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Hussein Ghanem, M.D. Professor of Andrology, Sexology & STDs Cairo University

Course: Optimization of response to ED pharmacotherapy Sidney Glina , Hussein Ghanem & Eusebio Rubio. Hussein Ghanem, M.D. Professor of Andrology, Sexology & STDs Cairo University. Modification of lifestyle to improve erectile function. Presentation Objectives.

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Hussein Ghanem, M.D. Professor of Andrology, Sexology & STDs Cairo University

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  1. Course: Optimization of response to ED pharmacotherapySidney Glina, Hussein Ghanem & Eusebio Rubio Hussein Ghanem, M.D.Professor of Andrology, Sexology & STDs Cairo University Modification of lifestyle to improve erectile function

  2. Presentation Objectives • Outline the link between Lifestyle factors and Cardiac & Sexual Health. • Clarify if lifestyle modifications can really enhance sexual function. • Discuss if our guidance is effective in changing patients’ lifestyles?

  3. Al Suwaidi J, et al. Clin Card 8/01How much sooner does obesity give you a heart attack? Age

  4. Mittleman MA et al, N Engl J Med 1993;329:1677 Rodriquez BL et al, Circulation 1994;89:2540 Hakim AA et al, Circulation 1999;100:9Effects of Exercise on CHD Risk Reduction CHD Risk Age Exertion Frequency

  5. Hu FB et al, JAMA 2003;289:1785Daily Activities, Obesity & Diabetes per 1 hour/day

  6. Comparison of Exercise & Antidepressants Blumenthal JA et al, Arch Intern Med 1999;159:2349 Beck’s Depression Index 156 with MDD (age, > or = 50 years) were assigned randomly to a program of aerobic exercise, antidepressants (sertraline hydrochloride)

  7. ICSM-5 step management algorithm – Paris 2009

  8. The second Princeton consensus on sexual dysfunction and cardiac risk: new guidelines for sexual medicine. Jackson G, Rosen RC, Kloner RA, and Kostis JB. J Sex Med 2006;3:28–36. •  The recognition of ED as a warning sign of silent vascular disease has led to the concept that a man with ED and no cardiac symptoms is a cardiac (or vascular) patient until proven otherwise. • Men with ED and other cardiovascular risk factors (e.g., obesity, sedentary lifestyle) should be counseled in lifestyle modification. 

  9. Cardiometabolic risk and female sexual health: The Princeton III summaryMiner M, Esposito K, Guay A, Montorsi P, and Goldstein I. J Sex Med 2012;9:641–651. • Promotion of healthful lifestyles, including healthy diet and exercise, for prevention and treatment of women of all ages yields benefits and reduces the burden of chronic diseases beyond the specific effects on sexual dysfunctions (Mainly arousal).

  10. Lifestyle & Medical Risk Factors associated with ED • Lifestyle factors • Physical inactivity • Unhealthy diet • Obesity • Smoking, Alcohol abuse & drug abuse • Medical factors • DM • Hypertension • Dyslipidemia • Hypogonadism • Insufficient Sleep • Work stress Hatzichristou, Rosen, Derogatis, et al. Recommendations for the clinical evaluation of men and women with sexual dysfunction.J Sex Med 2010;7:337–348.

  11. Effect of Medical & Lifestyle factors on ED Risk Source: Chronic Disease/Lifestyle Increased ED Risks* Review: Diabetes1,2  4.1  2.0 Smoking4 Peripheral vascular disease1  2.6 Cardiac problems1 1.8 Reviewer Memo: Hyperlipidemia1  1.6 Hypertension1,2  1.6 Depression3,4  1.8 Obesity x 2.0 *Age-adjusted odds ratio. 1. Martin-Morales A et al. J Urol. 2001;166:569-575. 2. Braun M et al. Int J Impot Res. 2000;12:305-311. 3. Goldstein I. Am J Cardiol. 2000;86(suppl):41F-45F. 4. Feldman HA et al. J Urol. 1994;151:54-61. Slide Modified: Memo:

  12. How can we maintain / restore Erectile Function? Avoid smoking, excess alcohol & drugs Sleep well & control work stress

  13. Insulin Resistance Hyperinsulinemia Hyperglycemia Atherosclerosis Dyslipidemia • Penile / Int pudendal • Coronary arteries • Carotid arteries • Cerebral arteries • Aorta • Peripheral arteries Hypertension Inflammation Impaired Fibrinolysis Endothelial Dysfunction Multiple Factors Associated With Obesity Give Rise to Increased Risk of CVD How can Obesity & Sedentary Lifestyle cause ED or CVD Primary Metabolic Disturbance Intermediate Vascular Disease Risk Factor Intravascular Pathology Clinical Event Unhealthy diet, Obesity & Physical inactivity CVD & ED Despres JP, et al. Abdominal obesity and metabolic syndrome.Nature. 2006;444:881-887.

