Know and always try to improve on at least four parameters: fasting cholesterol level, blood pressure, glucose, and body mass index (BMI) and/or waist circumference (WC). The gastric bypass surgery data should be referenced in patient discussions to provide motivation for the benefits of weight or waist loss in individuals of all body types.

The lack of general health knowledge exhibited by some patients and even future healthcare professional is concerning. For example, surveys of the general population indicate that a majority of individuals do not know their cholesterol parameters or most risk factors for CVD, and this finding is consistent regardless of age, race, and even gender [8–11]. In my experience when the dual concern of CVD and overall urologic health is emphasized and promoted, patients tend to become familiar with all of their clinical values, numbers, and overall risks. It is of interest that at least in the USA the prevalence of CVD is still high. For example, almost 15 % of men and 10 % of women have CVD between the ages of 20 and 39, and that number increases to approximately 40 % from the ages of 40 to 59 years, over 70 % from 60 to79 years, and over 80 % from 80+ years of age [12]. These prevalence numbers are quite surprising for some patients, but again this places disease risk in perspective.

Patients should also be educated regularly on the normal values of a cholesterol panel because they are regularly updated by expert guideline groups, such as the National Cholesterol Education Program (NCEP) [13, 14]. For example, a man attending a free PSA (prostate-specific antigen) screening would appear to be at risk of ending up with a myopic health and disease perspective unless other screenings, such as blood pressure, cholesterol, weight, and/or glucose, were also proffered. Preliminary empirical evidence of this concern lies in recent data from the Surveillance, Epidemiology and End Results (SEER) tumor registry, which suggests that men diagnosed or treated for prostate cancer need to focus as much on cardiovascular prevention owing to the observed competing causes of mortality [15]. Patients simply need other resources, apart from overburdened primary care practitioners, to emphasize and review basic optimal lipid and general health values [13, 14]. Table 1.1 is a modified quick review for patients and urologic health professionals.

The NCEP suggests a first cholesterol screen at age 20 [13], which is approximately at least 20–30 years before a suggested PSA test or colonoscopy, but few, if any, individuals in my experience have had a lipid test at this early age. Clinicians can assist patients in adhering to this early screening age. For example, when men with a family history of prostate cancer or erectile dysfunction (ED) or an early diagnosis of most diseases inquire about what their children or other family members should do first to prevent this condition from happening to the next generation, a common suggestion that I reiterate for children or adolescents is to just have an initial blood pressure, cholesterol, and glucose screening test and to maintain a healthy weight. In my experience, this tends to surprise and simplify patient concerns because this is an unexpected suggestion. The time is now more appropriate than ever for this approach because of the recent concern about abnormal lipid levels among adolescents screened in the USA, which is approximately 20–43 %, based on a variety of factors, especially weight status (normal, overweight, or obese) [16].

Other novel cardiovascular markers, such as high-sensitivity C-reactive protein (hs-CRP), or traditional ancillary markers, such as hemoglobin A1c, and evidence of subclinical atherosclerotic disease should also be discussed with the patient [3, 12, 17]. Even a referral to a cardiologist may be appropriate for some individuals, because some of these markers may also be related to overall mortality as well as CVD risk and some specific urologic health conditions [18].

Other tangible advantages may occur for the patient and clinician that continue to follow these overall cardiovascular markers. For example, cholesterol levels are an adequate indicator of how well a patient may be adopting lifestyle changes or even medication compliance following a PSA test, ED diagnosis, or after some definitive therapy. If these numbers improve, it may be more likely that the patient is following a urologic health lifestyle program. High-density lipoprotein (HDL) provides a good indicator of the commitment to aerobic exercise and is in a sense the “truth serum” as to how much physical activity has recently occurred. HDL tends to rise, at times substantially, with a greater amount of aerobic physical activity [19], and a higher HDL may be correlated with a lower risk of abnormal prostate conditions [20, 21]. Triglycerides are an indicator of changes in belly (visceral) fat, because this compound is generally stored in this anatomic location with increasing blood levels, and triglycerides have also been associated with some prostate conditions [22].

Blood pressure monitoring should also be emphasized as much as any other value. The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure altered the criteria for what defines a healthy blood pressure [23]. Individuals and their partners should be informed that normal blood pressure is less than 120/80 mm Hg, and individuals with a systolic blood pressure of 120–139 mm Hg or diastolic blood pressure of 80–89 mm Hg are actually considered to be “prehypertensive”; lifestyle changes should be advocated in these individuals (Table 1.2) [23].

