours of sleep a night. Rhythm matters, and particularly testosterone peaks in the morning and it goes down during the day. And when you screw up your wake sleep cycle, it can affect testosterone. It can affect your endothelial production. So just get a rhythmic rhythm, get sunlight early in the morning, which helps program your circadian rhythm and your pineal gland. Don't be in bright lights at night.
Dim the lights, sleep with blackout curtains. Amazing, amazing adventure. I love them. Try to reduce blue light an hour before bed. Do stress relief techniques. Again, stress plays a big role in erectile dysfunction. Meditation, breath work, active relaxation, higher cortisol stress, lower testosterone. Now what about supplements? Well, there's a lot of things you can try, but a multivitamins are important in mineral fish oil. Omega threes really help with that. Inflammation, they help with mood, they help with libido. Vitamin D, very important. Low levels are associated with low testosterone. In men. It's important. Low testosterone is something that can be sometimes supported with herbs, and there's a long history of use. A lot of research on this like long jack fagre, maca, sometimes using DHA, which is a hormone, can help if you have a lot of stress. You can use some of the adaptogens like ashwagandha ginseng, Siberian ginseng, Rhodiola, magnesium.
There's some that really help for libido. A lot of people are selling this online, but you want to find good quality products. But Tonka Alley is something that's been talked about a lot recently. A study found that supplementing with Tonka Alley really reduced tension, stress and anger and confusion and cortisol, but it increased testosterone by about 37%. It's an ancient remedy, but it could help improve your stress hormone profile and help your sex drive. So it might be worth a try. There's another one called Schadt. I dunno if I'm pronouncing it right, but it's an Ayurvedic compound from black brown exudate that oozes from sedimentary rocks around the world, largely in the Himalayas. It increases libido. It's a great antioxidant. It helps blood flow, it helps sexual performance, prevents premature ejaculation, maintains erection. And there's been randomized placebo controlled trials, believe it or not. One was done of 75 healthy volunteers aged about 45 to 55 and taking about 250 milligrams twice a day.
Really improved DHA testosterone levels. So that's good. Now, there's a lot of other treatments that you might consider after you do all the lifestyle and supplement things. It might be helpful. And these really have to be decided on a case by case basis. Pelvic floor therapy, I would consider checking that out. If you're a bike rider, if you've had any injuries, surgeries, some of those pelvic floor muscles get wonky and they can be helped by massage and treatment with a pelvic floor therapist. That's something we talk about lot medicine, but it's important. There's also peptides. Now, peptides we mentioned are these little small mini proteins like insulin ozempic, but there's a lot of 'em, thousands of them. And some improve testosterone, some improve growth hormone, and they can help with lean muscle mass recovery, increased energy, bone density, just to mention a few. kisspeptin is one that helps with testosterone test.
Morlin lin CJ 1295 all can be potentially helpful and you'd want to work with a doctor to do that. Obviously, testosterone placement therapy, you have to be a good candidate. You have to do the right test. All the things we mentioned that you can get on function health really depends on the individual, your age, overall factors. And it's something you decide with an expert. And it's not just like everybody gets it. There's these low T clinics out there that give everybody disaster. I'm not a big fan of that. I think there's a risk to it. I think it really has to be personalized and individualized, but it can really, if you are not responding to other interventions, it might be helpful. And then some of this can be really effective. So there's certain reasons you wouldn't do it. Like if you have potentially risk benefit issues, we'll talk about what those are.
But certain blood conditions and certain prostate issues that might be concerning. But there was a big concern about heart disease and it does raise cholesterol. And so there was this belief that it increased the risk of heart attacks. So it was a big trial. It was called the Traverse trial, published in the New England Journal of Medicine. It was a placebo controlled study with men aged 45 to 80 who had low testosterone, and they were at increased risk of cardiovascular disease and heart attacks. And the goal of the study was to look at the efficacy and the safety of testosterone replacement therapy. Now, what they found was no significant difference, no significant difference in major adverse cardiovascular events between testosterone and the placebo groups. And that suggests that testosterone replacement therapy is not more harmful than a placebo in that population. So now there were some limitations in the study.