  14. Esposito K, Giugliano F, Maiorino MI, and Giugliano D. Dietary factors, Mediterranean diet and erectile dysfunction. J Sex Med 2010 Acute variations of plasma glucose &lipid levels may cause early injury in endothelial cells.

  15. 2010

  16. Obesity & Testosterone deficiencyCause or effect? Visceral obesity seems to be both the cause & the consequence of TD. Third International Consultation of Sexual Medicine (Paris 2009). Buvat, Maggi, Gooren et al, Endocrine Aspects of Male Sexual Dysfunctions. J Sex Med 2010;7:1627–1656.

  17. Between the lowest rib and the top of the iliac crest Tape should be snug & parallel to the floor without causing compression Measuring waist circumference Iliac crest NHLBI. www.nhlbi.nih.gov.

  18. Ethnic specific values for waist circumference: The International Diabetes Foundation consensus

  19. Exercise may reduce CVD and all-cause mortality N = 9791; moderate physical activity vs little or no physical activity Adjusted HR (95% CI) Favorsexercise Favorsno exercise Normal BP All-cause death 0.75 (0.53–1.05) CV death 0.76 (0.39–1.49) Prehypertension All-cause death 0.79 (0.65–0.97) CV death 0.79 (0.58–1.09) Hypertension All-cause death 0.88 (0.80–0.98) CV death 0.84 (0.73–0.97) 0.5 1.0 1.5 0 2.0 Hazard ratio Fang J et al. Am J Hypertens. 2005;18:751-8. NHANES 1 Epidemiological Follow-up Survey (1971–1992)

  20. Practical advise about physical activity • 30 ms of moderate-intensity physical activity preferably daily. • Incorporate exercise into your daily routine • Take stairs • Walk, cycle • Park further away • Go down on an earlier bus stop. • A pedometer (10,000 steps) • Surgeon General’s Report on Physical Activity and Health • American Diabetes Association. Diabetes Care. 2007;30:S4-41.

  21. Why is vascular ED an early warning sign for CVD?

  22. clinical symptoms ED silent ischemiastabil/non- anginaAMI TIA stroke intermittentclaudication Size of arteries (mm) proximal LAD(3-4) internal carotid(5-7) femoral artery(6-8) penile artery (1-2) obstruction of the Artery O (%) 50 % obstruction CAD CVD PAD ED plaque: only ED plaque: clinical CAD • Montorsi et al., Eur Urol 2003

  23. Is obesity a further cardiovascular risk factor in patients with ED?Corona et al, J Sex Med. 2010 Jul;7(7):2538-46 • Observational prospective cohort study of 1,687 patients (mean follow-up of 4.3 ± 2.6 years). • Relationship between • Obesity • Arteriogenic ED • Major adverse cardiovascular events (MACE). Corona 2010

  24. Is obesity a further cardiovascular risk factor in patients with ED?Corona et al, J Sex Med. 2010 Jul;7(7):2538-46 1% fatal Severe ED predicted MACE (hazard ratio [HR] 1.75; 95% confidence interval 1.10–2.78; P < 0.05)

  25. Obesity & risk of major adverse cardiovascular events

  26. Arteriogenic ED ( PSV<25 cm/sec) predicted MACE Is obesity a further cardiovascular risk factor in patients with erectile dysfunction?Corona et al , J Sex Med. 2010 Jul;7(7):2538-46.

  27. Lifestyle factors in relation to ED

  28. Updated from: Obesity, dyslipidemias and erectile dysfunction: A report of a subcommittee of the sexual medicine society of North America. Mulhall J, Teloken P, Brock G, and Kim E. J Sex Med 2006;3:778–786.

  29. Smoking • Population-based cross-sectional study of 1,580 participants. • The IIEF-5 was used to assess erectile function. • Compared with never smokers, the odds of ED, adjusted for age, square of age, and CVD, were significantly higher among current smokers (odds ratio [OR] = 1.40; 95% confidence interval [CI] 1.02, 1.92). 2008 Chew K-K, Bremner A, Stuckey B, Earle C, and Jamrozik K. Is the relationship between cigarette smoking and male erectile dysfunction independent of cardiovascular disease? Findings from a population-based cross-sectional study. J Sex Med 2009;6:222–231.

  30. Smoking • Ratshas a constant influx of smoke using a specially constructed device. 24 Sprague Dawley (SD) rats were randomly into two groups: an experimental group and a control group. 36rats for the chronic cigarette smoke exposure were randomly divided into three groups: a control group and two experimental groups. • Electrical field stimulation of the cavernosal nerve to assess the erectile function,. • Vasoconstrictor effects & the decrease in testosterone levels after chronic smoking had some effects on erectile function in rats.  Park et al, 2012 Park MG, Ko KW, Oh MM, Bae JH, Kim JJ, and Moon DG. Effects of smoking on plasma testosterone level and erectile function in rats. J Sex Med 2012;9:472–481.