Blood pressure can be reduced with a healthier lifestyle [24]. This is a good indicator of lifestyle adherence or compliance, and a healthy blood pressure may also lower the risk of ED and benign prostatic hyperplasia (BPH) [25, 26]. Interestingly, one of the more subtle but prevalent etiologies of high blood pressure may be excessive alcohol consumption; this should be discussed with patients as much as sodium restriction [27]. Regardless of patients who adopt healthy lifestyle and behavioral changes should always be given encouragement to continue these changes because of the potentially profound impact these behaviors may have on overall and mental health [28, 29]. Due to the phenomenon of “white coat hypertension” it seems critical to encourage some patients to invest some money in an at-home blood pressure measurement device [30]. These devices have become cost-effective and potentially allow a more accurate assessment of the patient’s blood pressure status compared to the one or two values derived annually, for example, from a medical office.

Fasting blood glucose is as important as any other parameter for your patients. Abnormally high blood glucose and diabetes are considered a high-risk cardiovascular correlation, such that these patients are treated as if they already have established cardiovascular disease in terms of lipid control, for example [13]. The association between higher blood glucose levels and urologic disease is also emerging and continues to accumulate data in multiple areas such as BPH and accelerated hypogonadism [31, 32]. The relationship between glucose intolerance and sexual dysfunction is already well established in men and women [33, 34]. Patients appear more motivated to continue healthy lifestyle changes when there is some tangible healthy outcome with the behavioral change, and this becomes more probable when all numbers are utilized in the consult, including cholesterol, blood pressure, and glucose, for example, as opposed to just other single and disease-specific (PSA, etc.) values.

The negative impact of being overweight or obese on overall morbidity and mortality is also well known. Body mass index is moderately reliable as an isolated anthropometric measurement, but at least it is a rapid method to determine who may be overweight or obese [35]. Body mass index is defined as the weight (in kilograms) divided by the square of the height in meters (kilograms per square meter squared). Another method to calculate the BMI is to take weight in pounds and divide it by the height in inches squared and to multiply this number by 704 (pounds/inches² × 704). A BMI <25 is considered normal by the World Health Organization (WHO), whereas 25–29 is overweight, >30 is defined as obese, and 35 or more is considered morbidly obese. Several of the largest and most recent preventive medicine randomized trials of men or women have demonstrated that most individuals in these studies are indeed overweight at baseline, and this includes trials to prevent specific health abnormalities with prescriptions, supplements, or just dietary change [4, 7, 36, 37]. Thus, it has become so common for participants of clinical trials to be overweight or obese that only a small percentage of individuals in these studies have a BMI in the healthy range.

Waist-to-hip ratio (WHR) may be another rapid measurement to determine obesity [35]. An individual must stand during the entire measurement of WHR. Waist-to-hip ratio more precisely measures abdominal adipose circumference or tissue and fat distribution. The waist is defined as the abdominal circumference midway between the costal margin and the iliac crest. The hip is defined as the largest circumference just below the iliac crest. However, it requires more time and detail, which is why waist circumference alone is perhaps the easiest and fastest method to currently assess obesity, and is my preference together with pant size (waist size). “Belly fat” (visceral adipose tissue) seems to have one of the best predictive values of CVD and potential all-cause mortality risk among all the other weight parameters from some of the largest prospective studies in the world [38–40]. However, the combination of WC with a BMI measurement may have added predictability. Still, WC is also one of the best predictors of heart-unhealthy changes and/or future cardiovascular events, regardless of the age group and ethnic group studied [41, 42].

Waist circumference is also one of the five specific criteria of the metabolic syndrome. Waist circumference has a tangible advantage over BMI, which can be appreciated after an individual commits to resistance exercise. An increase in muscle mass from resistance activities such as weight lifting can actually cause an increase in BMI, which could be frustrating to the patient and clinician [35]. However, this does not generally occur when utilizing the WHR or WC measurement. Informing patients of their official WC and asking pant size allow these parameters to be documented in the chart and allow the patient to identify a goal of maintaining or reducing these numbers by the time of the subsequent clinical visit; therefore, there is a reduced emphasis on just the weight scale or trying to compete with a national standard. A patient with a BMI of 35 and a WC of 40 in. is not as concerning as an individual with similar measurements and a lack of aerobic fitness and some modicum of caloric control, or not being able to reduce their WC value slightly over time is more of an issue. A summary of the basic interpretation of the BMI and WC value is found in Table 1.3 [35].

Kidney stones and renal cell carcinoma (RCC) may have a strong relationship with obesity [43–46]. Obesity is also associated with lower testosterone levels, higher estrogen levels, and a higher risk of CVD, which could partially explain the preliminary finding that obese men have a higher risk of ED [47–49], but recent novel clinical research suggests that an improvement in these parameters occurs rapidly with just a 10 % weight loss from dietary changes alone [50]. I often wonder how many men and healthcare professionals realize that before recommending exogenous testosterone prescriptions or supplements, patients should be made aware of the simple fact that weight loss can result in significant increases in testosterone.