It was a small increase in total testosterone. They use a topical gel. Maybe it was the method administration, maybe injections would have a different result. But it's really a bit of a reassuring study. Now, it can improve when you take testosterone placement therapy. It can improve your symptoms of low testosterone. It can improve your quality of life. But it's really, I think a little more research is still needed, but I'm not concerned about it. In select patients that are followed carefully and followed up with lab work and their risk factors and their heart disease risks. So not so worried about it. Now, there's really no data on, again, a big worry, which is using testosterone replacement therapy and having an increased risk of prostate cancer. Now, in fact, low testosterone is associated with prostate cancer. So I think the fears around testosterone and prostate cancer and heart disease actually have been mostly put to bed, but we're still learning and doing more research.
Now, if you want to have a baby, it's a problem. So it's not great if you're trying to conceive because it shuts down the stimulation of the oli cells, which makes sperm, and that's not good. So you don't really want that. And I think that you can treat that with things like Clomid and other things to simulate your testicles if you're on testosterone, but it's something you did work with a doctor on. Also, you want to be careful if you have a history of prostate cancer, if you have heart failure, if you have a high PSA or enlarged prostate, if you have sleep apnea, if you have a high red blood cell count, it can be an issue. It can increase your red blood cells. So you can get thick blood and strokes and clotting. So you have to really track that and check your blood count.
So basically you need to see a doctor. If you can do this, you need a real thorough evaluation. You need the right blood test like we talked about from function health, you need a detailed medical history, a physical exam, and all that is really important if you're going to use testosterone. Now, what else is available? Well, shock wave therapy, it can be really something you can do and it's pretty safe. Low intensity shock waves, basically sound waves basically one or two times a week for 15 minutes for about six weeks, and that basically causes little microtrauma to the penis and that leads to something called angiogenesis. So basically when you have a trauma, it increases blood flow, new blood vessels to grow, and it recruits stem cells, so it can be really helpful and then some men find that very helpful. There are other therapies tend to be a little more experimental, a little more expensive exosomes, which are basically like the small vesicles that are released from your stem cells that carry RNA proteins, lipids, they don't really have the ability like stem cells to have any genetic identity, but they can really help inflammation and modulate the environment and may help in repairing and regenerating penile tissue.
And they basically are given by injection directly into the penis. So we need more trials on that, but they're really safe and you can get them from synthetic ones or donor derived, or even from your own stem cells are another thing to think about. They're found in your bone marrow fat tissue. You can use umbilical stem cells from donors. They actually can become something that can, I think it's going to be a very effective treatment, but again, it's expensive. It's not FDA approved and so forth. Other treatments, well hyperbaric oxygen, we talked about that on the podcast, but it actually increases blood flow. Again, it's a study by urologist in Turkey involved a hundred men and they compare the effects of oxygen therapy, Cialis, ALI or no treatment, and they basically found that the hyperbaric oxygen treatment for 90 minutes a day was compared to taking Tenda or Salis five milligrams a or placebo for a month.
And what they found was basically the oxygen and the ALIS groups both had a 50% improvement in erectile dysfunction. So that's pretty cool. It's a really safe treatment and the effect lasts about two months and basically it's kind of cool. So I think the oxygen therapy has less side effects. It also helps your body heal in other ways. It's been linked to increased nitric oxide and stem cells and all kinds of things. Other things for erectile dysfunction, well, there's injections and they called trimix, which you can use when you want to have sex. You inject a little bit of this medicine in the base of your penis and it makes your penis hard and you can have sex. It can be a problem if you take too much. It can lead to your long erections and you need to make sure you have the antidote.
There's PNL implants, there's vacuum pumps and all that you need to see urologists with. So this is a lot. We covered a lot of stuff around sexual health, men's health, testosterone, lifestyle changes. It's not something you have to suffer with if you have this or if your partner has this. It's something to think about getting on top of and not just letting go because it's embarrassing. It's not really just a bedroom problem as we discussed, instead of a window into your overall health, especially your heart and your metabolic health, and with functional medicine, there's silver lining that in understanding these lifestyle and diet changes, we can really make a big difference not just for your sexual health but your overall health. So thinking about getting on a healthy diet, getting off the stretch of sugar, exercising, getting on the right supplements, trying some of these experimental things like peptides, even hormone therapy, lots of explore that can lead not just to a better sex life, but a more vibrant, healthy life.
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