International Journal of Impotence Research (2006) 18, 370–374

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ORIGINAL ARTICLE
Dietary factors in erectile dysfunction
K Esposito1, F Giugliano2, M De Sio2, D Carleo1, C Di Palo1, M D’Armiento2 and D Giugliano1
1
Division of Metabolic Diseases, University of Naples SUN, Piazza Miraglia, Naples, Italy and 2Division of Urology,
University of Naples SUN, Piazza Miraglia, Naples, Italy

The role of dietary factors in erectile dysfunction (ED) has never been addressed. In the present
case–control study, we investigated the relation of the Mediterranean diet with ED. A total of 100
men with ED were compared with 100 age-matched men without ED. A scale indicating the degree
of adherence to the Mediterranean diet was constructed: the total Mediterranean diet score ranged
from 0 (minimal adherence to the Mediterranean diet) to 9 (maximal adherence). The percentage of
physical inactivity was greater in the ED group (35 vs 19%, P ¼ 0.04), whereas the diet score was
lower (4.770.5 vs 5.470.5, Po0.01), indicating a reduced adherence to the Mediterranean diet. In
analyses adjusted for the prevalence of associated risk factors (hypertension, hypercholesterole-
mia), body mass index, waist, physical inactivity and total energy intake, the intake of fruits and
nuts, and the ratio of monounsaturated lipids to saturated lipids remained the only individual
measures associated with ED. In conclusion, the results of the present study show that dietary
factors may be important in the development of ED: adoption of healthy diets would hopefully help
preventing ED.
International Journal of Impotence Research (2006) 18, 370–374. doi:10.1038/sj.ijir.3901438;
published online 5 January 2006

