Erectile Dysfunction Defined
Erectile dysfunction is the chronic inability to achieve or sustain an erection firm enough for sexual intercourse. The key there is chronic inability not being able to get it to get an erection. One evening does not qualify as erectile dysfunction.
It used to be more commonly referred to as impotency, but the medical community now prefers the term erectile dysfunction. ED is fairly common especially as men age, but sexual dysfunction should never be considered normal despite being common at any age.
ED has a significant impact on the quality of life of both sufferers and their partners. ED is different from other sexual issues such as lack of libido or sexual desire or difficulty ejaculating.
To achieve an erection the following actions must occur first. There must be a stimulus from the brain – in other words, there must be some kind of sexual interest, and this culminates into chemical cascades.
Then the nerves that are run from the brain down the spinal cord and out to the penis must function properly. Then the arterial blood supply to the penis must be adequate; in other words, enough blood must be able to fill up the penis. Finally, the veins within the penis must be able to trap the blood which keeps the erection hard.
If there is something interfering with any of these – whether it be an accident, an injury, a disease, a psychological issue – then a firm erection is prevented.
The diagram to the right shows some of the main structures of the penis including the dorsal vein in the various cavernous arteries an erection occurs when two tubular-like structures that run the length of the penis become engorged with blood individually they’re known as the corpus cavernosum.
On the diagram to the right you can see the two upper corpus cavernosum they’re partially separated by a septum lots of cavernosa spaces and they’re fed by cavernosa arteries.
The corpus spongiosum which is a single tube located below the corpora cavernosa that’s plural that contained the urethra may also become engorged with the blood but the corpus spongiosum contributes less to a firm erection than do the corpora cavernosa.
You can see in the diagram to the right the urethra is in the middle of the corpus spongiosum and this explains why it’s very difficult for a man to urinate while he has an erection.
Basically, it pinches off the urethra it makes it difficult for the bladder to empty. Although during ejaculation because of the smooth muscle contractions, semen is able to exit the urethra despite an erection. As an interesting sidenote, ejaculation doesn’t require an erection.
Physical issues caused most cases of ED, at least 80%, especially in older men.
Examples include blood vessel diseases especially atherosclerosis or clogged arteries, but also venous leakage nerve damage caused by spinal trauma or cerebral stroke and other diseases that affect nerves such as multiple sclerosis, ALS, also known as Lou Gehrig’s disease, Alzheimer’s or Parkinson’s disease.
Chronic illness is a common physical cause of ED including cancer, diabetes, chronic kidney and liver diseases.
Diabetes is a physical cause of ED because high levels of glucose in the blood are toxic and destructive to small nerves and blood vessels. The physical side effects from medications, alcoholism, and drug abuse are also significant causes of ED.
Erectile Dysfunction can also be caused by damage to the penis such as from blunt trauma, surgical side effect, or Peyronie’s disease which is an accumulation of scar tissue that leads to painful erections.
Surgeries that can certainly damage the penis include prostate gland surgery and also surgeries to enlarge the penis or aesthetically shape it; which are becoming much more common.
Obesity or mold hormone imbalance and metabolic syndrome are also possible physical causes of ED.
Diabetes is the most common physical cause of erectile dysfunction. As you can see from the pie chart below it is estimated that 40% that the physical causes of ED are due to diabetes.
The next most common physical cause is a vascular disease in particular atherosclerosis, but obviously, there is a relationship between diabetes and vascular problems because as I noted glucose high levels of glucose in the blood are very toxic and destructive to blood vessels and nerves.
Other physical causes include radical surgery. Radical surgery in this sense means removal of the prostate gland, because of excessive benign growth or because of prostate cancer.
Spinal cord injury estimated to be 8%, endocrine disorders particular problems with glands such as the thyroid adrenal glands, etc., and of course we have MS, and about 3% which is much more common in more northerly latitude psychological factors are responsible for between 10 and 20 percent of ED, meaning that they’re the sole causes of between 10 and 20 percent although they can obviously compound any physical causes and of course strictly physical causes will eventually lead to some psychological issues with time.
Examples of psychological factors include excessive stress, depression, and other mental health issues.
For example schizophrenia, poor self-esteem, and of course, a very common one is simple performance anxiety. And this is being compounded and increased over the years because of the increase in pornography material so men that watch pornography watch the porn stars in action are much more likely to suffer performance anxiety in their own sexual situations.