Clinicians should begin to carry and utilize tape measures that can measure WC, and I often argue that this is as critical as the stethoscope. Clinicians should also refer patients on a consistent basis to ancillary diverse services such as nutritionists, therapists, social workers, a variety of professional and even surgical weight-loss programs, if needed, and recent consumer publications on weight loss. Simply becoming familiar with local weight-loss resources is an initial step in the appropriate direction for the patient and clinician. For example, inviting a medical director of a local weight-loss program to give grand rounds on the treatment plans they offer to the community demonstrates, in my opinion, commitment to this cause.

Another method that may provide positive teaching experience is to discuss or at least remind patients about the importance of a healthy weight by mentioning the gastric bypass or surgical weight-loss data. The intent is obviously not to advocate the use of gastric bypass or any type of surgery for every patient but to demonstrate how weight loss clearly and at times quickly impacts health. For example, researchers in the USA and Sweden found in separate studies that obese individuals who had gastric bypass surgery had a 30–40 % lower risk of dying 7–10 years after having the surgery compared to those that did not have the surgery [51–53]. The Swedish study was one of the longest studies ever published at that time of how this procedure impacts long-term health outcomes [52]. Researchers at the Goteborg University compared 4,047 individuals with a BMI of over 34, who received one of three types of surgery (banding, vertical-banded gastroplasty, or gastric bypass) or some dietary advice (control group). Some of the basic characteristics of these patients before the study started were the following:

After 10.9 years, those that received surgery lost 14–25 % of their original weight compared to 2 % in the other group. Out of the 2,010 surgery patients, 101 died, and there were 129 deaths in the comparison group of 2,037 patients. There was a 29 % significant reduction (p = 0.01) in the risk of dying from any cause in the surgery group. There were also lower risks of dying from cardiac disease and non-cardiovascular causes such as cancer. However, there was a higher rate of dying from infection (12 vs. 3 patients) and sudden death (20 vs. 14) in the surgery group. The most successful weight loss occurred in the gastric bypass group, where the average reduction in weight was about 30 % loss of their original weight. Interestingly, the risk reduction in disease and death was much larger in the older patients (about 25 %) compared to younger subjects (6 %).

In the US study (funded by a US government grant or branch of the National Institutes of Health), which was retrospective and not prospective, like the first study mentioned, researchers (University of Utah and other centers) looked at 7,925 severely obese individuals who had gastric bypass [51]. These patients were matched to 7,925 control individuals with identical weights and height. About 84 % of the patients were women, the average age was 39 years, and the average BMI was 45–47. After an average follow-up of 7 years, there were 213 deaths in the surgery group versus 321 deaths in the nonsurgical group. A total of 136 lives were saved per 10,000 gastric bypass surgeries after an average of 7.1 years following the actual procedure. The following interesting and significant results were found:

However, the surgery group had a 58 % significantly (p = 0.04) higher risk of dying from accidents, suicides, and other causes not related to the diseases they were studying. None of the nondisease causes of death (“accident unrelated to death, poisoning of undetermined intent, suicide, and other nondisease causes”) were significantly different but just higher, but as a combined group there was a significant difference. For example, 63 of the deaths out of 213 in the surgery group were from these causes (15 from suicide) compared to 17 of the 321 deaths in the control group. The researchers did mention that a large number of severely obese individuals have “unrecognized presurgical mood disorder or post-traumatic stress disorder or have been victims of childhood sexual abuse.” Some bariatric surgery centers recommend that all patients have a psychological evaluation and if necessary some kind of treatment before surgery and some type of surveillance after surgery, but arguably this should probably be the normal way patients are handled after reading this study. This should be kept in mind when talking to any patient about surgery or another method for weight loss over time.

An examination of more recent surgical series should continue to impress the healthcare professional and patients. In the Swedish Obese Subjects (SOS) study, an ongoing review of outcomes from 25 public surgical departments and 480 primary health centers in Sweden, a total of 2,010 obese patients matched to controls found a 53 % reduction in the number of cardiovascular deaths (p = 0.002), and the total of first-time cardiovascular events were reduced by 33 % (p < 0.001) [54]. Gastric bypass and other surgical weight-loss randomized controlled data for obese type 2 diabetics from the Cleveland Clinic also continued to demonstrate the profound and immediate changes with weight loss [55]. A significant reduction in the utilization of medications to lower glucose, lipid, and blood pressure occurred within 12 months of their study on 150 patients, which in some cases occurred before the patients were discharged from the hospital! In a similar study from Italy the complete remission rates of type 2 diabetics approached 75–95 % within 2 years [56]. Again, the profound health changes in individuals that lose weight from surgery are an adequate teaching tool for patients to understand the devastating consequences of abnormal weight gain of any type on the human body. Adipose tissue is not inert and secretes a variety of compounds and other inflammatory signals to the rest of the body that essentially cause even innate immune responses to occur against self. In other words, I often tell patients that greater accumulation of adipose tissue is somewhat tantamount to an autoimmune condition.