Keywords: healthy diet; erectile dysfunction; prevention

Introduction As ED and atherosclerosis may share some path-

A high prevalence of erectile dysfunction (ED) in
patients with cardiovascular risk factors has been
reported.1–3 Moreover, patients with ED have an
increased prevalence of coronary heart disease
(CHD) and peripheral vascular diseases.4 Kaiser
et al.5 have shown that subjects with ED but without
evidence of clinical cardiovascular disease and free
of traditional cardiovascular risk factors present
widespread abnormality of endothelial function as
has been seen in patients with cardiovascular risk
factors. According to a raising popular view,
subjects with ED seem to have a vascular mechan-
ism similar to that seen in atherosclerosis,6 and
therefore a diagnosis of ED may be seen as a sentinel
event that should prompt investigation for CHD in
asymptomatic men.7
Correspondence: Dr K Esposito, Division of Metabolic
Diseases, University of Naples SUN, Piazza Miraglia,
Naples 80138, Italy.
E-mail: katherine.esposito@unina2.it
Received 3 November 2005; revised 7 November 2005;
accepted 13 November 2005; published online 5 January
2006
ways,8 it seems reasonable to assume that dietary
factors, which are so important in reducing the
burden of CHD disease,9 may also play a role in
reducing the occurrence of ED. For example, there
are several observational studies associating the
Mediterranean diet with a lower risk of CHD
morbidity and mortality.10–13 Moreover, some ran-
domized clinical trials have shown a beneficial
effect of this dietary pattern on secondary preven-
tion of CHD.14,15 The effect of the Mediterranean
diet on CHD can be mediated through multiple
biological pathways other than serum lipids, inclu-
ding reduction of oxidative stress and subclinical
inflammation, amelioration of endothelial dysfunc-
tion and insulin sensitivity, mitigation of blood
pressure, and thrombotic tendency.9,16,17
To the best of our knowledge, the role of
dietary factors in ED has never been addressed. In
the present case–control study, we investigated the
relation of the Mediterranean diet with ED.
Subjects and methods
Men were recruited to the outpatient departments at
the University of Naples SUN, Italy, after exclusion
 Dietary factors in erectile dysfunction
K Esposito et al
371
criteria have been verified with the aid of a personal frequency (times per week), duration (in minutes
health and medical history questionnaire, which per time), and intensity of sports- or occupation-
served as a screening tool. Exclusion criteria were related physical activity. Participants who did
age less than 20 or higher than 80 years, diabetes not report any physical activities were defined
mellitus (fasting plasma glucose higher than as sedentary.
126 mg/dl in at least two occasions), impaired renal Current smokers were defined as those who
function, pelvic trauma, prostatic disease, cardio- smoked at least one cigarette per day or have
vascular disease, psychiatric problems, use of drugs, stopped cigarette smoking during the past 12
or alcohol abuse (4500 g/week in the last year). All months. Former smokers were defined as those
participants provided written informed consent and who had stopped smoking more than 1 year before.
the study protocol was approved by the ethics The rest were defined never smokers.
committee of our institution. Height and weight were measured to the nearest
Erectile function was assessed by completing the 0.5 cm and 100 g, respectively, with participants
International Index of Erectile Function (IIEF)-5, wearing lightweight clothing and no shoes. Body
which consists of items 5, 15, 4, 2, and 7 from the mass index (BMI) was calculated as weight in
full-scale IIEF-15.18 A score of 21 or less indicates kilograms divided by height (in meters) squared.
the presence of ED.
Usual dietary intake was assessed with a food
frequency questionnaire listing approximately 140
Statistical analysis
foods and beverages commonly consumed in Italy.
Comparison of group difference in baseline
Portion size was calculated on the basis of informa-
characteristics was made by analysis of variance
tion provided on household units and photographs of
(ANOVA) for continuous variables and by w2 test
usual portion sizes, and was then used for estimation
for categorical variables. Associations between
of consumed quantities. A total of 14 all-inclusive
normally distributed continuous variables and
food groups or nutrients were considered: potatoes,
group of patients were evaluated through ANOVA,
vegetables, legumes, fruits and nuts, dairy products,
whereas the associations between skewed variables
cereals, meat, fish, eggs, monounsaturated lipids
and groups of patients were evaluated through the
(mainly olive oil), polyunsaturated lipids (vegeta-
Kruskal–Wallis test. Multivariate regression analysis
ble-seed oils), saturated lipids and margarines, sugar
tested the independent association of nutrient
and sweets, and non-alcoholic beverages. Intake of
intake, BMI, waist, physical activity, and total
each of the indicated groups in grams per day and
energy intake with the dependent variable (IIEF
total energy intake were calculated.
score). A value of Po0.05 was considered signi-
A scale indicating the degree of adherence to the
ficant. All analyses were conducted using SPSS
Mediterranean diet was constructed according to
version 9.0 (SPSS Inc., Chicago, IL, USA).
Trichopoulou et al.10 A value of 0 or 1 was assigned
to each of nine indicated components with the
use of the median as the cutoff. For beneficial
components (vegetables, legumes, fruits and nuts, Results
cereal and fish), persons whose consumption was
below the median were assigned a value of 0 and The clinical characteristics of the study population
persons whose consumption was at or above the are shown in Table 1. As age represents the main
median were assigned a value of 1. For components risk factor for ED, the two groups of subjects with
presumed to be detrimental (meat, poultry, and
dairy products), persons whose consumption was
below the median were assigned a value of 1 and Table 1 Lifestyle and clinical characteristics of subjects with
and without ED
persons whose consumption was at or above the
median were assigned a value of 0. For ethanol, a Subjects Subjects P
value of 1 was assigned to men who consumed with ED without ED
between 10 and 50 g/day. As in Italy monounsatu-
rated lipids are used in much higher quantities than Number 100 100
polyunsaturated lipids, we used the ratio of mono- Age (years) 54.175.1 53.174.7 0.15
IIEF 15.473.5 23.670.9 o0.001
unsaturated to saturated lipids rather than the ratio BMI (kg/m2) 27.474.1 26.573.7 o0.01
of polyunsaturated to saturated lipids. The total Waist (cm) 9878 9577 o0.01
Mediterranean diet score ranged from 0 (minimal Diet score (0–9) 5.470.5 4.770.5 o0.001
adherence to the Mediterranean diet) to 9 (maximal Physical inactivity (%) 35 19 0.04
adherence). Current smoking (%) 26 12 0.06
Hypercholesterolemia (%) 26 13 0.06
Physical activity status of the subjects was
evaluated through a modified version of a self- Data are mean7s.d. Hypertension was defined as blood pressure
reported questionnaire provided by the American 4140/90 mmHg; hypercholesterolemia was defined as total
College of Sports Medicine,19 which assesses the cholesterol 4200 mg/dl.