Essentially any lifestyle choice that impairs blood flow or damages nerves dramatically increases the risk for ED. The most common ones include tobacco smoking. In fact, smokers have twice the risk of ED compared to non-smokers. Tobacco smoke contains various carcinogens but it also contains compounds that damage blood vessels and nerve fibers.
Chronic Alcoholism is a very common cause associated with ED, but so is binge drinking even just for one evening. As most men are aware of the irony is that drinking alcohol often increases libido and it also reduces inhibitions but it’s a central nervous system depressant so it kind of causes a bit of a disconnect below the waist, if you get my meaning.
Lifestyle Factors That Can Cause ED
Illicit drug abuse is associated with a higher incidence of ED. In particular, the use of amphetamines, cocaine, and marijuana, using prescription meds can also increase your risk of ED, and the drugs most commonly associated with ED are antidepressants, antihistamines, analgesics, or pain killers, and medications used to control hypertension.
Obesity and lack of exercise are also lifestyle factors, as is cycling. In fact, avid cyclers suffer more ED because the bike seat puts pressure on the perineum which contains blood vessels and nerves that feed the penis. Avid cyclists also suffer a much higher incidence of prostate problems, including benign hypertrophy and prostate cancer.
Lack of sleep often causes chronic fatigue which can lead to or trigger ED, primarily because of the lack of energy which reduces libido and also, the associated hormonal imbalance.
Many issues can result from ED including unsatisfactory sex life, the inability to get a partner pregnant, although keep in mind an erection is not necessary for ejaculation mantle and that’s an emotional stimulation is really the primary ingredient. Marital and relationship problems are common compounding stress and anxiety from the workplace or from raising kids etc.
ED also usually leads to a continual or chronic feeling of embarrassment in men, which of course is tied hand-in-hand with low self-esteem because of these feelings low self-esteem depression, and embarrassment there is an increased risk of drug and alcohol abuse for those men and suffer from ED.
According to the Massachusetts male aging study, approximately 40% of men experienced some degree of erectile dysfunction at age 40, and this is compared to 70 percent of men at age 70 that report at least some degree of ED.
Keep in mind that to be diagnosed as ED, there has to be a bit of an established pattern not just one night of binge drinking for example. Overall about 52% of American men have some sort of ED. You can look at the bar graph to the right blue that’s the 52% in other words 48% of American men apparently do not suffer from ED or ED they don’t report.
Within the 52% of men that do, 25% report or are diagnosed as having moderate levels of ED, and I guess a loose definition of moderate could be the failure to achieve an erection greater than 50% of the time.
Although less than 90% of the time, 10% of American men either diagnosed with or report complete erectile dysfunction; which is total failure at least 90% of the time if not 100% of the time.
And then 17% of American men are diagnosed with or report minimal erectile dysfunction. And again it’s a rather loose definition, but usually, failure to achieve erection up to 50 percent of the time. Beyond 50 percent is usually categorized as moderate ED.
Keep in mind that these definitions of mild, moderate, and severe are relatively subjective because for some men may not achieving an erection 10% of the time is a disaster; It’s a serious problem for them. Whereas another man not getting an erection 10% of the time may be considered completely normal and fine. It is a subjective issue to a certain extent and these definitions are not set in stone.
Having said that, moderate to severe erectile dysfunction does dramatically increase with age. There is about a 20% incidence of men. This is in American men by the way between the ages of 50 to 55. Moderate to severe ED increases to 48% – incidents for men between the ages of 60 to 65, and it’s about 82% for men between the ages of 70 to 75. Again we can see in the diagram below how that dramatically increases.
There seems to be a slightly different prevalence of ED among racial and ethnic groups.
For example, some research indicates that Hispanic and Asian men appear to have an increased risk of moderate levels of ED compared to African Americans or Caucasians of European ancestry. On the other hand, Asian and African American men are least likely to be diagnosed or to suffer from severe ED. African-American men are also least likely to report ED issues so the actual prevalence is difficult to gauge in relation to other ethnic groups.
Obviously many factors are involved here, not just skin color. These have to do with cultural habits, dietary factors, etc.
Let’s summarize the major w for men older than 50 years of age regardless of ethnicity.
