Prostate health: nutrition and lifestyle interventions

Almost all men will develop some prostate enlargement as they age therefore prostate health is an increasingly important concern. Benign prostate enlargement (BPE), also known as benign prostatic hyperplasia (BPH) is an enlargement of the prostate¹ which may develop gradually over a number of years. It is the most common urological condition among men.

While surgery and medication are treatment options for BPH, there are also nutritional and lifestyle changes that can be made to help promote better prostate health in general and manage symptoms of BPH. Other conditions that can affect the prostate include cancer and prostatitis (inflammation of the prostate gland) although BPH will be the focus of this blog.

The prostate gland

The prostate is a small gland found only in men and is part of the reproductive system. Initially, it is approximately the size of a walnut, but increases with age. The prostate surrounds the urethra and is located just below the bladder and in front of the rectum.

The word “prostate” is taken from the Greek expression “one who stands before,” which describes its position in the body. Its most important function is the production of a fluid that, together with sperm cells from the testicles and fluids from other glands, makes up semen. Its muscles help push semen through the urethra which is a narrow tube that connects to the bladder and runs through the middle of the prostate and along the length of the penis, carrying both urine and semen out of the body. 

Benign prostatic hyperplasia

The prostate can grow from the size of a walnut to the size of a lemon and it is estimated that about 50% of men over the age of 50, and 80% of those older than 70 suffer from BPH.²

The gradual increase in size may not cause symptoms until it has enlarged sufficiently to cause problems. In some men the symptoms are mild and don’t require treatment; in others, the symptoms can be troublesome and have a major impact on life. BPH is the most influential factor for the development of lower urinary tract symptoms (LUTS). BPH isn’t cancerous and is not thought to increase the risk of developing prostate cancer.

Symptoms of reduced prostate health due to BPH

The severity of the symptoms may not always relate to the size of the prostate but depend on how much the prostate presses on the urethra and bladder. Common symptoms of BPH include:

• Frequency – urinating more, often at night (nocturia)
• Urgency – urgent need to urinate
• Poor emptying – not being able to fully empty the bladder
• Hesitancy – trouble starting to urinate
• Poor stream – weak urine stream
• Dribbling – at the end of urination

Less common symptoms include:

• Blood in urine
• Urinary tract infections
• Not being able to urinate

Note

You should always see a doctor if any of these symptoms occur, and it is important to seek medical confirmation. Differential diagnosis for prostatitis and cancer of the prostate should be carried out by a doctor.

Causes/aetiology of benign prostatic hyperplasia

BPH is a multifactorial disease, where the pathogenesis seems to be correlated with a number of different factors which include:

• ageing
• oxidative stress
• hormonal changes
• inflammation
• obesity
• metabolic syndrome 

Oxidative stress

Oxidative stress – is described as the imbalance between production of reactive oxygen species (free radicals) and antioxidant defences. It has been considered to be one of the mechanisms that triggers the development and progression of BPH and levels of antioxidants, such as zinc, are often found to be decreased in BPH.^1,2 In addition, studies have shown increased prostatic lipid peroxidation and reduced endogenous antioxidants (glutathione, superoxide dismutase, catalase).³

Hormones

Hormones such as testosterone and oestrogen undoubtedly play a role in BPH. For instance, the prostate is an oestrogen target tissue and ageing and obesity increase the plasma oestrogen to androgen ratio. Environmental oestrogens, which can be endocrine disruptors may also play a role – and can be found in the water, plastics (BPA) and commercially-raised meat and dairy. They are certainly having an effect on sperm count with reports highlighting the impact.⁴  

Inflammation

A significant correlation has been found between prostate size and both acute and chronic inflammation and data suggests that this could be a causative effect, rather than occurring simply as a consequence. Potential causes include infectious agents, toxins, diet, lifestyle factors, hormonal or metabolic imbalances or a combination of these. Low testosterone is also associated with increased inflammatory mediators.

Obesity

Obesity has been associated with a risk of BPH in observational studies. In a study carried out last year, independent causal roles of high waist circumference, BMI and sedentary behaviour were found in BPH.⁵

Metabolic syndrome

Metabolic syndrome is a condition that includes a cluster of risk factors including abdominal obesity, high blood pressure, impaired fasting glucose, high triglyceride levels, and low HDL cholesterol levels. Research has shown that rates of BPH are higher among men with high blood pressure and diabetes.¹ In addition, several studies have demonstrated that fasting serum insulin levels were significantly higher in men with BPH than in controls and correlated with the annual BPH growth rate.^6,7 Statistics show 26.5%–55.6% prevalence of metabolic syndrome in men with LUTS was reported in worldwide studies.⁸ 

