Today’s Health Tip addresses erectile dysfunction (ED), a much too common problem that is sadly often overlooked or dismissed as a medical problem when men see their primary care doctors. It can affect men of all ages, especially if they are overweight with that “beer belly” appearance or drink alcohol or smoke marijuana on a regular basis. ED increases in frequency with age, obesity, and in men taking statins and blood pressure medicines for heart disease and hypertension, or antidepressants/mood stabilizers that can increase prolactin and lower testosterone. Men who drink alcohol every day have even higher risk of ED as they get older, gain body fat, and are taking any of these medications I just mentioned.
I have been evaluating and treating men with erectile dysfunction for 40+ years, beginning with specialty training at Johns Hopkins Hospital as part of the multispecialty Sexual Health Consultation Team. ED is one problem in Men’s Health that urgently needs a comprehensive initial medical evaluation and then an integrated treatment plan that encompasses the medical factors (hormonal, vascular, metabolic, neurological), lifestyle habits, and the way that ED can have adverse effects psychological factors such as a man’s performance anxiety, self-esteem and relationship. It is rarely possible to see significant improvement in ED with just taking Viagra or Cialis, OR just taking Testosterone therapy.
Complete evaluation of all the physiological factors should include endocrine testing, metabolic testing, nutritional deficiencies that can impair nerve and vascular pathways, assessment of penile blood flow dynamics, assessment of sleep quality and duration (which affects nocturnal penile erections). There are critical implications for developing an individualized and effective treatment plan to first accurately assess areas of dysfunction between psychological and physiological.
If you want to see major improvement in quality and duration of erections, treatment of ED needs a much broader and more integrative approach—including medication, diet, proper supplements to increase Nitric Oxide production and decrease inflammation/microvascular damage, the right type of exercise to reduce excess body fat, attention to sleep hygiene, cognitive therapy, and even innovative therapies such as GainsWAVE low-intensity shockwave therapy that uses sound waves to stimulate blood flow and promote healing. That’s why it’s so important to start with an extremely thorough comprehensive medical-endocrine-metabolic-vascular-psychological evaluation to get the most effective help for ED, not just a piece meal approach with either Viagra/Cialis or Testosterone alone although either or both will often be part of an integrated treatment plan.
In today’s Health Tip, I want to focus primarily on Nitric Oxide—the tiny molecule that helps coordinate all these pathways regulating the erectile process, because it is one that is often overlooked in medical evaluations. It is beyond the scope and space for this short article to go into detail on all of the physiological pathways and how they work together, and all of the diagnostic testing I use to assess patients in my practice, but you can check out my other articles and seminars in these links for more information, particularly my entire series on testosterone replacement therapy (TRT) in our Faith Over Fear archives at these links:
- The Hidden Health Costs of Low T in Men
- The Hidden Health Costs of Low T in Men: PART II: Health Benefits of Testosterone, studies on Testosterone therapy after successfully treated prostate cancer
- The Hidden Health Costs of Low T in Men: PART III: Androgen Deprivation Therapy – Risks and Benefits
- The Hidden Health Costs of Low T in Men: PART IV
Today I want to explore with our readers what action steps you can take on your own to improve the quality of erections, and what questions and options to discuss with your own physicians.
Healthy Erections: More Complex Than You Realize!
The human penile erection is a complex process involving the coordinated interaction of vascular, hormonal, neurological, and psychological organ systems. Failure of erectile function can occur from dysfunction in ANY of these areas, and most commonly involves several pathways at the same time. The goal of a comprehensive evaluation is to establish the degree to which physiological factors AND psychological contribute to erectile dysfunction for each patient. There is no “one-size-fits-all” approach, nor is there a single treatment options (medication OR supplement) that addresses all these complex factors in achieving health erections.
Erections begin with sexual stimulation, but achieving an optimal erection depends on far more than just sexual desire. There are many more interacting factors that must work together in a coordinated way to achieve the neurovascular event of a healthy firm erection. One small molecule helps coordinate this response: nitric oxide, commonly abbreviated NO, that signal the nerves, blood vessels, hormones, and smooth muscle to work together for the erection to occur.
If nitric oxide is deficient, hormone replacement therapy AND Viagra/Cialis may fail to work. This is the “blunting” effect of low nitric oxide. Nitric oxide is necessary for proper signaling in the brain for the nervous system to fully interpret sexual hormone signals. Nitric oxide tells blood vessels and erectile tissue to relax, allowing blood to enter the penis. When the body produces too little NO—or destroys it before it can act—erections become less firm or harder to maintain. Supporting this pathway through exercise, healthy eating and supplementation can help protect and improve healthy erections.