Approximately 30–60 min of physical activity a day or more on average should be the goal, which should include lifting weights/resistance exercises several times per week. Equal emphasis should be placed on aerobic and resistance exercise; one is not more important than the other.

Physical activity, defined as at least 180 min of vigorous exercise weekly, was associated with an approximate 70 % lower risk of aggressive prostate cancer, advanced disease, and a potential for improved survival in the Health Professionals Follow-up Study [57]. Over 47,000 men were included in this cohort, with a mean follow-up period of 14 years. Researchers appropriately concluded their publication by recommending at least 30 min a day of physical activity for all individuals due to the overall health benefits of this intervention. Smaller recent investigations have not been able to replicate these profound findings [58, 59], but a recent prospective study that followed men after diagnosis of prostate cancer found a significant reduced progression of their disease in men that were more active even in terms of just walking [60]. Also, a randomized trial demonstrated a significant improvement in continence rates after surgery for men engaged in more than just Kegel exercises but also light activity and a variety of pelvic core strengthening routines [61]. Overall the data are encouraging and strong enough to suggest prostate and renal cell cancer risk reduction with exercise, but the research on bladder and testicular cancer prevention is weak and does not suggest any correlation [62].

Regardless, the morbidity and mortality from CVD is impacted by exercise, but weight lifting also seems to provide additional benefits. For example, data derived from the Health Professionals Follow-up Study, which prospectively followed over 44,000 men for 12 years, found that men jogging for 1 h or more per week had a 42 % reduction (p < 0.001 for trend) in the risk of coronary heart disease (CHD) [63]. Men who just walked for 30 min or more per day or who were involved in other physical activities also experienced a risk reduction in CHD versus those who did not engage in these activities. Men performing regular resistance exercise (weight lifting) for just 30 min or more per week experienced a 23 % risk reduction (p = 0.03 for trend) in CHD. This was a novel finding because previous prospective studies had not adequately addressed this subject. Weight training can increase fat-free mass and lean body weight, reduce sarcopenia, increase resting metabolic rate, slightly increase testosterone levels, and potentially reduce the risk of abdominal adipose deposition [64, 65]. Weight training or resistance training also appears to improve glucose parameters, including insulin sensitivity, and may slightly improve lipid levels and reduce hypertension [65, 66], which are all potential risk factors for ED and other men’s health conditions. Physical activity may also dramatically reduce the impact of sympathetic overload that may be one of the many earliest damaging etiologies of BPH [67]. One of the best past reviews on physical activity and cardiovascular disease found ample evidence for exercise to favorably impact markers of heart disease, including triglycerides, apolipoprotein B reduction, HDL, low-density lipoprotein (LDL) particle size, and a reduction in coronary calcium [68]. Thus, aerobic and resistance activity need to be emphasized equally because of the documented synergism.

The mental health improvements with increased exercise appear to be just as notable as the physical health benefits [69, 70]. For example, one often-referenced trial published over a decade ago included 156 adult volunteers with major depressive disorder (MDD) randomly assigned a 4-month course of aerobic exercise (30 min 3 times/week), sertraline therapy, or a combination of exercise and sertraline [71, 72]. After 4 months patients in all three groups demonstrated significant mental health improvements; however, after 10 months, individuals in the exercise group had significantly lower recurrence rates compared to individuals in the medication group of the study. Exercising during the follow-up period was associated with a 51 % reduction in the risk of a diagnosis of depression at the end of the investigation. Even recent randomized studies of patients with significant comorbidities such as heart failure have significant improvements in physical and mental health with regular exercise [73]. It is important to explain to patients that if the overall results from exercise studies were viewed similar to a specific pharmacologic intervention, then it probably would have already garnered attention worthy of a Nobel Prize in arguably multiple categories of medicine. Also, the ability of exercise to work synergistically with medication is also notable.

Still, despite the plethora of positive research, are healthcare professionals excited about recommending exercise to their patients? The National Health Interview Survey (NHIS) data are recorded throughout the year from the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics (NCHS) by interviewers from the US Census Bureau [74]. It is a household-derived survey, and interviews are usually conducted in the respondent’s homes. Questions were asked in 2000, 2005, and 2010, with over 20,000 in each of these years sampled that visited with a physician or other healthcare professional within the past 12 months. In the most recent year of data gathering, which was 2010, about 32 % of adults who had visited with a physician or other healthcare professional had been recommended to begin or continue exercise or some form of physical activity. Between the years of 2000 and 2010, the percentage of adults given exercise advice increased by approximately 10 %, and women were more likely than men to have been advised to exercise, and one-third of patients with cancer were also recommended exercise. Thus, only one in three adults who had seen a physician or healthcare professional in the past 12 months had been told to begin or continue exercise/physical activity. You have the ability to improve these numbers everyday in your practice, and I would encourage you to take advantage of this situation.