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Nutrition and lifestyle interventions to improve prostate health 

Evidence shows that diet modification, specific nutrients and lifestyle changes can favourably influence BPH symptoms and can help to promote better prostate health.⁹

Diet

Growing evidence suggests a potential link between nutrition, in particular the “Western-style diet,” and BPH. For instance, Western diets, typically high in refined carbohydrates and red meat may increase the risk for BPH, whereas a higher intake of vegetables, omega-3 fatty acids, and dietary vitamins may provide benefit for BPH.¹⁰ In similar research, data suggests that a diet that is more adherent to the Mediterranean diet or that emphasizes the presence of vegetables, fruits, nuts, legumes, and fish may have a beneficial role on BPH.²

In further support of these findings, the Prostate Cancer Prevention Trial (PCPT) with a cohort of 18,800 patients found that compared with men eating less than one serving of vegetables per day, men eating four or more servings had a 32% decreased BPH risk.¹¹ In the same trial, a slight relationship between a lower risk of BPH and multiple nutrients, such as lycopene, vitamin D and zinc was also established for this group.¹¹

Another study investigated the effects of fruits, vegetables and micronutrients on BPH and found an inverse correlation between intake of vegetables, especially those rich in beta-carotene, lutein, vitamin C, and BPH.¹² More recently, a systematic review carried out this year found that overall, the literature suggested plant-forward diets confer a protective effect on BPH.¹³ 

Balance blood sugar levels/hormones 

Certain dietary factors were shown to have an impact on metabolic disorders that lead to diabetes and obesity – both of which effect BPH and LUTS. The dietary patterns associated with increased risks included starches and red meats, whereas vegetable consumption is associated with a decreased risk.¹⁴ Correction of metabolic syndrome, has been identified as a factor that can impact on the progression of BPH.¹⁵ Avoiding or minimising sugary, processed foods and refined foods is recommended as they are rapidly converted into glucose and raise blood levels quickly. Consuming plenty of healthy protein sources such as poultry, fish, and eggs and healthy fats such as olive oil, avocado, nuts, seeds and oily fish is also recommended. Fat and protein in a meal will slow down the release of glucose into the bloodstream.

Polyphenols

Polyphenols are plant-based molecules with antioxidant properties and may also exert phyto-oestrogenic activity. They are classified into 5 groups including flavonoids, curcuminoids, phenolic acids, stilbenes, and lignans and research has shown that the prostate gland is one of the tissues where dietary polyphenols exert their actions.

Actions include:

• inhibiting inflammatory mediators
• acting as selective androgen modulators
• inducing cell death
• repairing antioxidant defence mechanisms
• having phyto-oestrogenic activity

Foods rich in polyphenols include tomatoes, seeds (pumpkin, flax, sesame), nuts, green tea, cocoa, olives, parsley, celery, kale, broccoli, spinach, legumes and berries/grapes. 

Pumpkin seeds – are rich in carotenoids and phytosterols and contains a wide range of vitamins, minerals, amino acids and mono and polyunsaturated fats. They are also well-known for their zinc content and men with prostate problems have been noted to have dramatically decreased zinc levels. Pumpkin seed has historically featured in the natural approach to treatment for BPH in a number of countries. Potential anti-androgen and anti-inflammatory properties were suggested as the benefit of the pumpkin seed to the prostate – research showing significant results achieved on the International Prostate Symptom Score (IPPS). In one study, overall, in men with BPH, 12 months of treatment with pumpkin seed led to a clinically relevant reduction in IPSS compared with placebo.¹⁶ 

Lycopene – is a carotenoid found in red/orange fruit and vegetables and has been shown to have a role in the prevention and management of BPH – mainly through its:^17-19

• antioxidant activity
• inhibition of cell cycle progression
• induction of apoptosis
• increasing of gap-junctional cell communication
• inhibition of insulin-like growth factor I signal transduction 

In one study, those taking lycopene had increased plasma concentrations of the carotenoid and showed no further enlargement of the prostate; in contrast, progression of BPH continued in the placebo group. The researchers concluded that lycopene inhibited the progression of BPH.²⁰ Tomatoes are an excellent source of lycopene. 

Zinc – research has consistently showed the role of zinc in prostate function.²¹ High levels of zinc are essential for maintaining prostate health due to its role in apoptosis and truncation of the Krebs cycle.²² In prostatic tissue derived from BPH, zinc levels have been shown to be decreased by more than 50%.²³ Zinc can be found in meat, fish, legumes, nuts, seeds and wholegrains.