International Journal of Impotence Research

 Dietary factors in erectile dysfunction
K Esposito et al
372
or without ED were matched for age (71 year). was a significant inverse association between the
Compared to the group without ED, subjects with ED Mediterranean diet score and ED (Po0.01).
were slightly heavier and with a greater waist, and
were more likely to be hypertensive and hypercho-
lesterolemic although this did not reach the level of
statistical significance (P ¼ 0.06). Current smoking Discussion
was found to be similar in the two groups. Lifestyle
characteristics were found to be different between The results of the present study demonstrate that
groups: in particular, the percentage of physical men with ED show, as compared with age-matched
inactivity was greater, whereas the diet score was men without ED, a difference in lifestyle attitudes
lower, indicating a reduced adherence to the that may play a role in the development and
Mediterranean diet in the ED group. progression of ED. In particular, the prevalence of
Table 2 shows the daily dietary intake of several unhealthy dietary patterns and physical inactivity
food groups. As expected, high Mediterranean were significantly higher in men with ED.
diet scores were characterized by high intakes of We confirm here that weight is associated with
vegetables, legumes, fruits and nuts, cereals, fish, ED, as BMI was significantly higher in men with ED
and olive oil, and relatively low intakes of dairy as compared with men without ED. Prospective
products and meat (data not shown). Positive studies, such as the 9-year follow-up study of
associations with ED were found for selected food MMAS1 and the 25-year follow-up Rancho Bernardo
groups: in particular, the intake of vegetables, fruits Study,2 reported that body weight was an indepen-
and nuts, and the ratio of monounsaturated to dent risk factor for ED, with a risk exceeding 90%
saturated lipids were significantly lower in subjects of controls (OR between 1.93 and 1.96, respectively).
with ED. In analyses adjusted for the prevalence of In our study, visceral obesity, as measured with the
associated risk factors, BMI, waist, physical inactiv- waist circumference, was more pronounced in
ity and total energy intake, the intake of fruits and subjects with ED and was more strongly associated
nuts (P ¼ 0.02), and the ratio of monounsaturated with ED than BMI. Although the relation between
lipids to saturated lipids (P ¼ 0.04) remained the visceral obesity and ED may not be readily apparent,
only individual measures associated with ED. a growing body of evidence implicates central
Table 3 shows the distribution of subjects adiposity as a key regulator of inflammation.20
according to the Mediterranean diet score. There Among the various adipokines released by the
visceral adipocytes, both tumor necrosis factor-a
and interleukin-6 seem to play a major role, as they
Table 2 Daily dietary intake of several food groups in the two can depress endothelial function.21 As endothelial
groups of subjects dysfunction is increasingly acknowledged as an
early sign of generalized atherosclerosis and associ-
Subjects Subjects P
with ED without ED
ates with ED,6 one possible mechanism linking
visceral obesity to ED may be through the increased
Vegetables (g/day) 4917115 5257125 o0.05 release of adipokines. We did not find significant
Fruits and nuts (g/day) 3217101 3547112 o0.05 association between the prevalence of hypertension
Ratio of monounsaturated 1.4570.5 1.670.5 o0.05 and hypercholesterolemia and ED, although this
lipids to saturated lipids might have been the result of the strict entry
Legumes (g/day) 9.273.5 10.273.5 0.08
Dairy products (g/day) 160787 150775 0.3
criteria, which excluded subjects with diabetes or
Cereals (g/day) 2417132 2557121 0.39 drug users.
Meat (g/day) 120755 110745 0.16 We have found that the intake of some foods was
Fish (g/day) 2378.6 2577.8 0.08 less represented in subjects with ED: in particular,
Olive oil (g/day) 32710 34711 0.18 the calculated intakes of vegetables, fruits and nuts,
Energy intake (kcal/day) 24407890 23507900 0.4
and the ratio of monounsaturated to saturated lipids
were significantly lower in men with ED. Interest-
ingly enough, each of these nutrients has been
Table 3 Distribution (%) of subjects with or without ED across
associated with a decreased risk of CHD, through
tertiles of the diet score an effect of improving endothelial dysfunction22
and decreasing inflammation.23 In general, the
Diet score Diet score (4–6; Diet score P intake of foods that are more likely to be associated
(0–3; low) moderate) (7–9; high) with increased CHD risk was higher in men with ED,
whereas the intake of foods that are associated with
With ED 42 38 20 0.024 decreased CVD risk was reduced. The concept of
Without ED 30 33 37
dietary patterns has recently attracted considerable
Low, moderate, and high indicate low adherence, moderate
interest in the field of nutritional epidemiology.24
adherence, and high adherence to the Mediterranean diet, In a subcohort of healthy men from the Health
respectively. Professionals Follow-up Study, Fung et al.25 dis-

International Journal of Impotence Research


cerned two major dietary patterns: the prudent
pattern characterized by higher intake of fruit,
vegetables, whole grains, and poultry; and the
Western pattern characterized by higher intake of
red meat, high-fat dairy products, and refined
grains. A positive correlation has been found
between the Western dietary pattern and plasma
biomarkers of obesity and cardiovascular disease
risk, such as plasma concentrations of inflammatory
(C-reactive protein) and endothelial dysfunction
(ICAM-1, VCAM-1, P selectin) markers.26 Moreover,
a dietary pattern that was high in sugar-sweetened
soft drinks, refined grains, diet soft drinks, and
processed meat, but low in wine, coffee, cruciferous
vegetables and yellow vegetables was associated
with an increased risk of diabetes and inflammatory
markers in the Nurses’ Healthy Study.27 As inflam-
mation may play a causative role in ED,28 a reduced
low-grade inflammation by healthy dietary patterns
may be implicated in the association of increasing
adherence to Mediterranean diet and reduced pre-
valence of ED.
In our study, we found that a dietary pattern that
was high in fruit, vegetables, nuts, whole grains, and
fish, but low in red and processed meat and refined
grains was more represented in subjects without ED
as compared with men with ED. This dietary pattern
is quite similar to the traditional Mediterranean diet,
which is characterized by a high intake of vegeta-
bles, legumes, fruits and nuts, and cereals, and a
high intake of olive oil associated with a low intake
of saturated fats, a moderate intake of fish, a low-to-
moderate intake of dairy products, a low intake of
meat and poultry, and a regular but moderate intake
of ethanol, primarily in the form of wine and
generally during meals.29
In conclusion, the results of the present study
show that dietary factors may be important in the
development of ED and claims for the widespread
application of current nutritional guidelines, which
insist upon increasing consumption of vegetables,
fruit, nuts and healthy fats,30 whose intake is less
represented in ED patients.
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