Lifestyle Changes to Prevent BPH:

Heart Healthy = Prostate Healthy

Mark A. Moyad

enign prostatic hyperplasia (BPH) is a common

condition of older men.
Results from autopsy
studies have demonstrated
microscopic evidence of BPH in
40% of men aged 50 to 60 and
90% of men aged 80 to 90 (Berry,
Coffey, Walsh, & Ewing, 1984).
BPH is characterized by a prostatic epithelium and fibromuscular
tissue overgrowth predominantly
in the transition zone and periurethral area. Clinically, this condition causes obstructive and
lower urinary tract symptoms.
The gold standard therapy for
BPH is a transurethral resection
of the prostate, which is performed over 200,000 times yearly
in the United States (Graves &
Gillum, 1997).
Why BPH occurs is not exactly understood but probably reflects
a multifactorial process (Morton,
Turkes, Denis, & Griffiths, 1999).
Some of the potential etiologies of
BPH include androgens being converted to dihydrotestosterone, increased prostatic smooth muscle
tone and increased sympathetic
adrenergic neuronal effects of the
autonomic nervous system, increased amounts of estrogen with
aging that promote cell growth,
increased oxidative or free radical
effects, increased insulin levels,

Mark A. Moyad, MPH, is the Phil F.

Jenkins Director of Complementary/
Alternative Medicine, University of
Michigan Medical Center-Dept. of
Urology, Ann Arbor, MI.

Benign prostatic hyperplasia (BPH) is one of the most prevalent conditions found in men, and increases with age. Drug, surgical, and
phytotherapy tend to dominate the medical literature when discussing potential treatments for this condition. These treatments
have demonstrated remarkable effectiveness for the various degrees
of BPH. However, the potential for lifestyle changes to actually prevent this disease or reduce the severity of this condition when used
as an adjunct to conventional treatment is not only intriguing but is
strongly supported by past limited studies. More research is needed,
but the time is ripe to discuss with patients the potential lifestyle
changes that could influence risk. Obesity, a lack of physical activity,
dyslipidemia, diabetes, hypertension, a heart unhealthy diet, and
other factors may significantly increase the risk of BPH. Patients
should be told that factors that increase the risk of cardiovascular
disease seem to be associated with an increased risk of BPH or a
greater severity of BPH.

and elevated cholesterol levels.

Some of these etiologies are supported by treatments that may alleviate symptoms of BPH. For example, drugs that inhibit the enzyme
5-alpha-reductase (block the conversion of testosterone to dihydrotestosterone) tend to reduce the
size of a large prostate, while
alpha-1-adrenergic receptor blockers not only reduce blood pressure,
but relax the prostate and can alleviate symptoms of BPH (Djavan,
2003).
Lifestyle changes have received a minimal amount of clinical attention overall in the medical literature. However, the limited studies to date seem to suggest a consistent positive impact
of lifestyle changes to either prevent BPH or the development of
existing disease in many individuals (Platz et al., 1998). The time
seems more than ripe for clinicians to discuss these data with
patients concerned about BPH.

UROLOGIC NURSING / December 2003 / Volume 23 Number 6

Obesity and BPH

Obesity has been associated
with prostate size and an
increased severity of obstructive
urinary symptoms. This association has not been limited to men
in the United States. For example, a past community-based
cross-sectional epidemiologic
investigation was conducted in
Yonchon County, Korea (Lee et
al., 1997). The Korean adaptation
of the International Prostate
Symptom Score (IPSS) was used.
A total of 514 patients were
included, and 119 (23.2%) had
moderate to severe BPH (IPSS >
8). Researchers found that waistto-hip ratio, which is a measure
of abdominal obesity, was associated with biphasic relationship
to BPH. Both obese and lean
patients were more likely to have
BPH compared to men of mean
weight. This finding is possible
because a low BMI has been associated with higher testosterone

439

Table 1.
A Partial List of Lifestyle Changes/Conditions That May
Influence the Risk or Progression of BPH
Lifestyle Changes/
Other Parameters

Comment

Blood pressure

Increased pressure may increase

risk.

Cholesterol

High cholesterol and/or lower HDL

(good cholesterol) may increase
risk.

Diabetes

Increased insulin and glucose levels may stimulate prostate growth.

Diet (overall)

Higher caloric intakes and zinc

may increase risk, and fruit consumption may reduce risk.

Obesity

Greater weight may increase risk.

Physical activity

Increased physical activity may

reduce risk.

Plant estrogens

Soy, flaxseed, and other dietary

sources of plant estrogens may
reduce the risk of BPH.

Zinc (diet) and zinc supplements

Zinc in mega-doses (>100-150

mg/day) may increase the risk of
BPH.