Phytosterols – Plant sterols, known commonly as phytosterols, are plant-derived compounds that are structurally related to cholesterol. Early human diets were likely rich in phytosterols; however, the typical Western diet today is relatively low.²⁴ A number of potential health benefits for plant sterols have been demonstrated in relation to BPH and the results of a few clinical trials suggest that phytosterol supplementation at relatively low doses can improve urinary tract symptoms. In a six-month study of 200 men with symptomatic BPH, 60 mg/day of a β-sitosterol preparation improved symptom scores, increased peak urinary flow, and decreased post-void residual urine volume compared to placebo.²⁵ A systematic review that combined the results of clinical trials found that β-sitosterol extracts increased peak urinary flow by an average of 3.9 mL/second and decreased post-void residual volume by an average of 29 mL.^26,27 Nuts, wholegrains, legumes and vegetables are good sources.

Urtica dioica (stinging nettle root) – analysis of this plant has revealed the presence of a number of well-known compounds, including beta-sitosterol, quercetin and rutin. In a clinical trial, 287 BPH patients who had been treated with nettle showed significant reduction in IPSS, serum PSA and prostate size.²⁸ In two further clinical trials on BPH patients, nettle had a better impact in reducing patients’ clinical symptoms than placebo.^29,30 

Lifestyle

Some reversible risk factors for BPH have been identified such as low physical activity, overweight/obesity and hypercaloric nutrition.¹⁵ Physical activity and weight-loss are therefore two of the most important factors to take into account.

Exercise – in a systematic review moderate exercise was found to favourably influence BPH.³¹ It can also help to maintain a healthy weight, reducing the risk for obesity and related issues. Regular exercise can support blood glucose levels by building muscle and therefore increasing glycogen storage, so that more glucose can be taken out of the blood.

Smoking – studies investigating changes in molecular expression have shown that inflammation, generation of reactive oxygen species, and downregulation of glucocorticoid receptor are induced in the prostate by exposure to cigarette smoking. These changes could underlie the disruption of proliferative and apoptotic balance of the prostate cell and the development of prostate proliferative diseases.^32-34 

Excessive alcohol – excessive intake has been shown to damage the structure of organelles of the prostate cell, which could cause abnormal prostate proliferation.³⁵ 

Remove or minimise caffeine and alcohol – which can irritate the bladder and make urinary symptoms worse.

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Prostate health references

Introduction

1. NHS Inform. Benign prostate enlargement. Available at: https://www.nhsinform.scot/illnesses-and-conditions/kidneys-bladder-and-prostate/benign-prostate-enlargement/ [accessed 20^th October 2023]
2. Russo, G. I., (2021). Relationship between Dietary Patterns with Benign Prostatic Hyperplasia and Erectile Dysfunction: A Collaborative Review. Nutrients, 13(11), 4148. 