Reduce unhealthy dietary fat intake and increase the consumption of healthy fats, which should simultaneously lower overall caloric intake.

The NCEP recommends that saturated fat be reduced to less than 7 % of total calories to reduce the risk of CVD [13]. In my opinion, this is simply an indirect method to achieve partial caloric reduction [75]. Many foods that contain high levels of saturated fat also contain the highest levels of trans fat (“partially hydrogenated fat”), cholesterol, and, more importantly, total calories. For example, there are almost twice as many calories in 8 oz of whole milk (5 g of saturated fat) compared to skim or soymilk (0 g of saturated fat each), and there are almost four times as many calories in whole milk compared to almond milk. Thus, identifying two similar products, such as milk, meats, dairy, chips, and so forth, and choosing the item lower in saturated fat in general allows for a profound (at times) reduction in total caloric intake, which is critical to helping maintain or reach an appropriate weight or waist size and improving overall heart health.

Yet, simply reducing all saturated fat in an individual’s diet is not necessarily a practical and healthy dietary lifestyle change, because some saturated fats in the diet may promote healthy parameters. The current cardiovascular goal of obtaining less than 7 % of calories from saturated fat seems almost ideal from past studies, because getting minimal to no calories from saturated fat not only is too excessive; it actually appears to reduce levels of HDL (“good cholesterol”) from past CVD and other health-promoting clinical trials [76, 77]. Aggressively reducing saturated fat consumption also implies that this type of fat, in and of itself, is heart unhealthy, which is not accurate from the largest recent meta-analysis of prospective studies [78]. And, in some countries around the world where overall caloric intake is very low compared to the USA, saturated fat may have some tangible cardiovascular benefits, but this also needs to be placed in perspective [79]. For example, in some regions of the world, such as Japan, a closer look at healthy individuals with the largest intakes of saturated fat would actually lead to their being placed in the lowest category of saturated fat intake in the USA, if they were to immediately migrate to the USA [79]. Regardless, a potential impact of reducing saturated fat, in my opinion, is that it may reduce overall caloric intake and reduce weight and waist gains. Another benefit of reducing saturated fat is that it allows for the opportunity to reduce dietary cholesterol intake and increase the consumption of other monounsaturated and polyunsaturated fats that have shown a greater reduction in CVD from past clinical trials and epidemiologic research [80, 81]. If the patient has normal weight, exercise, and other heart-healthy parameters, then the concern over saturated fat intake should not be as acute, because caloric restriction or caloric control in some form by these individuals is not as beneficial. A summary of the different types of dietary fat, food sources, and impacts on specific lipids is found in Table 1.4 [75].

Consume a diversity of low-cost fruits and especially vegetables and do not consume high-calorie, high-cost, and high-antioxidant exotic or even traditional fruit juices (unless there is a low-calorie option).

Media attention and research appear to focus on one fruit or vegetable with each passing year. Clinicians need to be able to remain somewhat objective and explain to patients that these media reports do not necessarily represent any major research breakthrough but rather support the ongoing and past research that consuming a diversity of low-cost fruits and especially vegetables is just one practical and logical approach to improving urologic health. Several examples of this controversy exist, including the past attention focused on the compound lycopene in tomatoes in preventing prostate and other cancers based on numerous epidemiologic studies and a notable meta-analysis [82]. However, this meta-analysis concluded by reminding readers that this is just further evidence that a diversity of fruits and vegetables was important for a healthy diet, but this appeared to be misconstrued. Tomatoes were never the only or necessarily the primary source of lycopene. A variety of other healthy products contain this compound, such as apricots, guava, and pink grapefruit [83–86]. Watermelon is also an outstanding source of lycopene and is the largest source per gram compared to any other nutritional source, including tomato products. Regardless, lycopene has minimal overall beneficial data in and of itself to solve various urologic issues, but at least the compound and products that contain this compound are generally safe or even heart healthy [87–89].

The ongoing pomegranate juice and supplement research has experienced a somewhat similar story, but with a slightly different message for clinicians. The first attention-gathering study did not include a placebo group or another group of men that consumed another type of healthy juice product [90], and other studies in urology have questionable methodology and results [91]. Yet, this should not be construed as a lack of efficacy, and some of these companies should be lauded for at least investing in research, but an objective overview of the preliminary research and the caloric contribution of these and other juices is necessary. Many brands of these novel juices contain at least 140 cal per 8-oz serving, which is a caloric contribution similar to commercial regular soft drinks and alcoholic drinks (approximately 100–150 cal) [75]. In partial defense of some of these companies, it is also laudable that some lower-calorie exotic juice options from these same manufacturers are now becoming commercially available. Still, many of these juices are expensive in comparison to cheaper nutritious and lower-calorie products. Additionally, drug and juice interactions are still being researched, which is important because grapefruit juice studies have provided a paradigm of medication interactions [92], but novel juices such as pomegranate may also cause some potential concern with medications metabolized by CYP3A4 [93, 94]. In reality, if a patient believes in pomegranate juice or another product I often recommend a lower-calorie or a no-calorie option and utilize weight and other heart-healthy changes as the primary driving force of whether or not to continue or advocate for or against this patient-driven regimen.

