Endothelial Dysfunction

Blood flow. That's what it's all about for us guys. We need it for optimal brain function.  We need it for cardiovascular health and athletics.  And, most importantly some of us might argue, we need to for maximum bedroom performance. But it's all dependent on our endothelium, that delicate lining of our arteries that pumps out nitric oxide.  Unfortunately, the endothelium is under attack by a Western lifestyle. Damage begins accumulating from a very young age due to inflammation, oxidation, skewed lipid profiles and toxins (especially smoking).

Most of us think of our arteries, including the ones in our penis, as a hose.  However, this is actually a poor analogy, because our arteries can expand (dilate) and contract (constrict).  When duilated, the arteries literally become wider and blood flow is increased.  This also drops blood pressure, because there is more space (or volume actually) for your heart to pump the blood.

So what controls endothelial function?  This is actually an involved subject, but there are three primary chemicals that can dilate/constrict your arteries:

1.  Nitric Oxide. Just about every male knows about this heavy hitter. Nitric oxide is what is increased (through action on an enzyme called NOS) by PDE5 Inhibitors such as Viagra and Cialis.

2.  Acetylcholine.  This is a less powerful, but nonetheless significant vasodilator. Interestingly enough, it is used in research labs to measure endothelial function.

3.  Noradrenaline (norepeniphrine).  This stress hormone will put the brakes on artery expansion and your erections. Some noradrenaline is actually a good thing and keeps you from destroying your penile tissues due to priapism, an erection that persists for hours.

These three are natural acclerators/decelerators of blood flow and endothelial function.  So what don't they work in your middle-aged and senior years?  Why do so many 35+ men struggle with endothelial issues?

The problem lies with a modern  lifestyle that literally attacks the endothleium. This a very involved subject, but the Cliff Notes version is the following:

  1. Inflammation triggers LDL (your "bad" cholesterol) particles to become lodged underneath the endothelium
  2. These LDL particles tend to oxidize, i.e. become free radicals.
  3. White blood cells come to the rescue and begin to swallow these LDL particles.
  4. The accumulation of these white blood cells become foam cells, which eventually can form artery-clogging, endothelium-smothering plaque.

As you can imagine, every step in this process is hard on the delicate lining of the arteres, especially the inflammation, oxidation and plaque-raising stages.  All of these will tend to lower nitric oxide over time and decrease the flexibility of arteries to dilate.

Accelerating the process is the increased blood pressure that results from a decrease in nitric oxide and narrowing arteries due to arteriosclerosis.  See my link on 30+ Natural Ways to Lower High Blood Pressure for some additional information. 

Measuring Endothelial Dysfunction

Can you measure endothelial function?  There are some excellent ways that are done in sophisticated research settings.  Unfortunately, for the Everyman like you and me, these are simply too expensive and, therefore, there is no perfect replacement methodology.  You can get a pretty idea, however, by using some of the less expensive, more available techniques listed below:

1) FMD (Flow Mediated Dilation).  This is most common method used by doctors, but does have some potential inaccuracies associated with it and is expensive unless covered by insurance.

2) Nitric Oxide Test Strips.  Neogenis recently developed test strips that can quite accurately estimate your endothelial nitric oxide levels. The test strips seem to work quite well, but they do not give an actual numerical reading.  Instead, it is kind of "litmus" test where you have four color regions on a test strip that give you an idea of your NO. Of course, the big advantage is that they are relatively inexpensive and can be done in the privacy of your own home. For more information, see my link on Nitric Oxide Test Strips.

3) Blood Pressure. Blood pressure is not actually a direct measure of endothelial dysfunction. However, the two are definitely related. You can measure this at home with an inexpensive blood pressure monitor.  From what I have heard, it is important to get one that uses an arm band and not a wrist strap.  You also cannot trust the ones in big stores that are for public use with the unadjustable cuff. Again, arteries with endothelial dysfunction resulting from heavy plaque buildup and low nitric oxide levels will tend to have elevated blood pressure.  You want 120/80 or below.