Aetiology, nutrition and lifestyle

1. Sauer, A. K., (2020). Zinc Deficiency in Men Over 50 and Its Implications in Prostate Disorders. Frontiers in oncology, 10, 1293.
2. Christudoss, P., (2011). Zinc status of patients with benign prostatic hyperplasia and prostate carcinoma. Indian journal of urology : IJU : journal of the Urological Society of India, 27(1), 14–18.
3. Udensi, U. K., (2016). Oxidative stress in prostate hyperplasia and carcinogenesis. Journal of experimental & clinical cancer research : CR, 35(1), 139.
4. Rozati, R., (2002). Role of environmental estrogens in the deterioration of male factor fertility. Fertility and sterility, 78(6), 1187–1194.
5. Wang, Y. B. (2022). Causal relationship between obesity, lifestyle factors and risk of benign prostatic hyperplasia: a univariable and multivariable Mendelian randomization study. Journal of translational medicine, 20(1), 495.
6. Dahle, S. E., (2002). Body size and serum levels of insulin and leptin in relation to the risk of benign prostatic hyperplasia. The Journal of urology, 168(2), 599–604.
7. Kopp W. (2018). Diet-Induced Hyperinsulinemia as a Key Factor in the Etiology of Both Benign Prostatic Hyperplasia and Essential Hypertension?. Nutrition and metabolic insights, 11, 1178638818773072.
8. Ngai, H. Y., (2017). Metabolic syndrome and benign prostatic hyperplasia: An update. Asian journal of urology, 4(3), 164–173.
9. Das, K., & Buchholz, N. (2019). Benign prostate hyperplasia and nutrition. Clinical nutrition ESPEN, 33, 5–11.
10. Western diet and benign prostatic hyperplasia [online] Available at: https://www.sciencedirect.com/science/article/abs/pii/B9780128197653000042. Accessed 27^th October 2023.
11. Kristal, A. R., (2008). Dietary patterns, supplement use, and the risk of symptomatic benign prostatic hyperplasia: results from the prostate cancer prevention trial. American journal of epidemiology, 167(8), 925–934.
12. Rohrmann, S., (2007). Fruit and vegetable consumption, intake of micronutrients, and benign prostatic hyperplasia in US men. The American journal of clinical nutrition, 85(2), 523–529.
13. Feiertag, N. (2023). Should Men Eat More Plants? A Systematic Review of the Literature on the Effect of Plant-Forward Diets on Men’s Health. Urology, 176, 7–15.
14. Espinosa G. (2013). Nutrition and benign prostatic hyperplasia. Current opinion in urology, 23(1), 38–41.
15. de la Taille, A., Descazeaud, A., & Robert, G. (2018). Prévenir le développement et de la progression des SBAU liés à l’HBP [How to prevent LUTS due to BPH development and progression]. Progres en urologie : journal de l’Association francaise d’urologie et de la Societe francaise d’urologie, 28(15), 821–829.
16. Vahlensieck, W., (2015). Effects of pumpkin seed in men with lower urinary tract symptoms due to benign prostatic hyperplasia in the one-year, randomized, placebo-controlled GRANU study. Urologia internationalis, 94(3), 286–295.
17. Wertz K,. Lycopene: Modes of action to promote prostate health.Arch Biochem Biophys. (2004) 430:127–34.
18. Linnewiel-Hermoni K,. The anti-cancer effects of carotenoids and other phytonutrients resides in their combined activity.Arch Biochem Biophys. (2015) 572:28–35.
19. Sharoni Y, Carotenoids and transcription.Arch Biochem Biophys. (2004) 430:89–96.
20. Schwarz, S., (2008). Lycopene inhibits disease progression in patients with benign prostate hyperplasia. The Journal of nutrition, 138(1), 49–53.
21. Sauer, A. K. (2020). Zinc Deficiency in Men Over 50 and Its Implications in Prostate Disorders. Frontiers in oncology, 10, 1293.
22. Franz MC, Zinc transporters in prostate cancer. Mol Aspects Med. (2013) 34:735–41.
23. Christudoss P,. Zinc status of patients with benign prostatic hyperplasia and prostate carcinoma. Ind J Urol. (2011) 27:14–8.
24. Linus Pauling Institute [online] Available at: https://lpi.oregonstate.edu/mic/dietary-factors/phytochemicals/phytosterols. Accessed 2^nd November 2023.
25. Berges RR,. Randomised, placebo-controlled, double-blind clinical trial of beta-sitosterol in patients with benign prostatic hyperplasia. Beta-sitosterol Study Group. Lancet. 1995;345(8964):1529-1532.
26. Wilt, T., Ishani, A., (2000). Beta-sitosterols for benign prostatic hyperplasia. The Cochrane database of systematic reviews, 1999(2), CD001043
27. Wilt TJ,. Beta-sitosterol for the treatment of benign prostatic hyperplasia: a systematic review. BJU Int. 1999;83(9):976-983.
28. Safarinejad MR. Urtica dioica for treatment of benign prostatic hyperplasia: a prospective, randomized, double-blind, placebo-controlled, crossover study. J Herb Pharmacother. 2005;5(4):1–11.
29. Melo EA,. Evaluating the efficiency of a combination of Pygeum africanum and stinging nettle (Urtica dioica) extracts in treating benign prostatic hyperplasia (BPH): double-blind, randomized, placebo controlled trial. Int Braz J Urol. 2002;28(5):418–25.
30. Schneider T, Rubben H. [Stinging nettle root extract (Bazoton-uno) in long term treatment of benign prostatic syndrome (BPS). Results of a randomized, double-blind, placebo controlled multicenter study after 12 months]. Urologe A. 2004;43(3):302–6.
31. Das, K., & Buchholz, N. (2019). Benign prostate hyperplasia and nutrition. Clinical nutrition ESPEN, 33, 5–11.
32. Dwivedi S., Tobacco exposure may enhance inflammation in prostate carcinoma patients: an explorative study in north Indian population. Toxicol Int. 2012;19(3):310–318
33. Lee J., Cigarette smoking and inflammation: cellular and molecular mechanisms. J Dent Res. 2012;91(2):142–149.
34. Veras A.S.C.,. Impact of cigarette smoke and aerobic physical training on histological and molecular markers of prostate health in rats. Braz J Med Biol Res. 2020;53(5)
35. Macke A.J., Petrosyan A. Alcohol and prostate cancer: time to draw conclusions. 2022;12(3)

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If you have questions regarding the topics that have been raised, or any other health matters, please do contact our team of Nutritional Therapists.

nutrition@cytoplan.co.uk
01684 310099

Last updated on 3rd January 2024 by cytoffice