Q. My boyfriend is 46, and over the last few years he’s started having trouble maintaining an erection. His doctor says there’s nothing medically wrong and has prescribed Viagra, but he’s nervous about using it. Are there any diet or lifestyle changes he could make that might make the drug less necessary?

A. Yes. When I was in medical school, I was taught that the major cause of impotence is psychological. We now know that it is mostly physiological. For many men, it’s not in their head, it’s in their arteries. The arteries in your heart aren’t the only ones that get clogged over time — it happens throughout your body, in men and in women. For men, the ability to get and maintain an erection is a direct function of blood flow to the penis, so anything that increases blood flow improves an erection, and anything that decreases blood flow makes it more difficult to have and maintain an erection. Approximately one-half of men over age 40 have problems at times with erectile dysfunction. Most men are embarrassed and don’t talk about it with their friends, or even their physicians, so they don’t realize how common it is — which often makes them feel even worse. No wonder Viagra is the biggest-selling drug of all time. Viagra works by stimulating nitric oxide, which dilates blood vessels and increases blood flow. (The Nobel Prize in medicine in 1998 went to the researchers who identified the role of nitric oxide in the cardiovascular system.) One of life’s ironies is that the very things our culture tells us are sexy and signs of the “good life” are also leading causes of impotence: A high-fat diet, alcohol, tobacco use, chronic stress, cocaine and many prescription drugs all reduce blood flow by constricting blood vessels, causing blood to clot, or promoting plaque buildup in your arteries. The good news is that when you change these behaviors, blood flow — and sexual function — can improve relatively fast. Your body also makes more nitric oxide — natural Viagra. For many people, improving sexual function is a more powerful motivator for lifestyle improvements than the prospect of living a little longer.

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