Fruits, and especially vegetables, in general have been associated with a reduced risk of some urologic conditions in past studies [95]. For example, the Brassica vegetable group is diverse and includes broccoli, brussels sprouts, cabbage, cauliflower, kale, watercress, and others and may slightly reduce the risk of urologic disease [96]. It is interesting that these products are very low in overall calories. The Allium vegetables have also been associated with a reduced risk, and this group includes chives, garlic, leeks, onions, and scallions [97]. Fruits and vegetables have unique and shared anticancer and anti-heart disease compounds that may contribute to improved overall health [95]. The sum of the epidemiologic data continues to support the increased consumption of a diversity of fruits and vegetables to potentially and favorably impact urologic health, but the overall data currently support a slightly greater potential reduction in CVD risk and mortality [98], perhaps through assisting in weight loss or via other heart-healthy compound(s) such as natural salicylates (i.e., aspirin derivatives) or other natural compounds in these products [99]. Clinicians should recommend fruit and vegetable consumption for better overall health, but not for cancer prevention, where the recent large-scale data appear to be less impressive [100, 101]. There are also certain high-risk factors for urologic disease such as bladder cancer and smoking that simply cannot be fully eliminated or erased by improving other aspects of lifestyle, such as increased fruit and vegetable consumption [102]. In other words, triaging lifestyle changes or recommendations from most to least important is critical to a patient’s success.

Consume more (soluble and insoluble) dietary fiber (20–30 g/day or 14 g/1,000 cal consumed), especially from food sources.

General and numerous health benefits derived from consuming dietary fiber have been well documented and include reductions in the following [103–106]:

For example, a pooled analysis of past cohort studies of dietary fiber for the reduction of CHD included research from ten international studies and included the USA [107]. Over a period of 6–10 years of follow-up, and after multivariate adjustment, it was revealed that each 10 g/day increase of calorie-adjusted total dietary fiber was correlated with a 14 % reduction in the risk of total coronary events and a 27 % reduction in risk of coronary death. These findings were similar for both genders, and the inverse associations occurred for both soluble (“viscous”) and insoluble fiber. Past studies have not observed a consistent benefit with one class of fiber over the other [108, 109]. Recent large US and other international studies have found even more striking overall potential benefits for consuming more dietary fiber. For example, the NIH-AARP US prospective cohort found not only a lower risk of dying from cardiovascular, respiratory, and infectious disease with greater intakes of fiber but a significantly lower risk of dying younger (“total death”) in men and women [110]. This study may represent a major shift into the research behind fiber intake because now the potential health impact may be so much larger than first realized, because reductions in the death rates of some of the largest causes of mortality may occur with greater fiber intakes [110, 111].

Even minor additions of fiber can positively impact medication dosages. A total of 15 g of psyllium husk supplementation daily with a 10-mg statin (simvastatin) was demonstrated to be as effective as 20 mg of this statin by itself in reducing cholesterol in a preliminary placebo-controlled study of 68 patients over 12 weeks [112]. Although adding soluble fiber from commercial products appears to be safe and synergistic with cholesterol-lowering medications [113], the first choice for increasing fiber intake should be food sources based on cost-effectiveness and simplicity.

A meta-analysis of 24 randomized placebo-controlled trials of fiber supplementation found a consistent impact on blood pressure reduction [114]. Supplementation with a mean dose of only 11.5 g/day of fiber reduced systolic blood pressure by –1.13 mm Hg and diastolic pressure by –1.26 mm Hg. The reductions were actually greater in older and more hypertensive individuals compared to younger and normotensive participants. Recent international studies continue to support the modest reduction or control in blood pressure with greater intakes of dietary fiber [115].

How much fiber should patients be consuming daily? Daily intakes of total fiber in the USA and many other Western countries is approximately 10–15 g/day, which is approximately only half or even less than half of the total amount consistently recommended by the American Heart Association (AHA) and American Dietetic Association (20–30 g/day) for adequate overall health [105, 106, 116]. Another perspective on recommended fiber intake for children and adults is that for every 1,000 cal of food and beverage consumed, there should be at least 14 g of fiber consumed.

