Studies Highlight Key Relationships Between Lifestyle, Sexual Health

BALTIMORE, May 15, 2020 /PRNewswire/ -- Lifestyle choices continue to be a leading risk factor for a wide array of health conditions, including lowered hormone levels and subsequent sequalae. The AUA will showcase three new studies exploring the impact of exercise and diet - as well as a review of declining testosterone levels in adolescent and young men - during a special event for media on Friday, May 15 at 1:00 p.m. Dr. Charles Welliver, a member of the AUA's Public Media Committee, will moderate this press session. The following abstracts will be highlighted during this important session:

Trends in Serum Testosterone Levels Among Adolescent and Young Adult Men in the United States (#MP-78-01): The prevalence of testosterone deficiency among American men is significant, with 10 to 40 percent of adult men and 20 percent of adolescent and young men (ages 15-39) having lowered levels of testosterone. Using serum testosterone level data from the National Health and Nutrition Examination Surveys (NHANES), researchers reviewed data for more than 4,000 men from 1999-2016, and found an overall decrease in testosterone levels over time. Though elevated body mass index (BMI) was associated with reduced testosterone levels, a decline in testosterone was identified even in men with normal BMI. In men with normal BMI, testosterone levels declined from 664.79 ng/dl to 529.24 ng/dl between 1999-2000 and 2015-2016.

The Association Between Exercise and Serum Testosterone Among Men in the United States (#PD25-03): Being overweight, poor eating habits and a sedentary lifestyle are common risk factors for testosterone deficiency. In this study, researchers explored the association between clinically practical, guideline-based activity levels (as defined by the Physical Activity Guidelines Advisory Committee) and serum testosterone levels recorded in the NHANES database from 2011-2016. Of the 7,597 men that met inclusion criteria for the review, most (5,164, 68 percent) met or exceeded recommended activity levels, while 2,433 (32 percent) did not. Low testosterone levels were detected in nearly one-third of the subjects, with those whose activity levels exceed recommendations had a significantly decreased likelihood of low testosterone compared to those with lower than recommended activity levels.

Can Organic Diet be Protective against Hypogonadism and Erectile Dysfunction? (#MP78-08): Organic diet may have a positive impact on hypogonadism and erectile dysfunction (ED), according to this study, which explored correlations between dietary habits (organic diet, consumption of processed foods and intermittent fasting) and symptoms of these conditions. Researchers reviewed data from five validated instruments, an expansive dietary survey and laboratory values for total testosterone, free testosterone and estradiol for 297 men. Hypogonadism and ED were less prevalent in men who adhered to an organic diet, and ED and lower urinary tract symptoms were less prevalent in men who performed intermittent fasting, suggesting that healthy dietary habits may be protective against these conditions.

"Our understanding of low testosterone continues to rapidly expand, and these studies highlight a variety of interesting relationships between low testosterone and modifiable factors like diet and exercise" Dr. Welliver said. "While pharmacologic options are the backbone of treatment for men with low testosterone, the safety of long-term use is still under investigation. Lifestyle changes have previously demonstrated to have a significant effect on testosterone levels in men and these findings further support those findings."

About the American Urological Association: Founded in 1902 and headquartered near Baltimore, Maryland, the American Urological Association is a leading advocate for the specialty of urology, and has nearly 22,000 members throughout the world. The AUA is a premier urologic association, providing invaluable support to the urologic community as it pursues its mission of fostering the highest standards of urologic care through education, research and the formulation of health care policy.


Trends in Serum Testosterone Levels Among Adolescent and Young Adult Men in the United States

Premal Patel, Richard Fantus, Soum Lokeshwar, Joshua Halpern, Cecilia Chang, Atil Kargi, Ranjith Ramasamy

Introduction: Testosterone deficiency has a prevalence of 10-40% among adult males and 20% among adolescent and young adult (AYA) men (males 15-39 as per the National Cancer Institute). With increasing prevalence of low testosterone in general population, we hypothesized that serum total testosterone (TT) levels will decline in AYA men. The objective of this study was to analyze serum TT levels in AYA males using data from the National Health and Nutrition Examination Surveys (NHANES) 1999-2016. We hypothesized that serum TT levels in AYA men have decreased over time.