- diabetes hypertension or high blood pressure
- high cholesterol which is also linked to a higher risk of atherosclerosis
- low testosterone levels which we’ll get into more in detail
- smoking of course as we mentioned earlier (smokers have twice the risk compared to non-smokers of cardiovascular disease in general, not just atherosclerosis but other issues with the heart)
- and of course depression.
These are the major risk factors for ED as alluded to previously.
There is a difference of opinion on the criteria for diagnosing ED; in other words, it’s quite subjective. Some doctors and men believe that any difficulty achieving and maintaining an erection is indicative of Erectile Dysfunction and is problematic.
Other medical sources define ED as not being able to achieve or maintain a firm erection at least 75 percent of the time they attempt sex, over the course of many weeks or months. I think all of us would agree that 75 percent of the time is a major problem but some of us believe that even 10 percent of the time would be a big problem.
In summary, it depends mainly on the man who suffers from ED and if and when they seek diagnosis or treatment as to whether or not a diagnosis of ED is agreed upon.
As an interesting aside, a significant percentage of men would rather claim they have ED or jump through all the medical hoops associated with ED rather than admit they are simply no longer attracted to their mates. Strange but true, not being attracted to your mate or having a naturally low libido is not considered a cause of ED.
Men have different levels of sexual interest and libido and some men just naturally have lower libido despite the fact that they have normal levels of testosterone. However, testosterone can become a factor if low levels are directly associated with low libido.
Some causes of low testosterone include hypothalamic-pituitary diseases, genetic diseases such as Klinefelter’s syndrome, damaged testes from direct trauma, or infections such as mumps. The main symptoms of low testosterone, aside from potentially the inability to achieve an erection in having low libido are:
- lack of a beard and body hair,
- decreased muscle mass,
- fatty accumulation around the midsection,
- and possible development of breast tissue which is called gynecomastia.
Before or during any tests your doctor should perform a medical history and a physical exam. It’s possible that a psychological referral may also be included especially if depression or other mental health issues is obvious because there are many different causes of ED. There are several different lab tests that may be useful.
For example a CBC or complete blood count which looks for anemia, which is indicated by low levels of red blood cells or abnormal red blood cell formation, low levels of hemoglobin and iron, but also looking for infection which would be characterized by increased levels of white blood cells. Liver and kidney function tests of course checking for the function.
A possible disease of these organs, lipid profile high levels of triglycerides and other lipids may indicate a higher risk of atherosclerosis, thyroid function tests, thyroid hormones such as thyroxine do help regulate the production of sex hormones such as testosterone. A blood hormone study – the general test, but of course testosterone and prolactin levels would be most relevant here.
A urine analysis may be helpful which looks at protein, glucose, white blood cell, and testosterone levels of course. High levels of glucose are associated with possible diabetes.
PSA tests prostate-specific antigen which determines if there is some kind of pathology of the prostate gland, whether it be benign hypertrophy or prostate cancer. Problems with the prostate do affect the ability to get an erection because of the proximity of the gland to the male penis.
Sometimes more specialized testing is needed to determine the cause and ED, such as duplex ultrasound. This is useful to evaluate blood flow and check for signs of a venous leak, but also atherosclerosis or potential excessive tissue scarring which is the case with Peyronie’s disease.
Nocturnal penile tumescence or NPT. These measures erectile function while you’re asleep.
Normally men should have five possibly six erections while they sleep. Fewer than these numbers where there are no erections during nighttime might indicate nerve function or circulation issues.
Penile bio geometry involves the use of electromagnetic vibration to determine sensitivity. If a man cannot feel these vibrations, it’s indicative of reduced nerve function. There is also vasoactive injection where an erection is produced by injecting a special solution that causes the blood vessels to dilate which allows blood to enter the penis.
The reactive injections are often combined with ultrasound studies.
Dynamic Infusion Cavernosometry. This is used for men that are diagnosed with ED to determine the severity of a venous leak so fluid is pumped into the penis at a predetermined rate and it’s measured how quickly it flows out. A dye can be added to this fluid and then x-rays can be taken.
Erection issues less than 20% of the time are not unusual in the American population and treatment is not typically recommended by most doctors, but again it depends on the doctor. It depends on the man suffering from the erectile problem. Erection problems greater than 50 percent of the time certainly indicate there is a serious problem requiring treatment.
Treatment options include the following general categories.
- Psychotherapy in terms of psychoanalysis or general counseling.
- Natural remedies. It’s a big category but includes herbs, vitamins, and other supplements.