Nitric Oxide: The Tiny Molecule Master Signal for Erections
During sexual stimulation, nerve endings release nitric oxide into penile tissue. Cells lining the blood vessels, called endothelial cells, also produce nitric oxide and help sustain the response. Nitric oxide activates an enzyme that increases cyclic guanosine monophosphate, or cGMP. This intracellular messenger lowers calcium signaling and relaxes smooth muscle in the penile arteries and the corpora cavernosa—the two principal chambers of erectile tissue. Blood flows into these chambers, which expand and compress the veins that normally drain the penis. This combination of increased inflow and reduced outflow creates firmness.
Nitric oxide is also the mechanism of action for the popular prescription medications – Sildenafil (Viagra), and tadalafil (Cialis). Each medicine slows down the breakdown of cGMP, allowing the nitric oxide-initiated signal to last longer. These medicines do not primarily manufacture nitric oxide, just makes it last longer. Nitric oxide is the key factor. If you aren’t making enough NO, or don’t have the dietary precursor building blocks to make it, then the medicines alone can’t be as effective as they should be.
When Nitric Oxide signaling falters
A “lack of nitric oxide” usually means reduced availability where it matters, rather than a clearly measurable, whole-body deficiency. The body may produce less nitric oxide, its enzymes may function poorly, or oxidative stress may destroy nitric oxide before it reaches nearby smooth-muscle cells.
Common causes of endothelial damage and reduced production of NO include the COVID shots, Diabetes, hypertension, smoking, abnormal cholesterol, certain medications, and vascular aging. Diabetes, anticonvulsant/mood stabilizer medicines plus pelvic nerve injury can also interfere with the nerve signals that initiate an erection.
ED does not automatically indicate JUST a nitric oxide problem. As I discussed in our seminars on Testosterone therapy, there are many other contributing causes: medication effects, low testosterone, medical conditions listed above, anxiety, depression, structural changes in the penis and impaired blood retention, to name a few of the common ones. In my medical experience working with men over 40 years of practice, I have found that over 95% of my patients have had more than one cause—many have multiple causes from the list I gave you above. Persistent ED is itself a marker for both early Diabetes and early cardiovascular disease, even before these diseases may have been officially diagnosed. Again, that is why it is so important to have a thorough evaluation before starting any therapy or medication.
Nitric Oxide Production: Two pathways, different nutritional tools
The body produces nitric oxide (NO) through two complementary routes. Understanding them helps explain why arginine, citrulline, and beet juice are not interchangeable but complement the actions of each other.
Healthy Erections: What arginine research shows
L-arginine supplies the raw material that nitric-oxide-synthase enzymes use to produce nitric oxide. For men with ED, the evidence is encouraging. A 2019 systematic review and meta-analysis included 10 randomized trials involving 540 men found that arginine-containing interventions, using doses ranging from 1.5–5 grams daily, improved mild-to-moderate ED compared with placebo or no treatment.
L-arginine supplements have additional benefits beyond increasing nitric oxide: protein synthesis, ammonia detoxification, hormone secretion, and immune function. Athletes often use L-arginine to increase “muscle pump” during a workout and for several hours afterward, and to increase in overall workout capacity (muscular endurance) and an increase in post-exercise recovery.
Healthy Erections: Where citrulline fits
L-citrulline helps replenish arginine. It largely avoids the intestinal and liver metabolism that limits oral arginine availability, and the body subsequently converts it to arginine. Arginine is a more direct route and currently has a larger direct ED trial literature than citrulline and is why I chose to use L-arginine in a sustained release form for the Truth for Health store’s TruNitric Oxide SR™..
Featuring TruNitric Oxide SR™.
TruNitric Oxide SR™ offers a sustained-release arginine alpha-ketoglutarate formulation that supports circulatory and cardiovascular health, as well as muscle function and adaptation to exercise. Its defining feature is the sustained-release delivery design. Rather than presenting arginine only as an immediate-release ingredient, this formulation releases it over time. This provides a different delivery approach—to prolong bioavailability of L-arginine to make nitric oxide.
TruNitricOxide SR™ also contains ACTINOS2, a mixture of both high- and low-molecular weight fractions of proteins and peptides that activate nitric oxide synthase (NOS) activity which boosts nitric oxide production, enhances transcription of the NOS gene and supports its role in reducing the negative feedback mechanism for nitric oxide production.
Studies found ACTINOS2 increases nitric oxide production in human endothelial cells in vitro from 9.5 to 12.7 times compared to a control.