4) IMT (Intima Media Thickness). This is actually a measure of arteriosclerosis. However, arterial plaque buildup and endothelial are definitely related. Arteriosclerosis is somewhat like A1C (glycated hemoglobin) in the sense that it is usually going to show the cumulative damage that has built up over the years. Lots of arterial plaque indicates lots of damage and hardened, stiffened arteries.

Natural Solutions for Endothelial Dysfunction

When you first realize you have endothelial dysfunction, it can be a "little bit scary" as my five year old would say.  What is very sobering is that you suddenly realize that you have years or even decades of heavy damage to your arteries. Suddenly, the whole picture seems hopeless.  The good news is that the body can remarkably recover and even heal itself as we will cover below.

CAUTION:  Talk to your doctor if you are on any heart or blood pressure medications before doing any of these. Some of these can alter absorption rates of certain medications for example.

Here are 10+ Ways to Get Back Your Endothelial Function:

1.  Nitrates.  Foods that contain nitrates can boost your baseline nitric oxide. Beetroot juice, spinach, lettuce and any green leafy vegetable has ample nitrates to get your arteries moving again.

5.  Nitric Oxide Boosting Supplements. Most of the supplements that have studies behind them will boost nitric oxide through one pathway or another. There are lots of ideas here in my link on Erectile Supplements. (Always talk to your doctor first.)

3. Low Fat Diet. When it comes to beating endothelial dysfunction, it is hard to beat a Low Fat Diet. This diet, popularized by men such as Pritikin, Ornish and Esselstyn, has actually been shown to arrest and, according to some studies, even reverse arterial plaque buildup. It also boosts blood flow and lowers

4. William Davis Track Your Plaque. This cardiologist has a strategy to reduce plaque.  I don't have personal experience with his approach, but he is well-known at this point and can be followed on the site "Track Your Plaque".  You can also read my review of his book Wheat Belly here.

5.  Nitric Oxide Boosting Foods. I cover these in my book called The Peak Erectile Strength Diet.

6.  Exercise. There is a simple solution to boost your nitric oxide and improve blood flow and endthelial function avaialbe to virtually every man: walk, move and exercise throughout the day. Instead of a 30 minute, once per day workout, just walk every few hours. This is how our bodies were designed and how every superculture on planet earth lives. These walking or exercise sessions boost your nitric oxide for several hours afterward just like Mother Nature intended it.

7.  Pomegranate Juice. I cannot say enough good things about Pomegranate Juice. It can boost nitric oxide, lower blood pressure and one study even shows it clearing out arterial plaque. For more information, read my link on Pomegranate Juice.

8. Testosterone. Yes, testosterone builds muscle and raises libido, but it also does three things that can directly improve your endothelial function: a) boosts nitric oxide levels by acting on NOS, b) lowers inflammation and c) protects your arteries from arteriosclerosis. So, if you are low or lowish testosterone and boost your baseline T enough through either Testosterone Therapy or natural methods, it can definitely help the lining of your arteries in multiple ways. For more information, see my links on Testosterone and Inflammation and Natural Solutions for Hardening of the Arteries.

9. Mediterranean Diet.  The Mediterrean Diet is protestosterone diet, based on fruit, vegetables, grains, wine and olive oil.  It has a nice benefit of being likely pro-testosterone in nature due to the 30-35% total fat levels and emphasis on monounsaturated fats. It has been shown in a number of studies - on men with elevated cholesterol or obese for example [1][2] - to improve flow mediated dilation.

10. Drop the Vices.  #1 through #9 are not going to work if you are significantly overweight, smoking, using (most) recreational drugs, drinking immoderately or prescribed to certain medications. (Do not go off of a medication without talking to your physician.) All of these are incredibly hard on the endothelium.

So get out of the cycle now and get your endothelium back. Remember: "Never Say Die!"


1) Am J Clin Nutr August 2009, 90(2):263-268, "Close adherence to a Mediterranean diet improves endothelial function in subjects with abdominal obesity"

2) Annals of Internal Medicine, 2001, 134(12):1115-1119, "Mediterranean and low-fat diets improve endothelial function in hypercholesterolemic men"