Dietary fiber from food is easily achieved by low-cost sources of soluble and insoluble fiber. For example, I often tell patients to just consume a third of a cup of a bran cereal, which is approximately only the size of one to two liquor shot glasses, with flaxseed and some fruit, and before they leave the door in the morning, approximately 20 g of fiber will have already been ingested toward the 25–30-g goal [75]! Low-cost fiber sources such as flaxseed can provide potentially numerous heart-healthy and urologic-healthy benefits and outcomes [117–122]. Interestingly, the preliminary clinical data for flaxseed and urologic health including symptoms of BPH and prostate cancer molecular changes are arguably as strong as any other nutritional item ever tested in urology, especially when considering the benefit-to-risk ratio. Perhaps the low-cost and non-commercialization of this product on a large scale has led to the lack of adequate education that I have observed on this product. Flaxseed is also one of the highest plant sources of heart-healthy omega-3 fatty acids [118], and chia seed is arguably the largest plant source of fiber and omega-3 [123]. Both of these additions to the male health diet would be ideal.

Yet fiber itself appears to have become overtly commercialized, and in my experience, some patients are turning primarily toward powders and pills to solve their fiber deficit; this is not only costly but also provides primarily small amounts of primarily soluble fiber that make it difficult to reach their total fiber goal utilizing only these sources. For example, I often ask audiences and students how many fiber capsules/pills are needed to be consumed daily to obtain just 20–30 g of fiber, and the answer always seems to provide adequate surprising value (the answer is 30–40 capsules/pills a day or more depending on the commercial source) [75]! A bolus of only soluble fiber without insoluble fiber can also create excessive bloating and other gastrointestinal issues because soluble fiber can be utilized and metabolized extensively by gut flora. Research continues to support the overall and heart-healthy benefits of fiber, especially when it is primarily derived from food sources [105], because these sources also provide a unique and optimal balance of soluble and insoluble fiber.

Consume moderate (approximately two servings or more) weekly intakes of a variety of healthy fatty fish, but fried and high mercury concentrated fish should be generally discouraged. Other healthy plant-based sources of omega-3 fatty acids (e.g., nuts and healthy plant cooking oils) should also be equally emphasized.

Numerous types of oily fatty fish contain high concentrations of marine-based omega-3 fatty acids (compounds known as “EPA” and “DHA”). Fish are also the best natural food source of vitamin D₃ (cholecalciferol), and they contain high concentrations of high-quality protein and a diversity of minerals [75]. Omega-3 fatty acids from food sources have exhibited numerous benefits in terms of reducing the risk of a variety of prevalent chronic diseases [124, 125], especially some aspects of cardiovascular disease [126–132].

A variety of healthy fatty/oily fish contain high levels of omega-3 fatty acids, vitamin D, and protein, including salmon, tuna, sardines, anchovies, whitefish. Other baked, broiled, raw, but not fried, fish are potentially beneficial [75]. Diversity should be encouraged to increase compliance and exposure to a range of nutrients. The benefit of fish consumption to reduce the risk of certain urologic diseases is preliminary [133, 134], but a fairly recent meta-analysis suggested that the sum of the evidence actually suggests a greater reduction in prostate-cancer mortality compared to morbidity [135]. There is also growing evidence for an ability of omega-3 from fish to reduce the risk of kidney stones [136, 137].

The true clinical impact of mercury from fish on adult individuals remains controversial [138, 139], and it is possible that mercury may reduce some of the benefits of fish consumption [140]. Four types of larger predatory fish have been most concerning (king mackerel, shark, swordfish, and tilefish), because they have the ability to concentrate larger amounts of methylmercury over their longer life spans. However, moderate and recommended consumption (two to three times per week) of most fish should have minimal impact on human mercury serum levels. A large investigation of moderate mercury serum levels in older individuals found little to no negative long-term impacts on neurobehavioral parameters [141]. A randomized trial of mercury exposure from dental amalgam in children also found no significant health issues [142]. The positive impact of consuming fish appears to outweigh the negative impact in the majority of individuals with the exception of women considering pregnancy or who are pregnant. One of the largest US cohorts to recently evaluate this issue found lower cardiovascular disease risk in adult men and women consuming higher amounts of fish regardless of mercury exposure (benefit > risk) [143]. Interestingly, low-cost and low-mercury fish such as anchovies and sardines have some of the highest concentrations of omega-3 oils that are used in omega-3 fatty acid clinical trials utilizing dietary supplements for heart disease and cancer [75]. It should also be kept in mind that the AHA recommends about two servings of fish per week and plant omega-3 consumption [144], which I try to reiterate often to urologic patients. Thus, the healthiest sources of omega-3 compounds in food are coincidentally very low in mercury. Fish-oil supplements for completely healthy individuals or for chronic disease prevention do not have data, and the use of fish oil to prevent heart disease in a primary or secondary prevention setting has mixed results because of potential subgroup benefit or harm [145–148].