- Vacuum devices commonly known as pumps.
- Drug therapy of course.
- And as a last resort, surgical procedures.
Psychological factors directly cause or initiate between 10 to 20 percent of ED, but purely physical causes eventually lead to more psychological or emotional issues such as depression and anxiety.
So after a period of time, the physical goes hand-in-hand with a psychological and they’re very difficult to determine which came first. It’s a bit of a chicken versus the egg sort of dilemma.
Psychological counseling sessions typically focus on relationship difficulties or performance anxiety, which seems to be much more common in men who view or read excessive pornography, work problems, and stress financial troubles; which of course are much more common in times of so-called economic downturns. Poor self-image certainly plays a role as does drug and alcohol dependency.
Let’s start with an overview of the natural remedies that can be used and are used to treat ED.
There are a variety of natural treatments and approaches such as lifestyle change. In other words, quit smoking, reduce intake of alcoholic beverages – for men the maximum recommended daily intake is two alcoholic drinks per day.
Exercising more, losing weight, controlling blood glucose levels, and managing stress would all fall under lifestyle changes.
Herbal remedies. It’s important to note that none are really accepted by mainstream medicine or the FDA but the vast majority are safe time-proven and relatively inexpensive.
Homeopathic tinctures. These are often based on herbs or minerals. Homeopathy is not generally accepted by mainstream medicine, but it’s certainly been around as a competitor for mainstream medicine since the mid to late 1800s.
Nutritional supplements. These include amino acids, bioflavonoids, vitamins, minerals, and hormones such as DHEA.
Another natural remedy that can sometimes be used for ED is acupuncture; which in general promotes healthy nerve and blood flow, which are obviously two big factors in ED.
Chinese, African, and many other cultures have long used herbs to treat erectile dysfunction, but these remedies are usually not well studied by American researchers.
Natural Remedies for ED
Common herbal remedies include Korean red ginseng which is considered the most potent form of ginseng. It helps regulate so-called yang energy in the body which can boost vitality and stamina, combat fatigue, enhance libido and help with ED depending on its cause.
Ashwagandha is sometimes called Indian ginseng. I’m referring to East India, not Native American Indians. Because Ashwagandha has similar effects as Korean ginseng, although there is no research regarding ED. Common side effects of ashwagandha include drowsiness, so it shouldn’t be combined with other sedatives either natural or drug-based.
Ginkgo biloba. This is a vasodilator and blood thinner that increases blood flow and relaxes smooth mush muscle tissue. It’s also a good antioxidant. Some studies do show that ginkgo is particularly effective for ED caused by antidepressant drug use.
Yohimbe bark is from certain varieties of trees common in Africa. It contains about 6% of a compound called yohimbine which stimulates pelvic nerves, dilates blood vessels, and increases heart rate. In fact, a 1990 Journal of Urology meta-analysis found that yohimbine induces erections in 30% of men with erectile dysfunction by increasing blood flow to the penis and stimulating their libidos.
Yohimbe bark is potentially dangerous in larger doses because it can cause a severe reduction in blood pressure, dizziness, hallucinations, and paralysis. In this sense, Yohimbe bark is relatively unusual as a possible remedy because of its potential for serious side effects.
Horny goat weed. This was mainly an aphrodisiac, but it’s also used for erectile dysfunction. The leaves contain flavonoids, polysaccharides, sterols, and an alkaloid called Magna fluorine. Horny goat weed’s mechanism of action is still largely unknown.
DHEA (dehydroepiandrosterone) is a steroidal hormone produced by the adrenal glands which sit atop your kidneys. The body converts DHEA into male and female sex hormones such as testosterone and estrogen. It may help some men with ED especially if they have low testosterone levels and that can be established as the cause of the ED.
Some research shows that low DHEA levels are common among men with ED, particularly men younger than 60 years of age. However, supplements do not appear to benefit ED if it’s caused by diabetes or nerve issues such as MS.
The supplements are made from dioxygen which is a compound found in soy and wild yams. All supplements were taken off the market in 1985 because of concerns of false claims, but DHEA was reintroduced as a nutritional supplement in 1994.
The long-term safety of taking DHEA supplements is unknown, so exercise caution.
Arginine is a non-essential amino acid used to make nitric oxide which is a chemical that signals the smooth muscle to relax and allows blood vessels especially arteries to dilate. Some research has concluded that arginine at doses between 1,500 and 5,000 milligrams daily for up to six weeks improves erectile dysfunction which is why it’s sometimes called natural viagra.