I also selected our TruNitricOxide SR™ product because it is manufactured in the United States using the highest purity (>98.0%) of commercially available L-arginine alpha ketoglutarate. This formulation is designed to deliver L-arginine alpha ketoglutarate in a controlled manner over a period of approximately 4-6 hours.
Healthy Erections: Food and Lifestyle Foundations
The strongest nutritional strategy is not a single “erection food.” It is a dietary pattern that supports the cardiovascular and metabolic systems on which erections depend.
- Mediterranean-style Meal Plans: The Foundation
A Mediterranean-style pattern emphasizes vegetables, fruit, legumes, whole grains, nuts, fish, and olive oil while limiting frequent processed meats and heavily refined foods. Research links this pattern with lower ED risk, and selected intervention studies suggest improvements in erectile function.
A 2020 cohort study followed 21,469 men. Among men younger than 60, those with the highest Mediterranean-diet scores had a 22% lower relative risk of developing ED than those with the lowest scores. Another study, a two-year randomized trial involving men with metabolic syndrome and ED also found improvements with a Mediterranean dietary intervention.
- Mediterranean Foods that Support Healthier Erections
Note: The evidence is strongest for combining these foods consistently. - What about beets, cacao, and watermelon promoted as “nature’s Viagra”
Beet juice can increase nitrate and nitrite availability and modestly reduce blood pressure in some people. However, a standardized nitrate product provides a more predictable exposure than random servings of juice which can depend on many other factors including brand quality, other added fruit juices and sugars, etc.
Raw or natural cacao provides flavanols that can support endothelial NO signaling. Processing matters: alkalization, also called Dutch processing, substantially reduces flavanol content.
Watermelon contains citrulline, but ordinary servings are not equivalent to the measured supplement used in a clinical trial. Calling watermelon “natural Viagra” overstates the evidence.
These are certainly healthy foods, and the beet juice supplies the clearest NO-related mechanism but may not be an effective ED treatment alone.
The Many Benefits of Exercise on Healthier Erections: it matters more than you think!
Aerobic exercise has direct evidence for improving erectile function. Trials commonly use 30–60-minute sessions, three to five times weekly. A practical goal is approximately 150–160 minutes each week, built up gradually. Brisk walking, swimming, and other comfortable aerobic activities are a good way to start. Consistency is the most important part of any exercise routine. Resistance training can complement the routine, but aerobic exercise has clearer direct evidence for ED
.
But there are many other frequently overlooked benefits of resistance (weight training) with aerobic exercise to help improve erectile function via other pathways. Here are just a few:Dr. Vliet’s Guide to Additional Exercise Benefits for Healthy Erections - Exercise increases loss of body fat that decreases testosterone action due to the estrone in body fat that increases sex hormone binding globulin and lowers free testosterone.
- Exercise increases muscle mass that adds another dimension to healthy testosterone production
- Exercise lowers inflammation and improves blood flow and nitric oxide production – benefitting penile blood flow to sustain erections.
- Exercise increases physiological relaxation that helps improve sexual arousal and helps reduce performance anxiety
- Exercise helps improve self-image with improved body composition and fitness, which in turn helps improve self confidence that can improve performance.
Lifestyle strategies to Improve Erectile Quality Steps YOU control and can take now include these lifestyle strategies:
- Stop smoking (both tobacco and marijuana impair erections via different pathways and mechanisms)
- Reduce heavy alcohol use (or cut it out completely for six months and observe the benefits!)
- Set up a regular exercise program
- Lose excess body fat
- Monitor blood pressure and blood glucose levels
- Improve sleep hygiene, and establish a regular sleep-wake cycle
- Evaluate suspected sleep apnea, especially when loud snoring, witnessed breathing pauses, or marked daytime sleepiness occur. Sleep-apnea treatment can improve erectile function in some men.
- Nasal breathing and humming are other interesting lifestyle strategies that have become popular lifestyle “hacks” but do have some credibility. Both nasal (and not mouth) breathing and humming increasing locally produced sinus nitric oxide that reaches the lungs. That is a real physiological process, but unfortunately it does not establish that nasal breathing or humming treats ED or substantially increases penile nitric oxide availability.
- Meditation, prayer, and relaxation training all help reduce lifestyle situational stress that can impair erections
- Relationship enhancement: take time for “date nights,” set aside time for focused foreplay to enhance sexual arousal and relaxation. Work with a couples’ therapist if significant marital conflicts are affecting performance for both partners.
Lifestyle benefits usually unfold over months to years. Exercise trials have typically assessed outcomes over several months, with a median intervention duration of six months. So don’t give up if these strategies don’t show immediate improvement! This is a marathon, not a sprint, and the changes you make now will have lasting benefits over many years!