Tree nuts share some similar clinical positive impacts of marine omega-3 oils. A consistent reduction in the risk of CHD and/or sudden cardiac death has been associated with an increased consumption of a diversity of nuts in prospective studies, and they can also reduce inflammatory markers that impact a variety of organ systems [149–154]. Nuts contain a variety of potential beneficial compounds, such as ALA (the primary plant-based omega-3 fatty acid), other polyunsaturated fats, monounsaturated fats, vitamin E, magnesium, potassium, fiber, and flavonoids [75]. Nut consumption via an improvement in heart health may also improve urologic health and even erectile health [155]. However, the primary limitation of tree nuts is their high caloric content when going beyond several servings a day. Healthy plant oils utilized for cooking such as soybean, canola, olive oil, safflower, and so forth also contain a high concentration of omega-3 fatty acids, monounsaturated fat, and numerous other vitamins and minerals such as natural vitamin E [75]. Most cooking oils contain 120 cal per tablespoon; therefore, moderation again is the cornerstone to good health and nutrition.

Educate patients on the first six heart-healthy lifestyle changes, because only 1–2 % of individuals are able to follow these on a regular basis. It is the sum of what is accomplished in moderation that has the highest probability of impacting urologic health compared to just one or several lifestyle changes in extreme (similar to cardiovascular disease prevention). Add other parameters as personally needed and triaged (tobacco cessation, sodium reduction, alcohol in moderation, pill reduction or addition, etc.).

If multiple lifestyle changes or if achieving numerous healthy parameters over time appears to be associated with the largest improvements in health, then this theory should be tested. It has been tested over the years, and the results are profound. For example, data from the National Health and Nutrition Examination Survey (NHANES) was utilized that included 44,959 US adults 20 years of age or older [156]. Mean age was 46–47 years, and approximately half of the participants were women. Median follow-up was 14.5 years. A total of only 1–2 % of the participants met all seven of the health parameters. Amazingly, there was a 51 % reduction in all-cause mortality, 76 % reduction in cardiovascular mortality, and 70 % reduction in ischemic heart disease (IHD) mortality for participants meeting six or more metrics compared to one or fewer. Achieving a higher number of cardiovascular health parameters also appeared to be correlated with a lower risk for all-cancer mortality. The following seven goals/parameters were utilized in this study:

Another classic example of the benefit of just following one or two of the above healthy lifestyle parameters is derived from the Nurses’ Health Study, which reviewed 24 years of follow-up data in 116,564 women who were 30–55 years old in the 1970s and were healthy and not diagnosed with cancer or cardiovascular disease [157]. During the 24 years of study, a total of 10,282 deaths occurred mostly from cancer (5,223 deaths) and cardiac disease (2,370), but 2,689 deaths occurred from other causes. Regardless of whether the researchers looked at dying from any cause, an interesting trend occurred when multivariate relative risks were utilized. Women who were of normal weight and exercised about 30 min a day had the lowest risk of dying of any cause compared to any other type of woman in this cohort. However, the researchers also found that thin women that hardly exercised had a greater chance of dying of any cause compared to thin women that exercised regularly. Obese women that rarely exercised had the highest chance of dying early, but the researchers also found that obese women (of the same general weight) that exercised about 30 min a day had a lower risk of dying from any cause compared to the obese women that rarely exercised! Thus, the greatest probability of living longer can be found in normal-weight individuals who exercise 30 min daily or more and follow other healthy lifestyle parameters, but even if an individual is overweight or obese and exercises, it still counts as an investment in long-term health. Interestingly, these same data and results can easily be derived from notable male cohort studies [158, 159].

Other past general health comprehensive lifestyle studies have demonstrated that few (less than 5 %) individuals have reported adhering to numerous moderate healthy behaviors at one time [160]. Again, the collective sum of what is accomplished, rather than one or two specific behavioral changes, has the largest impact on cardiovascular markers, CVD, cancer, and all-cause mortality [161]. Thus, I often use checklists derived and modified from the Mediterranean diet US study [162], the INTERHEART study, and other lifestyle studies to ensure verve and compliance in patients [75, 163–167]. These studies essentially found that regardless of race, age, genetics, and geographic location, the ability to essentially maintain numerous consistent features of lifestyle and/or diet was associated with an 85–95 % reduced risk of a cardiovascular event, and similar behaviors and changes in other recent studies demonstrated an improved ability to live far beyond average life expectancy with minimal mental or physical morbidity. The critical primary characteristics in these individuals included behavioral changes, with no benefit or detriment derived from a dietary supplement.

Table 1.5 is a modified, often utilized handout or checklist that I created and provide to individuals seeking to increase their odds or probability of living longer and better through dietary changes adapted from a Mediterranean diet [75]. How many patients or even colleagues have all of these features or need to work on these changes? How many urologic health conditions could be prevented or improved with these heart-healthy changes?