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Lifestyle and erectile quality
Why are lifestyle issues so important?
During evolution it was important for conditions to be ideal in order for the offspring to be able to survive. Early man had to be physically fit to be able to escape from or fight predators to protect his family. There had to be enough nutrition regardless of what type of foods were available - antioxidants from greens and berries, L-arginine from meat, omega-3's from fish, and calcium from milk. In times of severe stress his ability to reproduce would be limited, and when conditions were ideal, the chance of conception would be maximized. It is not surprising that the factors allowing for erection are so redundant. The very survival of our species has depended on the "Survival of the Firmest." Below you will see that physical activity, normal weight and lean muscle mass, antioxidants, omega-3's and avoiding oxidative stress such as with obesity and smoking are all important for maximizing erectile quality. You will find more detailed information regarding ways to maximize your sexual relationship in our book "survival of the Firmest" available on Amazon/kindle or itunes or by purchasing below, a link will be sent to you for download suitable for viewing on your laptop or other devices.
"Survival Of The Firmest" $9.99
References with a short description of the key findings are also provided (see "references").
Obesity (BMI over 30) and erectile function
Excess fat tissue, particularly when deposited in the abdomen from excess carbs and alcohol (the “beer belly”), interferes with the action of insulin, an important stimulator of NO.
A heavier person burns more calories, which causes oxidative stress. Poor insulin action raises blood sugar levels and both sugar and oxidative stress decrease NO. Fat tissue also releases inflammatory compounds that increase oxidative stress as well as directly reduce NO. All of these factors create the “perfect storm” for erectile dysfunction (ED), which is strongly related to an expanding waistline (Esposito,2004). To make matters even worse, obesity causes high blood pressure that further increases ED 2-3 fold (Doumas, 2006).
The great thing is that all of these effects of obesity can be reversed with weight loss. Our book, “Survival Of The Firmest” (download above) and our recent paper on the "Obesity pandemic" (pdf available for download without charge) will together give many suggestions on how to tackle this very difficult problem. For a much more extensive roadmap for weight control, you can download our book, “The Obesity Crisis – learning to survive in a health-hostile environment" $9.99
Exercise and erectile function
Men who are sedentary have a 10-fold increase of mild to severe difficulties with erection (Agostini, 2011). Moderate exercise decreases ED by two thirds and a high degree of exercise by 80% compared with men who do not exercise (Akkus, 2002). Exercise is the most important stimulator of erectile quality because it markedly reduces oxidative stress, and possibly by other mechanisms. For example, autopsies of young, healthy, and presumably sexually active men, revealed significantly better developed muscle attachment areas on the penile sheath (showing that the pelvic floor muscles were more active in those younger compared to older men (Tajkarimi, 2011). The pelvic floor muscles may have developed with physical exercise and/or with the reflex contractions occurring during intercourse (see "How an erection works - pelvic floor exercises)".
Nutrition and erectile function
A “prudent” diet improves erectile function, i.e less red meat and more seafood, fruits and vegetables, often referred to as the “Mediterranean diet"; (Esposito, 2006). Trans fats should be avoided entirely, for example, doughnuts, Danish pastries, French fries and fried foods in general. Studies point to antioxidants, monounsaturated oils, and omega-3’s as the factors involved in these benefits and these are therefore discussed in detail below.
Antioxidants:
NO is extremely unstable. Its production and lifespan in the body depend on antioxidant protection. Since two major antioxidant systems in the body are decreased in men with ED, exercise and antioxidants in the diet or supplements are very important. Pycnogenol (Horphag Research and Health Science), a well characterized and standardized preparation of antioxidants, has been shown to markedly improve erectile function (Stanislavov, 2008). The commercial preparation studied also contained L-arginine, but at a dose with little effect itself. Pycnogenol alone markedly stimulates NO and contains polyphenols similar to those in blueberries, green tea, red wine, and chocolate. Pycnogenol is marketed from a number of online sources. Other excellent antioxidants are listed to the right of each of these pages. Note that those in vegetables and fruit increase with cooking unlike vitamins, which can decrease, and that some spices are also potent antioxidants (Tumeric is considered to be a reason for the unexpected lower incidence of Alzheimer’s in India). Vitamins C and E are relatively weaker antioxidants. We do not recommend taking vitamin E, as a moderate dose has been linked to increased all cause mortality and prostate cancer, and it can markedly increase the chance of bleeding when taken with aspirin (many older men are advised by their physicians to take low dose aspirin to reduce the chance of a heart attack). Chocolate is highlighted separately on the page on supplements because it increases NO even in healthy men, suggesting that augmenting antioxidants may improve erectile function in men not having ED (Fisher, 2003), and because it has been reported to decrease death from heart attacks (Katz, 2011). As with most antioxidants, cocoa alone is very bitter, causing chocolate to be marketed with substantial added sugar. Sugar can erase the majority of NO stimulation (Meldrum, 2011), which is why we suggest a dark, low sugar chocolate bar with only 6 grams of sugar per 40 gm but with added vanilla to enhance flavor. See "supplements".
