Q&A: What men with diabetes should know about reducing risk for erectile dysfunction
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Susan Weiner, MS, RDN, CDN, CDCES, FACES, talks with Brenda Jagatic, BScN, RN, CDCES, about the prevalence of erectile dysfunction for men with diabetes and healthy lifestyle behaviors to help lower risk.
Weiner: What is the prevalence of erectile dysfunction among men with diabetes?
Jagatic: Men with diabetes have a 3.5 times greater risk for erectile dysfunction (ED) than men without diabetes. In a 2016 meta-analysis, the prevalence of ED was 37.5% for men with type 1 diabetes and 66.3% for men with type 2 diabetes. Risk for ED increases with age and longer duration of diabetes.
Weiner: Do men with diabetes worry about how diabetes will affect their sex life?
Jagatic: Yes. A personal anecdote: 40 years ago, my husband was diagnosed with type 1 diabetes at age 23. One of his initial concerns was: Will this impact my sex life? His concerns were valid, since ED is more prevalent in men with diabetes.
Exploring and responding to men’s concerns about how diabetes will affect their sex life provides an opportunity to increase their awareness of the power of a healthy lifestyle to reduce their risk of ED.
Weiner: Why is ED a critical component of the clinical management of diabetes?
Jagatic: Healthy sexuality is an important part of one’s physical and mental health. It includes emotional, psychological, physical, intellectual and spiritual dimensions. Sex has many health benefits, including relieving stress, helping with sleep, supporting the immune system, natural pain relief, contributing to mental health, deepening emotional intimacy with a partner, strengthening the pelvic floor and it can be good for the heart.
Most men are uncomfortable sharing concerns about ED with their professionals and many health care providers are not comfortable about asking patients personal questions about their sex life. Research shows a discrepancy between ED self-reports and medical diagnosis: In a 2021 survey, only 7.7% of self-reported cases of ED were diagnosed by a professional.
By initiating this discussion, health care professionals can educate and empower men with diabetes. This can build trust, increase patient satisfaction, enhance patient engagement in preventive care, and improve both patient quality of life and clinical outcomes. A medication review can identify medications that may be causing or contributing to ED. A diagnosis of ED in men with diabetes can be a warning sign of cardiovascular disease and prompts a proactive CV workup per Princeton III guidelines.
Weiner: How can healthy lifestyle behaviors prevent, manage and/or reverse ED?
Jagatic: According to the Mayo Clinic, lifestyle changes are as powerful as medications in helping with erections. Lifestyle changes should both precede and accompany ED treatments.
Healthy lifestyle behaviors can have a positive impact on some of the psychological (ie, stress, anxiety, depression) and physical causes (ie, endothelial and neural dysfunction) of ED by enhancing the production and/or the effects of nitric oxide and improving blood flow.
Nitric oxide, a compound made by the body, improves the health and function of blood vessels. It relaxes muscles in the penis, increases blood flow and facilitates an erection in response to sexual stimulation. Nitric oxide also relaxes blood vessels around the heart, lowers blood pressure and reduces likelihood of platelets clumping to form clots — and this reduces risk for myocardial infarction.
Weiner: Can you give examples of lifestyle behaviors that affect the risk of developing ED for men with diabetes?
Jagatic: Yes, of course. Let’s review six lifestyle behaviors:
- Healthy eating: Research shows a high intake of fat and sugar is linked to decreased vascular nitric oxide and a plant-based diet decreases the risk for CVD and ED. The package insert for Viagra (sildenafil citrate, Pfizer) explains that a fatty meal can impair its effectiveness.
- Being active: Sedentary behavior is a risk factor for ED. Physical activity can increase serum nitric oxide levels, reduce the risk for ED and can improve erectile function for men with by vascular ED.
- Sleeping well: Short sleep duration damages endothelial function by reducing nitric oxide bioavailability and is associated with ED and depression. Shift workers are at greater risk. It is recommended individuals get 7 to 9 hours of sleep each night.
- Healthy coping: Stress can impact the sexual response and contribute to ED. Finding positive ways to manage stress, such as mindfulness and relaxation techniques, can improve sexual function and relationships.
- Smoking cessation: Smoking impairs endothelial function by decreasing the formation of nitric oxide and increasing the degradation of nitric oxide via generation of oxygen-free radicals. Smokers are at greater risk for ED and CVD. Most smokers want to quit. Most will need smoking cessation counseling and medications to succeed.
- Limit alcohol intake: High concentrations of alcohol or chronic alcohol ingestion impairs endothelial and nitrergic nerve functions in association with reduced nitric oxide bioavailability. Alcohol-induced sexual dysfunction often is reversible with cessation of alcohol use. This can be incorporated into motivational counseling for heavy drinkers providing an impetus for change.