Overall Recommendation

Heart
=
Healthy

levels (Eldrup, Lindholm, &

Winkel, 1987), and abdominal
obesity may increase sympathetic activity or may increase estrogen levels (Troisi, Weiss, &
Parker, 1991).
Past limited studies also suggest that diabetic and obese men
have larger prostate glands. A
Swedish study of 250 patients
with BPH symptoms with or
without metabolic syndrome
characteristics were included in
this study (Hammarsten &
Hogstedt, 1999). Researchers
found that the median annual
BPH growth rate was 1.04
ml/year. Patients with rapidly
growing BPH had a significantly
higher prevalence of noninsulin-dependent diabetes mellitus, and were significantly
more obese. The results of this
study suggested that men with
fast-growing BPH have higher

440

Prostate
Healthy

insulin levels and/or a defect in

glucose uptake. A followup to
this study by the same
researchers that included 307
patients found a similar effect to
the first study (Hammarsten &
Hogstedt, 2001).

Physical Activity and BPH

A study of obesity and BPH
in the Health Professionals
Follow-up Study (HPFS) found
that physical activity was associated with a lower risk of BPH
possibly by maintaining a
healthy weight and through other
mechanisms (Giovannucci et al.,
1994). A followup retrospective
study to the HPFS identified
1,890 men who had BPH surgery
or 1,853 men who scored 15 or
more points out of 35 on the 7
questions from the American
Urological Association Symptom
Score (Platz et al., 1998). A total

of 21,745 men were considered

controls because they scored 7
points or less on the same symptom score. Researchers controlled
for age, race, alcohol intake, and
smoking status. Greater physical
activity was significantly and
inversely related to total BPH
(25% reduction), surgery for BPH
(24% reduction), and symptomatic BPH (25% reduction).
Interestingly, walking was the
most prevalent physical activity,
and men who walked 2 to 3
hours a week had a 25% reduction in risk for total BPH. Men
who were more physically active
were also less likely to smoke,
were leaner, less likely to have
diabetes, and more likely to
drink more alcohol and consume
more calories. In the Physicians
Health Study, men who exercised had a reduced risk of BPH
surgery compared to sedentary
men (Gann et al., 1995).
However, men who exercised
experienced an increased risk
with increasing amount of exercise. This may have resulted
because of the small number of
men (n=320) studied or men in
this cohort who exercise regularly were more likely to be treated
for BPH compared to men who
do not exercise as much.
However, the more recently published large population-based
Massachusetts Male Aging Study
included 1,709 men followed for
9 years (Meigs, Mohr, Barry,
Collins, & McKinlay, 2001).
Increasing levels of physical
activity were associated with a
reduced risk of BPH. Men in the
highest level of physical activity
had an odds ratio of 0.5 (50%
reduction) compared to men in
the lowest levels of physical
activity.

Cholesterol/Heart/
Cardiovascular Disease
And BPH
One of the most consistent
findings in the limited lifestyle
changes and BPH data have found
that what tends to be heart
unhealthy is also prostate
unhealthy (Moyad, 2003). Most
studies have found a relationship
between some parameter of car-

UROLOGIC NURSING / December 2003 / Volume 23 Number 6

diovascular disease and increased

BPH. For example, a lower highdensity lipoprotein (good cholesterol) has been associated with a
greater risk of BPH (Hammarsten
& Hogstedt, 2001; Lee et al,. 1997).
HDL has clearly demonstrated to
be involved in the transport of
cholesterol from tissues back to
the liver. Therefore, the higher
the HDL level, the less likely it
seems that cholesterol is able to
cause dysfunctions of a variety of
enzymatic or other pathways. It
is also interesting that physical
activity increases HDL; therefore,
this may be another mechanism
whereby exercise reduces the
risk of BPH. Furthermore, many
of the common medications for
BPH tend to increase the levels of
HDL in the serum (Akbay et al.,
2001; Denti et al., 2000). Some
recent studies have also found a
correlation between prostate size
and a greater risk for cardiovascular disease (Sandfeldt & Hahn,
2003).

Other Lifestyle Changes

and BPH
Recent limited studies seem
to support some type of role of
other lifestyle changes with an
increase or decrease in the risk of
BPH. For example, plant estrogens found in some foods such as
soy-based products and flaxseed
tend to inhibit the enzyme 5alpha-reductase (Morton et al.,
1999). This may be one reason
why these foods may lower the
risk of BPH. High intakes of
dietary zinc and zinc supplements may increase the uptake of
testosterone and increase the risk
of BPH, while fruit intake may
reduce the risk of this condition
(Lagiou et al., 1999). In addition,
a recent epidemiologic investigation found an increase risk of
BPH for men who consume
greater intakes of calories or energy from their diet (Suzuki, Platz,
Kawachi, Willett, & Giovannucci,
2002).