Omega-3 fatty acids:
An omega-3 has been shown to increase NO in human vascular lining cells approximately 3-fold (Okuda, 1997). The mediterranean diet, of which fish (and therefore omega-3) intake is prominent, has been shown to increase erectile function (Esposito, 2006), although it also increases antioxidant intake. Omega-3's stabilize the myocardium and therefore could reduce the chance of a heart attack being fatal. Men with ED can have unrecognized cardiovascular disease (see "erections and health")
Blood flow presumably is also very important for function of the testicles. In one study two agents known to increase nitric oxide increased the circulating level of testosterone. (Stanislavov), 2008).
A recent study associated minor increases of circulating omega-3 levels with increased prostate cancer. Other studies have shown associations with reduced prostate cancer and suppressive effects on prostate cancer tissue. Associations do not show cause and effect relationships. The small increase of omega-3 levels could have been associated with other factors that increase prostate cancer. For example, overcooking of meat and fish has been associated with increased prostate cancer risk. People who don't eat fish regularly complain that it is bland and lacking in taste. If men in the above study who were accustomed to overcooking foods simply had a minor increase of fish intake because they found that fish had sufficient flavor when it was fried or grilled, a false association of omega-3 levels with increased prostate cancer could be created.
An easy and inexpensive way to get omega-3’s is from fish oil. A reasonable dose is 1,000-2,000 mg, but make sure that is the amount of EPA and DHA (the two principal omega-3’s) and not just the amount of oil, (commonly highlighted on the front of the bottle). They are listed on the nutrition label on the back of the bottle.
Omega-3’s are very sensitive to oxidation, so always take a good level of antioxidants along with boosting your omega-3 intake. Also, they work together to enhance male sexual function.
Cook foods less
When foods are overcooked (such as with barbequing, broiling, grilling, and frying) toxic compounds called advanced glycation end products (AGE's) are produced that accumulate in the body as people age, cause oxidative stress, and are thought to be involved in diabetic vascular disease and aging. 
In this picture from a supermarket supposedly specializing in wholesome food choices, note the prominent grill marks on these otherwise healthy salmon filets! Besides increasing AGE's, the char contains cancer-causing chemicals. For more ways to limit intake of these toxic chemicals, see an article published by the American Dietetic Association (Goldberg, 2004).
Personal habits
Smoking:
Smoking causes extreme oxidative stress which together with other complex mechanisms decreases NO and doubles the chance of having ED (Feldman, 2000). Second hand smoke also decreases erectile function. The reduced NO in smokers was shown to be completely reversed by vitamin C, 1,000 mg and Vitamin E, 800 IU, with NO even increasing to above that in non-smokers (Pellufo, 2009). As discussed above we do not recomment taking vitamin E. Clearly the increased vascular disease and lung and other cancers in smokers are more important reasons to quit. However, if that is just not possible we urge maximum attention to increasing antioxidant intake (see above, to the right and "supplements").
Caffeine:
As previously mentioned, coffee is a good source of antioxidants. 
Expresso has less caffeine, which allows greater intake without feeling jittery or causing potential cardiac side effects. We also mentioned that NO release is extended by a cyclic-AMP mediated process and cyclic AMP is increased by caffeine. Therefore coffee intake is a positive rather than a negative for maximizing erectile function.
Alcohol
Moderate alcohol decreases ED (Cheng, 2007) by increasing NO (Abou-agag, 2005). Excessive alcohol in the mouse was shown to decrease NO in vascular lining but not in the penile nerve endings (Aydinoglu, 2008). That, and by blocking the effects of stress, may be why excessive alcohol has not been reported to cause ED, although it does lead to premature ejaculation. In a recent high profile paper it was suggested that even one serving daily was negative for overall health. The statistical analysis in that paper has been questioned, so the overall risks versus benefits of moderate alcohol intake will continue to be controversial.
The environment
Plastic recycle number 7 (polycarbonate and “other”) should be avoided. Polycarbonate releases the hormone disruptor Bisphenol A. BPA is also in food can linings and the heat activated receipts we all handle (wash your hands after handling). BPA levels have been associated with decreased testosterone levels.
Stress and depression
Finally, any discussion of lifestyle and erectile function would be 
incomplete without discussing the effects of anxiety, stress, and depression. Anxiety and stress can constrict the penile blood vessels and reduce blood flow into the penis so that none of the other helpful strategies work. Depression can cause ED and antidepresants can worsen the condition. Medical help may be necessary and a man with ED must advise his physician that medication effects on his erectile function are a concern.
Here is where all the trouble starts
Even more important is to not let decreased erectile function wear away at your relationship with your partner, including your sexual enjoyment. 
Above all do not be tempted to look for stronger sexual stimuli as a quick fix that can have disastrous effects for your relationship, family, and friends.
If you pay attention to all of our recommendations
"Survival Of The Firmest"
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