However, high doses of arginine may stimulate the body’s production of gastrin, a hormone that increases stomach acidity. So high doses are not appropriate for people with gastric ulcers. Arginine may also alter potassium levels if taken in large doses especially in people with liver disease. Arginine is commonly found in a wide variety of foods such as meat, poultry, fish, and dairy.
For those biochemists, there is a molecular depiction of arginine to the right carnitine is a substance that helps turn fat into energy and it’s also a fairly powerful antioxidant that combats atherosclerosis.
Some studies suggest that supplemental forms of carnitine in particular Proprio know as L-carnitine and acetyl l-carnitine enhance the effectiveness of Viagra, which results in improved erectile function.
Propionyl L carnitine plus viagra may be significantly more effective than taking Viagra alone. Carnitine is also effective for erectile dysfunction caused by diabetes.
Other nutritional supplements used to treat ED naturally include bioflavonoids, zinc, magnesium, vitamins C and E, and flaxseed products.
Vacuum devices improve the firmness of erections by increasing blood flow to the penis and vacuum devices are available with or without a prescription. Approximately 80% of men who use a vacuum device are able to obtain an erection hard enough for sexual intercourse. Vacuum erection devices are typically made of three parts.
One part is a clear plastic tube that slides over the penis, another important part is a manual or battery-operated pump that sucks the air out of the plastic cylinder and of course, this draws in more blood to the penis, and the third major component of these vacuum devices is some sort of an elastic ring that’s placed around the base of the penis after an erection is achieved, which prevents the blood from escaping from the penis.
On the downside, vacuum devices are typically cumbersome and compromise spontaneity. Furthermore, the elastic rings may lead to irritation bruising, or pain.
The most common oral medication prescribed to men with ED are called Phosphodiesterase Type 5 Inhibitors and they include sildenafil brand, brand name viagra which is still the most commonly sold pde5 inhibitor, Tadalafil brand-name Cialis which has the longest half-life and last the longest, Vardenafil brand names Levitra or Staxyn and the newest one called Avanafil fill brand-name Stendra which has the fastest onset and was approved by the FDA in 2012.
Other less common and less effective oral meds for ED include taking antidepressants such as Trazodone. A main non-oral alternative for ED is called alprostadil which is available as an injection or suppository.
All pde5 inhibitors work similarly that is they enhance the effects of nitric oxide which I’ve described as a chemical that relaxes smooth muscles in the penis and increases blood flow.
Approximately 80% of men who take pde5 inhibitors as directed have firmer and longer-lasting erections however these types of drugs do not stimulate libido or impact testosterone levels. pde5 inhibitors are typically taken by the mouth of a one-hour or possibly 45 minutes before wanting to have sex, and they should not be used more than once a day.
Viagra, Levitra, and stand row last about 5 hours although Cialis can work up to 36 hours because its half-life is much longer with the exception of Staxyn which dissolves in the mouth and has a quicker onset. Most other pde5 inhibitors are swallowed in pill form. Combining pde5 inhibitors with blood pressure meds or nitrate drugs such as nitroglycerin tablets for angina pain is dangerous due to a potentially fatal drop in blood pressure, so it should be avoided.
The most common side effects of using pde5 inhibitors include headache, runny nose, dizziness, and flushing; which is particularly common with viagra and Levitra use, muscle aches and back pain, which is more common with Cialis use, and strange Bluegreen visual shading sometimes referred to as blue vision which is most commonly seen with Viagra and Levitra use.
The main reason why pde5 inhibitors lead to headaches and flushing is that they dilate blood vessels.
If depression is the predominant cause of our erectile dysfunction then various antidepressant meds may be indicated but ironically reduced libido is a common side effect of most antidepressants.
However, Trazadone is a serotonin antagonist and reuptake inhibitor antidepressant that also appears to possess significant stimulating effects on libido and erectile functions.
So in this sense, Trazadone is a bit of an unusual antidepressant. Some studies reported slightly better sexual function in men who took Trazadone but the follow-up trials are conflicting and some of the results are unconvincing as such current guidelines do not recommend taking Trazadone for the treatment of ED.
