Erectile Dysfunction Reversed After Adoption of a Whole Food Plant-Based Diet: A Case Report

Abstract

Background: Erectile dysfunction (ED) is the “canary in the coal mine” for coronary artery disease (CAD), typically presenting 3-5 years before CAD. Accordingly, vascular ED and CAD share similar risk factors. Case Summary: A 52-year-old male reported erectile dysfunction in 2019. In 2021, after coronary stent placement for stable CAD, he adopted a whole-food plant-based diet (WFPB) diet to improve his CAD risk. Within months, his erectile function began improving, and he experienced further improvement with increasing vegetable intake. By February 2024, he reported normal erectile function. Discussion: While prior literature describes modest improvement in erectile dysfunction with a Mediterranean diet, this case describes complete reversal of ED with a WFPB diet. By improving cardiovascular risk factors, a WFPB may ameliorate vascular function and vascular ED. Take Home Message: Erectile dysfunction secondary to atherosclerosis may be reversed with a whole food plant-based diet.

History of Presentation

A 52-year-old man, presented to the Montefiore Cardiac Wellness Program on 2/29/2024 as he was interested in optimizing his lifestyle to improve his cardiovascular health.

Patient was active, exercising 5-7 days per week—a combination of cardio and resistance training—without cardiovascular symptoms. His exercise frequency, duration, and intensity had remained stable for over 10 years.

His medications were aspirin 81 mg daily and rosuvastatin 40 mg daily. He had also been taking B12, 1000 ucg, intermittently since 2021.

Blood pressure was 110/72 mmHg, pulse 79 bpm, BMI 28 kg/m².

His physical exam was unremarkable.

Past Medical History

He reported erectile dysfunction since at least 2019. He had no history of hypogonadism, hypothyroidism, diabetes, depression, anxiety, illicit drug use, or trauma to the perineum. He had not used medications or supplements which impact erectile function, including beta-blockers, selective serotonin re-uptake inhibitors (SSRI), or phosphodiesterase-5 inhibitors (PDE5i).

He had a history of coronary artery disease. A drug-eluting stent was placed in his left anterior descending artery (LAD) at a different hospital system in January 2021, after asymptomatic LAD stenosis was observed on a “screening” coronary CT angiogram.

He also had hyperlipidemia for which he had been taking a statin since the age of 28. There was no family history of familial hypercholesterolemia.

Differential Diagnosis

Given his history, it was felt he had moderate ED secondary to atherosclerosis. However, ED has many other possible causes: psychogenic, neurologic, medication side effects, and hormonal imbalance.

Investigations

A few weeks after our initial visit on 2/29/2024, the patient was given the International Index of Erectile Function-5 (IIEF-5) questionnaire (Figure 1), a validated measure of erectile function. He filled out the questionnaire as if he were at four distinct time points in Figure 2, as we wished to evaluate whether there was an association between his diet and his erectile function.

Figure 1.

International index of erectile function-5 questionnaire legend: international index of erectile function - 5 (IIEF-5) is a validated scale for classifying erectile dysfunction, with lower scores indicating poorer sexual function. IIEF-5 scoring: 22-25: No ED (normal function), 17-21: Mild ED, 12-16: mild to moderate ED, 8-11: moderate ED, 5-7: severe ED. Scores range is 5-25. Reprinted with permission from Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A. Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot Res. 2000;11:319-326.

Figure 2.

IIEF-5 = International Index of Erectile Function-5, LAD = left anterior descending, WFPB = whole-food plant-based. Created in BioRender. Allen, K. (2025) https://BioRender.com/l5nrepd.

Regarding his diet, over his first ∼38 years, he consumed a “typical Western diet” heavy in processed meats and ultra-processed “junk” foods.

From 2011 until April 2022, he consumed a “mostly healthy” diet, where from Sunday night to Friday night, his diet consisted of salads (mixed greens and fruits), beans, mushrooms, whole grains, soups, plant-based shakes, and processed vegan snack foods. In contrast, from Friday night to Sunday afternoon, he would consume “high volumes” of cheese, meats, and ultra-processed “junk” foods.

In April 2022, with the goal of improving his cardiovascular health, he started a WFPB diet. The diet included vegetables, fruits, whole grains, potatoes, pulses, nuts and seeds, and eliminated all animal products and all ultra-processed foods. He then noticed gradual changes in his erectile function and by 6/2023, his moderate ED improved to mild ED.

While he had no history of low serum B12 and his serum B12 was 572 pg/mL (232-1243 pg/mL) on 1/26/2021, he empirically started intermittent doses of B12 in April 2022 as he heard B12 supplementation was important while on a plant-based diet.

In July of 2023, he heard that eating more green leafy vegetables may further increase nitric oxide production, so he increased his daily servings (each serving was a “large handful”) of greens from 3 to 6. His erectile function normalized by 2/2024.

Management

The patient adopted a WFPB diet with multiple daily servings of green leafy vegetables to help improve his cardiovascular health and experienced accompanying normalization of his erectile function.