Correct deficiencies, don’t just take supplements randomly
I know friends suggest new supplements, and guys at the gym are also talking about the latest gimmick to “build muscle” or “boost” sexual function. But you have to remember that nutrients help maintain normal hormone and metabolic balance and function, but supplements works most effectively when correcting a genuine deficiency. Adequate sleep, exercise, healthy meal plans (making sure you get the precursors needed for the body to make critical components like Nitric Oxide and your own testosterone!), weight management and stress management are the crucial foundations for your overall health, as well as healthy erections.
Clinical studies have found that nutraceutical effects to increase production of testosterone are generally modest and do not consistently translate into meaningful clinical benefits unless treating a documented deficiency demonstrated on reliable blood tests.
None of the above supplements should be described as a dependable way to restore normal testosterone or erections. Avoid building a large “testosterone and NO” stack based solely on possible mechanisms. A rise in a laboratory value is not the same as improved sexual function. I really don’t recommend all the “testosterone stacks” widely sold as alternatives to FDA approved testosterone replacement therapy in men with low T. You risk unwanted side effects and drug interactions with Rx medicines, and you risk the harms that come with missing out on proper treatment for your specific individual needs.
Cautions to Consider:
CAUTION: As always, we urge you to avoid supplements without checking knowledgeable sources to evaluate your medical situation, proper lab tests to verify what is needed, and to make sure to avoid adverse interactions with prescription medicines and other supplements you take. Under medical practice regulations, we are unable to answer individual medical questions or make specific individual supplement recommendations for people who are not established patients of Dr. Vliet’s independent medical practice (www.ViveLifeCenter.com).
“Natural” products can affect blood pressure and interact with medications and are not suitable for all men.
L-arginine can cause nausea, abdominal discomfort, diarrhea, bloating, and headache. It may add to the effects of antihypertensive drugs, prescription nitrates, or sildenafil. Mayo Clinic advises against L-arginine after a recent heart attack and identifies additional concerns with certain potassium-sparing diuretics, anticoagulants, and diabetes medicines.
Prescription nitrate medicines, such as nitroglycerin or isosorbide, must not be combined with PDE5 inhibitors (Cialis or Viagra) because the combination can cause dangerous hypotension. Ordinary nitrate-rich vegetables are not equivalent to prescription nitrate drugs, so are generally safe in normal portions.
Commercial sexual-enhancement honey packets, drinks, and proprietary blends warrant particular caution. FDA testing has repeatedly identified products containing undeclared sildenafil or tadalafil. A supplement’s absence from an FDA warning list does not establish its safety.
A critical point to keep in mind: supplements in the US have no regulatory oversight whatsoever for quality control, supply chain sources, contamination, or undisclosed added ingredients as I just mentioned –UNLESS THE PRODUCT HAS THE cGMP label on the bottle, as our products in the TFH Store have.
All Truth for Health Foundation Products Meet or Exceed cGMP Quality Standards, the highest quality standard for supplements sold in the USA. For more information, references from studies are listed in the Product Data Sheets for each product, available on our website. Check us out at www.TruthforHealth.org Click on tab for Store. OR www.shopTruthforHealth.com
Men with persistent or new ED should seek the comprehensive medical evaluation I described at the beginning of Health Tip that considers cardiovascular risk, glucose control, hormone status, medications, nutritional deficiencies, nerve function, and sleep disorders, and psychological contributors. Then an individualized, integrated treatment plan can be designed from all the modalities I described above in our our seminars (links at beginning of Health Tip).
Bottom Line
The most responsible approach combines a vascular-supportive lifestyle with a comprehensive individualized evaluation and plan. TruNitric Oxide SR™ is an excellent extended-release option for nutritional circulatory support, but remember healthy erections depend on the whole system — a healthy vascular system, healthy nerve function, optimal testosterone levels, adequate available local nitric oxide, healthy relationship and stimulation for optimal sexual arousal.
As you put all the pieces together that I have described today, I encourage you to consider our other natural medicines with our top quality, cGMP-compliant professional formulas: TruMitochondrial™ Boost, TruNAC™, Tru BioD3, Tru B™ Complex Full Spectrum, TruZinc™, TruC with BioFlavonoids (Natural sourced Vitamin C with complete Bioflavonoids), and TruProBiotic™ Daily to replenish critical bifidobacteria depleted by COVID shots, viral illnesses, and antibiotic therapy.
To Your good health and improving resilience!
Elizabeth Lee Vliet, MDClick here to read Dr. Vliet’s Health Tips
on these and more products.