Methods: NHANES is a nationally representative cross-sectional survey that examines the US population and over samples targeted populations, to obtain adequate samples for subgroup analysis and more reliable variable estimates. We found data cycles which had values for serum TT and analyzed changes in serum TT over time controlling for year of study, age, race, body mass index (BMI), comorbidity status, alcohol and smoking use, and level of physical activity. During the study periods, three different assays (Biotin-Streptavidin from 1999-2004, IS-Liquid Chromatography from 2011-2012 and High-Performance-Liquid-Chromatography Tandem Mass Spectrometry from 2013 onwards) were used; they have shown comparable testosterone values with only some additional accuracy in the latest modality.

Results: A total of 4,045 men had TT measured from 1999-2016. After controlling for confounders, TT was lower among men in the later (2011-2016) versus earlier (1999-2000) cycles (all p < 0.001). Mean TT decreased over time: 605.39 ng/dL, 567.44, 424.96, 431.76 and 451.22 for 1999-2000, 2003-2004, 2011-2012, 2013-2014 and 2015-2016, respectively (p < 0.0001). Elevated BMI was associated with reduced TT levels (p < 0.0001) with mean BMI increasing from 25.83, 27.21, 27.12, 27.81, 27.96 for 1999-2000, 2003-2004, 2011-2012, 2013-2014 and 2015-2016, respectively, p = 0.0006. Even in men with normal BMI (18.5-24.9), TT levels have declined from 664.79 ng/dL to 529.24 ng/dL between 1999-2000 and 2015-2016 (p < 0.05).

Conclusions: This is the first study to report declining testosterone levels in adolescent and young adult men. Further studies are required to understand the etiology of low testosterone in AYA men.

Funding Source: None


The Association Between Exercise and Serum Testosterone Among Men in the United States

Richard Fantus, Cecilia Chang, Nelson Bennet, Brian Helfand, Marah Hehemann, Joshua Halpern, Robert Brannigan

Introduction: Diet and exercise coupled with weight loss have been shown to improve serum testosterone (T) in overweight individuals. However, the association between T and clinically practical, guideline-based exercise levels have not been examined. We used the recently updated Physical Activity Guidelines Advisory Committee (PAGAC) recommendations for average weekly physical activity to investigate the relationship between recommended activity levels and serum testosterone.

Methods: We queried the National Health and Nutrition Examination Survey (NHANES) database from 2011-2016, including men between the ages of 18 to 80 who answered the physical activity questionnaire and underwent serum T testing. We converted all activity into metabolic equivalent of task (MET) minutes per week. Using the PAGAC recommendations, we divided the cohort into three groups based on activity level: less than recommended (<500 MET minutes/week), recommended (between 500 and 1000 MET minutes/week) and greater than recommended (>1000 MET minutes/week). We used multivariable logistic regression controlling for known confounders to analyze the association between activity level and low T (<300ng/dL).

Results: 7597 men met inclusion criteria. Most men (4461, 58.7%) had > 1000 MET minutes/week, 703 men (9.3%) met the recommended activity level (between 500 and 100 METS minutes/week), and 2433 (32%) did not meet the recommended level of activity (<500 MET minutes/week). Low T was detected in 2201 (29%) men. In multivariable analysis, men whose activity exceeded the recommended amount showed a significantly decreased likelihood of low T (odds ratio [OR] 0.678, 95% confidence interval [CI] 0.587-0.783, p < 0.001) compared to those with lower than recommended activity levels (Table).

Conclusions: This is the largest, nationally representative cohort to demonstrate that men whose activity exceeded recommendations had a decreased likelihood of low T. While future prospective studies are required to validate these findings, these data provide a basis for counseling patients regarding the positive association between exercise and serum T.

Funding Source: None.


Can Organic Diet be Protective against Hypogonadism and Erectile Dysfunction?

Farouk M. El-Khatib, Mohamad M. Osman, Linda M. Huynh, Sharmin Dianatnejad, Qiaqia Wu, Maxwell Towe, Natalie Yafi Roberts, Faysal A. Yafi

Introduction: There is increasing evidence supporting relationships between diet, hypogonadism, and erectile dysfunction (ED). We sought to assess the dietary patterns of patients presenting to a men's health clinic and to look for any correlations between dietary habits and signs and symptoms of hypogonadism and ED.