Weiner: What are some helpful tips to initiate a discussion about ED in clinical practice?
Jagatic: Practitioners do not have to be a certified sex therapist to approach this topic. Suggesting your patient complete a Quality of Life Enjoyment and Satisfaction Questionnaire (link below) can be a starting point for open dialogue about sensitive issues like ED.
Keeping it simple can help: “Mr. Smith, men with diabetes are at greater risk for ED. Research has shown that healthy lifestyle choices can help to prevent, manage and/or reverse ED. Would you be interested in learning more?”
Sharing a link to the following podcast can increase your patient’s awareness of the power of lifestyle: Mastering Diabetes: “Men’s Health & Diabetes – Tackling Erectile Dysfunction Through Lifestyle Changes” (link below).
Weiner: How can professionals support men with diabetes who are interested in making positive lifestyle changes?
Jagatic: As trusted sources for health information, professionals can encourage men with diabetes to take charge of their health and well-being by engaging in positive self-care practices. Referrals to supportive, skilled resources can empower men with diabetes to incorporate healthy lifestyle into their diabetes management. This could include certified diabetes care and education specialists, registered dietitians, board-certified health and wellness coaches, physical therapists, sleep specialists, podiatrists, smoking cessation programs, mindfulness programs, mental health counselors and Alcoholics Anonymous.
Two new recommendations in the American Diabetes Association’s 2025 Standards of Care focus on sexual health for men. The first recommendation states health care professionals should screen men with prediabetes or diabetes for potential symptoms of hypogonadism. If symptoms are present, a morning serum testosterone level should be collected.
The second recommendation states all men with prediabetes and diabetes should be screened for ED. The Standards of Care states ED is prevalent in 52.5% of men with diabetes. Screening should be emphasized in men with high cardiovascular risk, retinopathy, cardiovascular disease, chronic kidney disease, peripheral or autonomic neuropathy, longer duration of diabetes, depression, hypogonadism and those not meeting their glycemic goals.
- References:
- ADA Standards of Care in Diabetes – 2025. https://diabetesjournals.org/care/issue/48/Supplement_1. Published Dec. 9, 2024. Accessed Dec. 19, 2024.
- Arackal BS, et al. Indian J Psychiatry. 2007;doi:10.4103/0019-5545.33257.
- Arefirad T, et al. Front Physiol. 2022;doi:10.3389/fphys.2022.953912.
- Defeudis G, et al. Diabetes Metab Res Rev. 2021;doi:10.1002/dmrr.3494.
- Kouidrat Y, et al. Diabet Med. 2017;doi:10.1111/dme.13403.
- Mark KP, et al. J Sex Med. 2024;doi:10.1093/jsxmed/qdae008.
- Mastering Diabetes Audio Experience podcast. Men’s Health and Diabetes: Tackling ED Through Lifestyle Changes. https://podcasts.apple.com/us/podcast/mens-health-and-diabetes-tackling-ed-through/id1314224547?i=1000658595543. Accessed Dec. 10, 2024.
- Mayo Clinic. Erectile dysfunction FAQs. https://www.mayoclinic.org/diseases-conditions/erectile-dysfunction/multimedia/vid-20531989. Accessed Dec. 10, 2024.
- MedLinePlus. Drugs that may cause erection problems. https://medlineplus.gov/ency/article/004024.htm. Accessed Dec. 10, 2024.
- Nehra A, et al. Mayo Clin Proc. 2012;doi:10.1016/j.mayocp.2012.06.015.
- Perelman School of Medicine at the University of Pennsylvania. Quality of Life Enjoyment and Satisfaction Questionnaire – Short Form (Q-LES-Q-SF). Accessed Dec. 10, 2024.
- Toda N, et al. Eur J Pharmacol. 2010;doi:10.1016/j.ejphar.2010.09.042.
- Valderrama Rodriguez FM, et al. Int J Environ Res Public Health. 2023;doi:10.3390/ijerph20043739.
- Zhang F, et al. Nat Sci Sleep. 2022;doi:10.2147/NSS.S375571.
- For more information:
- Brenda Jagatic, BScN, RN, CDCES, is owner of HSH Lifestyles Healthier-Stronger-Happier LLC; an active member of the American College of Lifestyle Medicine; and was co-producer of the award-winning TV talk show Let’s Talk Sex Talk. She can be reached at brendaj@hshlifestyles.com.
- Susan Weiner, MS, RDN, CDN, CDCES, FADCES, is co-author of The Complete Diabetes Organizer and Diabetes: 365 Tips for Living Well. She is the owner of Susan Weiner Nutrition PLLC and is the Healio | Endocrine Today Diabetes in Real Life column editor. She can be reached at susan@susanweinernutrition.com; X (Twitter): @susangweiner; Instagram: @susanweinernutrition.
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