If oral pde5 inhibitors such as viagra do not significantly impact erectile dysfunction or perhaps the pde5 inhibitors can’t be taken for medical reasons then alprostadil is usually recommended. It’s a powerful vasodilator that triggers an erection within minutes and typically the erections last about an hour while porosity only works if the blood flow is intact.
However, now alprostadil is given in two different ways; intro cavernous injection whereas a solution of alprostadil is injected directly into the base of the penis. No more than three times per week is recommended.
After the patient learns how to perform the injections, he is expected to do it himself each time he’s interested in having sex, up to a maximum of three times per week.
There is an increased risk of damage scarring and priapism, which is prolonged and painful erections typically lasting more than four to five hours.
Another way of taking alprostadil is via suppository in this case pellets are placed into the urethra at the tip of the penis this method is typically less successful compared to injections although the side effects are also less.
As mentioned earlier testosterone is a male hormone or androgen produced mainly in the testicles, but also in the adrenal glands. It helps maintain bone density, fat distribution, muscle strength, and mass red blood cell production, sex drive or libido, and also sperm production. The hormone peaks during adolescence and early adulthood and then gradually decline about one percent per year beyond the age of thirty.
About twenty-five percent of men over the age of seventy do not produce enough testosterone. Testosterone therapy which can occur via injection or gel is only recommended as a treatment for ED when the levels are low.
However, slightly lower testosterone levels do not necessarily mean there’s going to be reduced libido or erectile dysfunction it best time to test the blood for testosterone levels is usually in the morning between the hours of 7 and 10 a.m. because testosterone levels are known to fluctuate quite significantly according to mood and dietary factors throughout the day.
Surgical Procedures to Treat ED
Surgical procedures are usually only recommended if the Erectile Dysfunction is severe enough or complete and there’s no response from psychological natural or pharmaceutical treatments – it’s the last resort.
- the placement of an implant that is either inflatable or semi-rigid and this happens usually on both sides of the penis,
- or vascular reconstruction surgery to improve blood flow or to reduce blood leakage from the penis and surrounding structures.
As noted there are two types of penile implants inflatable and semi-rigid rods. The inflatable type for the most common in the United States and they are more natural in the sense that they can be inflated to create an erection just prior to having sex and then deflate it afterward.
The diagram on the left is an example of a three-piece inflatable implant. The pump was within the scrotum sometimes to fit the pump within the scrotum a testicle has to be removed but that’s not normally the case. It was also a fairly large fluid reservoir inserted into the lower abdomen and of course, the two inflatables are inserted on either side of the penis. The two-piece inflatable model works in a similar way to the three-piece but the fluid reservoir is part of the pump implanted in the scrotum.
The advantage of having a three-piece is that there’s more fluid to pump into the penis which can give a more firm erection. In contrast, semi-rigid rods are always firm, but the surgery is less complicated and prone to failure.
Reconstruction surgery involves either repairing the arterial blockages to improve blood flow into the penis or reducing the venous leakage out of the penis. Penile arterial revascularisation is a procedure designed to keep blood flowing by rerouting it around blocked or injured vessels. Typically it’s indicated only for young men less than the age of 45 that have no known risk factors for atherosclerosis. The surgery is aimed at correcting any vessel injury at the base of the penis caused by blunt trauma or pelvic fracture in contrast to venous ligation surgery which focuses on binding leaky penile veins that are causing penile rigidity to diminish during erections.
Venous occlusion which is necessary for sufficient firmness depends on arterial blood flow and relaxation of the spongy tissue in the penis. However, the long-term success rate of this surgery is less than 50%.
Virtually every other disease gene therapy for ED is being studied by scientists. The question is what percentage of ED is related to faulty genetics? The belief is at very little ED is related to faulty genes, although future research should be able to tell us more. Scientists are also researching whether a substance made from spider venom could help with ED. A certain poisonous spider releases a substance from its bite it apparently triggers priapism which is a painfully prolonged erection typically lasting 4 or 5 hours or more.
You may be able to reduce the risk or incidence of ED with regular exercise, maintain a healthy diet and weight, stop smoking tobacco and marijuana, avoid alcohol and substance abuse. For men no more than two drinks a day alcoholic drinks. Maintain healthy blood glucose and cholesterol levels, control high blood pressure, take steps to reduce your stress – suggestions include yoga meditation or starting a new fun low-stress hobby. Get truly restful sleep at night, be cautious when bike riding long distances and finally get help for anxiety or depression.