How can you improve your sexual performance?

Here’s a very popular question – let’s see what the scientists have to say about it. On 13 November 2020, a new study was published in the Journal of the American Medical Association (JAMA Network Open). It states that following a Mediterranean diet is associated with a lower risk of erectile dysfunction. 

The study therefore clearly suggests that the Mediterranean diet is once again the best option, even for sexual health. The study was carried out on 21,469 men and focused on a Mediterranean diet, which emphasises the consumption of vegetables, fruit, cereals, pulses, fish, extra virgin olive oil and other sources of long-chain fats, whilst avoiding red meat and processed meat.

The study also showed that erectile dysfunction, particularly in young men, is an early sign of cardiovascular disease and can certainly impair quality of life. The issue becomes more complex when there are underlying hereditary genetic conditions that predispose individuals to major cardiovascular risk factors.

Consequently, to improve cardiovascular health and erectile function, men should first adopt a healthy, Mediterranean-style diet, combined with regular physical activity to maintain a healthy cardiovascular system.

Several studies have shown that men who combine physical activity with a Mediterranean-style diet can derive additional and greater benefits in supporting erectile function. Regular exercise and the Mediterranean diet do indeed stimulate the release of nitric oxide and improve the health and function of the endothelial cells that line the blood vessel walls.

It is often observed that overweight men who undergo healthy, well-managed weight loss improve their erectile function, optimise their testosterone levels and enhance their sexual wellbeing. 

Research has shown that men who follow the Mediterranean diet – which is low in saturated fats and rich in monounsaturated fats, omega-3 fats, nitrates and polyphenols (found in extra virgin olive oil, nuts, oily fish, fruit and leafy vegetables) are less likely to suffer from erectile dysfunction. 

Studies have also shown that men with metabolic syndrome – a combination of risk factors (high blood pressure, hyperlipidaemia and insulin resistance) – are more than 100 per cent more likely to have erectile problems than those who exercise regularly and watch what they eat. 

Are there any dietary supplements that can support sexual health?

Yes, there are substances that have been extensively studied in the scientific literature and can therefore be considered valuable allies for sexual health. Let’s take a look at them:

L-citrulline

L-citrulline is an amino acid which, when taken orally, is converted in the body into L-arginine. Scientific research has shown that L-citrulline significantly increases L-arginine levels in the body, more effectively than taking L-arginine itself. This results in increased production of NO (nitric oxide), the ultimate vasodilator.

By dilating the blood vessels, nitric oxide allows more blood to flow to the tissues and, consequently, to the penis. Research has shown that 5 to 6 grams of L-citrulline per day for seven days reduced the stiffness of blood vessels in middle-aged men (International Journal of Cardiology, 8 November 2010), thereby improving circulation.

Research has also shown that oral citrulline can improve erectile function (Sex Med, 2018). Oral citrulline supplementation at a dose of 5 grams per day (for 30 days) improves erectile function in men with erectile dysfunction (Urology, January 2011). 

A more recent study published in the July 2019 issue of the Journal of Andrology compared the erectile dysfunction medication sildenafil (50 mg) alone or in combination with L-arginine (3 grams) per day for eight weeks. 

The researchers concluded that adding L-arginine to sildenafil proved more effective than sildenafil alone for treating patients with erectile dysfunction. As L-citrulline is more effective than L-arginine at increasing blood arginine levels, it can be expected that citrulline will be much more effective than L-arginine in its synergistic mechanism of action with sildenafil.

Natural polyphenols from beetroot, grape skin and pine bark extracts

These contain powerful antioxidants that have numerous health benefits, including the stimulation of nitric oxide production and vasodilation.

Researchers at Norwich Medical School in the UK found that men who consumed a high amount of polyphenols in their diet had a 14 per cent lower risk of erectile dysfunction. Polyphenols are chemicals found in many plants that reduce inflammation, lower blood pressure, act as antioxidants and increase nitric oxide production (American Journal of Clinical Nutrition, 2016).

Vitamin C and N-acetylcysteine (NAC) 

These are antioxidants that enhance the action of polyphenols in the body. Men with erectile dysfunction (ED) have higher levels of free radicals and lower levels of antioxidants than men without ED. Antioxidants such as vitamin C and N-acetylcysteine (NAC), combined with folic acid, can improve erectile function in older men.

Vitamin C, NAC and folic acid act synergistically with polyphenols and the amino acid L-citrulline in the production of nitric oxide. Folic acid is a precursor of tetrahydrobiopterin (BH4) and, when combined with vitamin C and NAC, it plays an important role in the bioavailability of nitric acid and in the synthesis of nitric acid and nitric oxide at the endothelial level (in the blood vessels).

BH4 increases the bioavailability of nitric oxide in healthy adults, which could represent a promising treatment for erectile dysfunction.

N-acetylcysteine (NAC) is a more biologically active and stable form of the amino acid L-cysteine. NAC is capable of increasing the synthesis of glutathione, the body’s primary antioxidant. Research has shown that NAC can prevent oxidative stress and improve the bioavailability of nitric oxide.

NAC is also a precursor for the synthesis of hydrogen sulphide. Recent clinical studies suggest that hydrogen sulphide may be useful in the prevention and treatment of high blood pressure, cardiovascular disease, cancer, inflammation, neurodegenerative diseases and metabolic disorders, including obesity and diabetes. Research has shown that hydrogen sulphide (H₂S) is a powerful vasodilator that increases blood flow to the penis, thereby improving penile erection and sexual performance (Journal of Andrology, July/August 2012). 

Current pharmacotherapy for erectile dysfunction (ED) relies primarily on the use of phosphodiesterase type 5 (PDE5) inhibitors, but a large proportion of patients with ED are unresponsive to this therapy, so research is turning towards alternative treatments.

Given the growing evidence of the role of H₂S in erectile function and its ability to exert ‘pro-erectile’ effects via various mechanisms, H₂S represents a potential therapeutic alternative or adjunct to PDE5 inhibitors. (Journal of Sexual Medicine, 2011)

Research has indeed shown that NAC is a precursor of hydrogen sulphide (H₂S) and a safer source of hydrogen sulphide than sulphide salts such as sodium sulphide. Sulphide salts release hydrogen sulphide in an uncontrolled manner and can cause acute organ toxicity. NAC is undoubtedly the preferred and safest supplement for increasing hydrogen sulphide levels.

Niacin

Niacin is a B-complex vitamin and a powerful vasodilator. Niacin stimulates the release of histamine, which in turn stimulates the release of nitric oxide by endothelial cells, causing vasodilation and improving erectile function.

Science therefore presents us with these well-established facts, confirming that the synergistic combination of these molecules could be a valuable aid to sexual health. It should be remembered, however, that the foundation must be a healthy lifestyle, a balanced diet (such as the Mediterranean diet) and regular physical activity.