Conclusion
Some of the potential lifestyle
changes that may influence BPH
are included in Table 1.
No previous reviews of BPH

have focused entirely on lifestyle

changes that may affect this highly prevalent disease. Therefore,
what is the bottom line? Health
care professionals should begin
to educate patients on the potential impact of simplistic lifestyle
changes on this disease. It seems
that what is heart healthy is tantamount to a prostate healthy
diet. Obviously, more research in
this area is desperately needed.
Presently, the data support the
incorporation of lifestyle changes
for men not only trying to prevent this disease, but for men
already diagnosed with this condition. The importance of including this advice in a standard BPH
workup cannot be emphasized
enough. These recommendations
are not only simplistic, but they
may have a profound impact on
the overall health of patients and
not just on BPH itself. Therefore,
lifestyle changes not only make
sense for the patient in the urology clinic, but for the patient
attempting to improve his overall
quality and quantity of life.
Health professionals need to
begin bridging the gap between
preventive and urologic medicine.
References
Akbay, E., Bozlu, M., Doruk, E., Akbay, E.,
Cayan, S., & Ulusoy, E. (2001). Effect
of terazosin on the lipid profile in
patients with symptomatic benign
prostatic hyperplasia. Urologia
Internationalis, 67(2), 156-159.
Berry, S.J., Coffey, D.S., Walsh, P.C., &
Ewing, L.L. (1984). The development of human benign prostatic
hyperplasia with age. Journal of
Urology, 132(3), 474-479.
Denti, L., Pasolini, G., Cortellini, P.,
Sanfelici,
L.,
Benedetti,
R.,
Cecchetti, A., Ferretti, S., Bruschieri,
L., Ablondi, F., & Valenti, G. (2000).
Changes in HDL-cholesterol and
lipoprotein Lp(a) after 6-month
treatment with finasteride in males
affected by benign prostatic hyperplasia
(BPH).
Atherosclerosis,
152(1), 159-166.
Djavan, B. (2003). Lower urinary tract
symptoms/benign prostatic hyperplasia: Fast control of the patients
quality of life. Urology, 62(Suppl
3A), 6-14.
Eldrup, E., Lindholm, J., & Winkel, P.
(1987). Plasma sex hormones and
ischemic heart disease. Clinical
Biochemistry, 20(2), 105-114.
Gann, P.H., Hennekens, C.H., Longcope,
C., Verhoek-Ottedahl, W., Grodstein,
F., & Stampfer, M.J. (1995). A

UROLOGIC NURSING / December 2003 / Volume 23 Number 6

prospective study of plasma hormone levels, nonhormonal factors,

and development of benign prostatic
hyperplasia. Prostate, 26(1), 40-49.
Giovannucci, E., Rimm, E.B., Chute, C.G.,
Kawachi, I., Colditz, G.A., Stampfer,
M.J., & Willett, W.C. (1994). Obesity
and benign prostatic hyperplasia.
American Journal of Epidemiology,
140(11), 989-1002.
Graves, E.J., & Gillum, B.S. (1997).
Detailed diagnoses and procedures,
National Hospital Disease Survey,
1995. Vital Health Statistics 13, 130,
1-146.
Hammarsten, J., & Hogstedt, B. (1999).
Clinical, anthropometric, metabolic
and insulin profile of men with fast
annual growth rates of benign prostatic hyperplasia. Blood Pressure,
8(1), 29-36.
Hammarsten, J., & Hogstedt, B. (2001).
Hyperinsulinaemia as a risk factor
for developing benign prostatic
hyperplasia. European Urology,
39(2), 151-158.
Lagiou, P., Wuu, J., Trichopoulou, A.,
Hsieh, C-C., Adami, H-O., &
Trichopoulos, D. (1999). Diet and
benign prostatic hyperplasia: A
study in Greece. Urology, 54(2), 284290.
Lee, E., Park, M-S, Shin, C., Lee, H., Yoo,
K., Kim, Y., Shin, Y., Paik, H-Y., &
Lee, C. (1997). A high-risk group for
prostatism: A population-based epidemiological study in Korea. British
Journal of Urology, 79(5), 736-741.
Meigs, J.B., Mohr, B., Barry, M.J., Collins,
M.M., & McKinlay, J.B. (2001). Risk
factors for clinical benign prostatic
hyperplasia in a community-based
population of healthy aging men.
Journal of Clinical Epidemiology,
54(9), 935-944.
Morton, M.S., Turkes, A., Denis, L., &
Griffiths, K. (1999). Can dietary factors influence prostatic disease?
British
Journal
of
Urology
International, 84(5), 549-554.
Moyad, M.A. (2003). The ABCs of nutrition and supplements for prostate
cancer. Ann Arbor, MI: JW Edwards
Publishing.
Platz, E.A., Kawachi, I., Rimm, E.B.,
Colditz, G.A., Stampfer, M.J., Willett,
W.C., & Giovannucci, E. (1998).
Physical activity and benign prostatic hyperplasia. Archives of Internal
Medicine, 158(21), 2349-2356.
Sandfeldt, L., & Hahn, R.G. (2003).
Cardiovascular risk factors correlate
with prostate size in men with bladder outlet obstruction. British
Journal of Urology International,
92(1), 64-68.
Suzuki, S., Platz, E.A., Kawachi, I.,
Willett, W.C., & Giovannucci, E.
(2002). Intakes of energy and
macronutrients and the risk of
benign
prostatic
hyperplasia.
American Journal of Clinical
Nutrition, 75(4), 689- 697.
Troisi, R.J., Weiss, S.T., & Parker, D.R.
(1991). Relation of obesity and diet to
sympathetic nervous system activity.
Hypertension, 17(5), 669-677.

441