Outcome and Follow-Up

Despite having ED since at least 2019, his moderate ED (as measured by IIEF-5 score) became mild ED 15 months after adopting a WFPB diet. Then, approximately 8 months after continuing the WFPB diet and increasing his daily servings of greens from 3 to 6, his mild ED normalized. This improvement occurred without the use of PDE5i medications or supplements, other than intermittent vitamin B12. His erectile function remains normal on a WFPB diet with 6 daily servings of green leafy vegetables.

Discussion

Erectile dysfunction (ED) is the inability to achieve or maintain an erection satisfactory for sexual performance. ¹ ED is common, affecting 40% of men by age 40, and nearly 70% of men by age 70 in the United States (US). ² However, its prevalence may be underestimated due to underreporting and a lack of screening. ³ While there are numerous causes of ED, such as psychologic, neurologic, and endocrine, atherosclerotic vascular disease is the most common cause of ED in the US. ¹ Accordingly, ED and CAD share similar risk factors, such as hyperlipidemia, hypertension, diabetes, and smoking. As the pudendal artery is smaller than the coronary arteries, ED typically precedes clinically overt CAD by 3-5 years, and hence, ED has been called the “canary in the coal mine” for CAD. ¹

A Western-style diet, with its limited fruit, vegetable, and fiber content, and with its increased processed meat and ultra-processed food content, is a leading cause of atherosclerosis, and hence ED. A “smartly” or minimally processed WFPB diet that includes vegetables, fruits, whole grains, beans, and lentils, and excludes all animal products and ultra-processed foods may benefit vascular function and potentially improve ED, as it is rich in antioxidants and polyphenols, is anti-inflammatory, can improve cardiovascular risk factors, and may positively impact the gut microbiome.^4-7

More specifically, plant-based diets may improve endothelial and hence vascular function via multiple synergistic mechanisms. For example, beets and dark leafy greens are rich in inorganic nitrates, which when reduced to nitrite by oral bacteria, become a direct source of the vasodilatory compound, nitric oxide (NO), in the stomach. ⁸ Furthermore, the antioxidants found in abundance in healthful plant-based diets can neutralize reactive oxygen species and hence reduce degradation of NO.^9,10 Polyphenols in plant-based foods may enhance endothelial nitric oxide synthase (eNOS) activity and thereby potentially increase NO production, improving both endothelial function and vasodilation. ¹¹

With respect to atherosclerosis, nitric oxide may lessen the adhesion of leukocytes to the endothelial cell, thereby potentially slowing progression of atherosclerosis. ¹² In addition, LDL cholesterol in those consuming more plant-based foods may be relatively more resistant to oxidation than in those consuming less. ¹³ Fiber, present only in plant-based foods, may help promote and nourish a healthful gut microbiome, leading to the production of short chain fatty acids (SCFAs), such acetate, butyrate and propionate. ¹⁴ These SCFAs may have anti-inflammatory properties and may downregulate cholesterol production. ¹⁵ Hence, SCFAs may also improve endothelial and vascular function. ¹⁵

Accordingly, this WFPB dietary pattern, when well planned (eg, including vitamin B12 supplementation), is supported by the American College of Cardiology primary prevention guidelines. ¹⁶

In a randomized controlled trial of a Mediterranean dietary pattern, which is plant-predominant but also includes animal products, vs a more typical Western-style diet in subjects with mild to moderate ED, the Mediterranean diet improved erectile function more, as measured by IIEF score, than did the Western-style diet. However, the improvement was less dramatic than seen herein: in the Mediterranean arm which included 35 subjects, IIEF score improved from 14.4 ± 3.8 to 18.1 ± 4.2 after ∼2 years, whereas, in this case report, our subject’s IIEF score improved from 9 to 25 after ∼2 years. While this comparison is hypothesis-generating only, it suggests that a WFPB diet can more positively impact erectile dysfunction, when compared to a Mediterranean diet. ¹⁷ This difference may be attributable to the greater proportion of plant-based foods in a WFPB diet. Accordingly, some studies have suggested that consuming more of or exclusively a WFPB dietary pattern may improve various cardiometabolic outcomes to a greater degree than a Mediterranean-style dietary pattern.^16,18

This case suggests that a WFPB diet may reverse ED secondary to atherosclerosis. As such, we suggest additional studies evaluating the impact of a WFPB diet on erectile function, the impact of a WFPB dietary pattern vs a Mediterranean dietary pattern on erectile function, and the ability for potentially reversing erectile dysfunction with diet to motivate healthful dietary change.

Conclusions

To our knowledge, this case is the first to document the reversal of erectile dysfunction secondary to atherosclerosis following the adoption of a whole-food plant-based diet, thus supporting the benefit of this dietary pattern on vascular health.

Take Home Message

Erectile dysfunction secondary to atherosclerosis may be reversed with a whole food plant-based diet.

Appendix.

Abbreviations

CAD

Coronary artery disease

ED

Erectile dysfunction

WFPB

Whole-food plant-based

NO

Nitric oxide

SCFAs

short chain fatty acids

eNOS

endothelial nitric oxide synthase

IIEF-5

International Index of Erectile Function-5

LAD

left anterior descending artery

PDE5i

phosphodiesterase-5 inhibitors.

ORCID iDs

Kathleen Allen https://orcid.org/0000-0001-9518-4487

Robert J. Ostfeld https://orcid.org/0009-0004-4300-1596