  31. Lifestye Associations of unhealthy lifestyle factors with sexual inactivity and sexual dysfunctions in DenmarkChristensen et al, J Sex Med. 2011 Apr;8(4):971-5. 5,552 men and women aged 16-97 years Sexualdysfunctions were associated with • Increased waist circumference • Physical inactivity • >21 alcoholic beverages/week • Tobacco smoking • Hard drugs (ORs between 1.71 and 22.0) 2011

  32. Lifestyle Associations of unhealthy lifestyle factors with sexual inactivity and sexual dysfunctions in DenmarkChristensen et al, J Sex Med. 2011 Apr;8(4):971-5. Conditions associated with sexual inactivity: • Both underweight (BMI <20 kg/m(2) ) & obesity. Obesity (body mass index [BMI]≥30 kg/m(2) ) or a substantially increased waist circumference (men ≥102 cm; women ≥88 cm), • physical inactivity • Tobacco smoking in women

  33. Diet  Mediterranean diet & ED with type 2 diabetes. Giugliano et al.  J Sex Med 2010 • 555 (90.8%) of 611 diabetic men followed for at least 6 months. • Age 35–70 years • (BMI) of 24 or higher • HbA1c of 6.5% or higher or treatment with diet or oral drugs. • Food-frequency questionnaire and self-report measures of sexual function. 2010

  34. Diet characteristics • Diet based on plenty of vegetables (excluding potatoes), fruits, nuts, whole grains, legumes, fish, monounsaturated fatty acids. • Low-fat dairy products • Low consumption of saturated fat, red and processed meats. • No excess alcohol Mediterranean diet & ED with type 2 diabetes. Giugliano et al.  J Sex Med 2010

  35. Diet • Men more adherent to a healthy diet were: • Sexually active • Lower prevalence of ED & severe ED (P=0.01)  Mediterranean diet & ED .  J Sex Med 2010

  36. Beneficial impact of exercise and obesity interventions on erectile function and its risk factors.Hannan et al, J Sex Med. 2009 Animal Studies 2009 % body weight change & Erectile response

  37. Beneficial impact of exercise and obesity interventions on erectile function and its risk factors.Hannan et al, J Sex Med. 2009 Animal Studies Visceral adipose tissue & Erectile response

  38. European Urology • A urologist examined 674 men aged 45-60 yr at their place of work. • Physical examination • Medical history • (T) and SHBG • IIEF-5 • Paffenbarger score (PhA) was assessed in kilojoules per week (4.2 kJ=1 kcal).

  39. European Urology How much physical activity is needed to maintain erectile function? Vienna Municipality Study. Kratzik et al, Eur Urol. 2009 Feb;55(2):509-16 Results • A positive correlation between the IIEF-5 and the Paffenbarger score (r=0.164, p<0.001) • The risk of severe ED was decreased by 82.9% for males with PhA of at least 3000 kcal/wk (OR=0.171, p=0.018).

  40. Do lifestyle modifications improve sexual function?

  41. The Effect of Lifestyle Modification and Cardiovascular Risk Factor Reduction on EDA Systematic Review and Meta-analysisBhanu et al Arch Intern Med. 2011;171(20):1797-1803 740 participants from 6 clinical trials in 4 countries

  42. How effective is our guidance in changing patients’ lifestyles?

  43. Weight LossIntervention • Overweight diabetic men subjected to either: • Intensive lifestyle intervention versus • Conventional Diabetes support & educationSexual function was assessed after 1 year • Look AHEAD: Action for Health in Diabetes Wing et al, J Sex Med. 2010 Jan;7(1 Pt 1):156-65

  44. Weight LossIntervention & SF Diabetes support and education (DSE) Intensive lifestyle intervention (ILI)

  45. Diabetes Support & Education (DSE)? Oral & written information about • Healthy food choices • Physical activity.  Effects of weight loss intervention on erectile function in older men with type 2 diabetes in the look AHEAD trial. J Sex Med 2010;7:156–165.

  46. Intensive lifestyle intervention (ILI)? • Body Weight :Detailed advice about how to reduce body weight • Diet: • 7 sessions with a nutritionist • Personal goal-setting • Self-monitoring (food diaries) through a series of monthly small-group sessions. • Exercise: Individual guidance • Behavioral and psychological counselingwas offered

  47. Intensive lifestyle intervention (ILI) Diabetes support and education (DSE) • Greater improvement in EF (17.3 +/- 7.6 at baseline; 18.6 +/- 8.1 at 1 year) than in DSE (18.3 +/- 7.6 at baseline; 18.4 +/- 8.0 at 1 year); P = 0.06

  48. Physical Fitness & SF Cardiorespiratory fitness was found to be protective of ED in a multivariable analysis (OR = 0.61; P < 0.001)

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