Methods: Men who presented to our men's health clinic between August 2018 and June 2019 were enrolled. Clinical demographics were collected and patients completed the Androgen Deficiency in the Aging Male (ADAM), the International Index of Erectile Function (IIEF-5), STOP-BANG questionnaire screens for obstructive sleep apnea (OSA), Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder 7-item (GAD-7) questionnaires, as well as an expansive dietary survey. This included questions about consumption of water, coffee, sugary drinks, drinks with artificial sweeteners, alcoholic drinks, as well as dietary preferences such as organic diet, processed foods and intermittent fasting, amongst others. Laboratory values including total testosterone (TT), free testosterone (FT) and estradiol (E) were also collected. Univariate and multivariate analyses were constructed to identify demographics and dietary habits that were predictive of hypogonadism or ED. In this study, men were included if they answered all the questionnaires and were excluded if they received testosterone replacement therapy.

Results: During this period, 445 men presented to the clinic, of which 297 were included. Organic diet was followed by 30 (10.1%) men, 52 (19.4%) did not consume processed foods and 31 (11.7%) performed intermittent fasting. On univariate analysis, organic vs non-organic diet was significantly associated with higher SHIM scores 19.1±5.9 vs 16.4±7.9 (p= 0.03). Hypogonadism and ED were diagnosed in 3.3% and 33.3% in men who followed an organic diet vs 15.7% and 41.9% in men who did not (p= 0.069 and p= 0.366, respectively). After adjusting for age and BMI, adherence to an organic diet was significantly associated with higher SHIM scores (p= 0.045). Hypogonadism, ED and LUTS were diagnosed in 6.5%, 29.0% and 19.4%, respectively, in men who performed intermittent fasting compared to 15.5%, 41.4% and 31.9% in men who did not (p= 0.178, p= 0.187 and p= 0.154). Men who consumed processed foods were younger (p= 0.05) and had higher body mass index (BMI) (p= 0.033).

Conclusions: This is the first reported study showing that adherence to an organic diet may potentially be protective against hypogonadism and ED. Larger prospective interventional studies are needed to validate these results.

Funding Source: none


A Systematic Review and Evidence-Based Analysis of Ingredients in Popular Male Fertility Supplements

Manish Kuchakulla, Yash Soni, Premal Patel, Neel Parekh, Ranjith Ramasamy

Introduction: Many men take over-the-counter Fertility supplements that promise increasing their likelihood for conception. However, these supplements are not always supported by evidence. We sought to evaluate the evidence available for evidence available for the ingredients.

Methods: A total of 17 male fertility supplements were identified from popular online retailer A1 Supplements, Amazon, Vitamin Shoppe, and Walmart. Individual ingredients were identified for each supplement. The PUBMED and Cochrane Controlled Trials Register online databases were reviewed for randomized control trials studying the efficacy of each individual ingredient. We then categorized each ingredient based on the availability of evidence using an adapted version of the scoring system used by the American Heart Association. Scores were assigned to each categorical level of evidence for each ingredient and a composite score for each supplement was calculated to assess their overall level of evidence.

Results: A total of 90 unique ingredients were identified from the 17 supplements. The most commonly used ingredients were Vitamin E, Folic Acid, Zinc, Vitamin C, Selenium, Vitamin B12, L-Carnitine, and Maca. Whilst the most studied ingredients are L-Carnitine, Vitamin E, Vitamin C, CoQ10, and Zinc. In all, only 22% of ingredients used were found to have published evidence with respect to male fertility. Of these only 17% of ingredients had data published showing a positive effect. None of the supplements had any published evidence of their use in a randomized clinical trial. Our scoring system gave an average composite rating of 1.66 (on a scale to 5) for the evidence level of the popular supplements. Evolution 60 and Conception XR had the highest composite scores with 3.6 and 3.5, respectively. Strengths include a validated and standardized scoring system, as well as being the first to evaluate the level of evidence in a uniform manner. Limitations include the lack of granularity and heterogeneity in the RCT's that were included.

Conclusions: Many fertility supplements claim to improve fertility; however, their promises are rarely backed by evidence. Only 17% of ingredients used in popular fertility supplements had positive evidence demonstrated in randomized clinical trials, while only 20% have any evidence in RCTs at all. These products should be used with extreme caution and this information should be used when counseling patients.

Funding Source: Supported in part by Summer Medical Student Fellowship Program from AUA / Florida Urological Society

            Wendy Isett, AUA


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SOURCE American Urological Association