REVIEW

CURRENT
OPINION Nutrition and benign prostatic hyperplasia
Geovanni Espinosa

Purpose of review
Nutrition seems to modify the pathogenesis of benign prostatic hyperplasia (BPH) effect symptomology in
men suffering from lower urinary tract symptoms (LUTS). Although there are numerous pharmaceuticals and
procedures for these conditions, nutrition may improve outcomes as a primary approach or in tandem with
BPH medications or procedures. The purpose of this review is to highlight the benefits of nutrition and
dietary supplements in men with BPH and LUTS.
Recent findings
Dietary factors have an impact on metabolic disorders that lead to diabetes and obesity – both of which
inversely effect BPH and LUTS. Dietary patterns associated with increased risks include starches and red
meats, whereas moderate alcohol intake and polyunsaturated fat and vegetable consumption decrease
risks. Dietary supplements of zinc, saw palmetto, and beta-sitosterol in relieving BPH symptoms have had
mixed results. Randomized clinical trials of nutritional practices and other lifestyle alterations such as
exercise for the prevention or treatment of BPH and LUTS have yet to be performed.
Summary
Nutritional practices may provide for the prevention and treatment of BPH and LUTS while positively
affecting other systemic parameters. Whereas there are a few clinical randomized trials for the prevention
and treatment of BPH and LUTS, nutritional modifications may have a healthy lifestyle alternative with
minimal to no adverse effects.
Keywords
benign prostatic hyperplasia, beta-sitosterol, rye pollen extract, saw palmetto, starch

INTRODUCTION BPH, with the association being slightly stronger

Genetics, sex steroid hormones, and aging have for animal protein intake than for vegetable protein
been known to be the cause of lower urinary tract intake [6].
symptoms (LUTS) associated with benign prostatic Therefore at this time, ingesting excess animal
hyperplasia (BPH). More recently, epidemiological protein as a means to increase total protein intake is
data suggest the effects of nutritional factors not recommended. Instead, high-quality, plant-
modulating metabolism – including obesity and derived and cold water fish-based protein sources
blood glucose, exercise, and diet – substantially in moderate amounts are probably reasonable
bequeath to the development of these conditions choices until we know more about the relationship
[1]. Although the current research in the relation- of protein intake and BPH.
ship between nutritional practices and BPH symp-
toms are compelling, it is not conclusive as most are
FRUITS AND VEGETABLES
epidemiological in design. Randomized trials would
be of value to determine the precise nutritional Fruits and vegetables contain high levels of sub-
practice best suited for such patients in a clinical stances that can fight inflammation, including
setting. Small randomized clinical trials have been
performed, however, on a few herbal products, Department of Urology, NYU Langone Medical Center, New York, New
&
including saw palmetto [2,3 ], rye pollen extract York, USA
&
[4 ], and beta-sitosterol [5], with mixed results. Correspondence to Geovanni Espinosa, ND, LAc, Department of
Urology, NYU Langone Medical Cente, 150 East 3rd Street, New York,
NY 10016, USA. Tel: +1 917 209 6641; e-mail: geovanni.espinosa@
HIGH-PROTEIN DIET nyumc.org
An 8-year study of 3523 men with BPH cited that Curr Opin Urol 2013, 23:38–41
total protein intake is positively associated with DOI:10.1097/MOU.0b013e32835abd05

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 Nutrition and BPH Espinosa

management of BPH and other hormone-related

KEY POINTS abnormalities [10].
 Low starch, low animal protein, and higher servings One caution to remember about green tea is that
of fruit and vegetables seem to be protective against it contains caffeine, although at a much lower level
BPH. than does coffee, and somewhat less than black tea.
Caffeine is a diuretic and can stimulate the bladder,
 Whereas some zinc (100 mg/day) may be protective
causing an urgent need to urinate. On average, one
against BPH and LUTS, amounts of at least 100 mg/day
may increase the risk of prostate cancer. cup of green tea has 25 mg of caffeine, whereas black
tea has nearly twice as much. The decaffeinated
 Dietary supplements that include rye pollen extract version is also available.
(Cernilton) and beta-sitosterol may be helpful for BPH-
associated LUTS and nocturia, but newer and larger
clinical trials must be conducted to be conclusive. ZINC
The human prostate gland contains a higher level of
zinc than most other tissues [11].
There seems to be a decrease in zinc levels in
antioxidants, polyphenols, vitamins, minerals, and plasma and prostate tissue in men with BPH (and
fiber. Vegetables appear to have an important role in prostate cancer) as compared to normal prostate
preventing BPH. In a study – the Prostate Cancer [12].
Prevention Trial – 4770 participants were evaluated. Zinc has demonstrated to relieve LUTS probably
The investigators found a significantly lower risk due to its ability to inhibit 5-alpha-reductase [13]
of BPH among men who consumed at least four and/or by its ability to inhibit prolactin [14]. Pro-
servings of vegetables daily compared with those lactin has been shown to increase the uptake of
who ate less than one serving daily [7]. testosterone by the prostate, thereby leading to
Plant proteins combined with aerobic exercise increased levels of dihydrotestosterone (DHT) by
may be even more beneficial for prostate health providing more substrate [15].
than is protein from animal foods, such as meat, Studies have indicated that proper zinc status in
poultry, and eggs. Barnard and Aronson [8] reported men may help with BPH as well as prostate cancer as
that daily aerobic exercise along with a low-fat, shown by this preclinical study. Kristal et al. have
high-fiber diet consisting of whole grains, fruits, shown zinc to have a possible protective role in a
and vegetables can reduce factors associated with randomized trial of 4770 participants. BPH was
BPH (e.g. estradiol/testosterone ratio, insulin). assessed over 7 years and was defined as medical
Many high-fiber plant foods, such as whole grains, or surgical treatment or repeated elevation (>14) on
lentils, and beans, are also high in protein [8]. the International Prostate Symptom Score question-
naire. Although the association between zinc and
BPH in this study is compelling, the Food Frequency
LYCOPENE Questionnaire performs poorly in assessing associ-
In a randomized, double-blind, placebo-controlled ations between diet, nutrition macromolecules and
trial, it was found that lycopene, a component micromolecules, and disease [7].
found in tomatoes, may inhibit BPH progression Excessive consumption of zinc supplement of
and may ameliorate symptoms in patients at a dose more than 100 mg per day may significantly
of 15 mg/day for 6 months. Lycopene supplements increase the risk of advanced prostate cancer [16].
are safe and well tolerated. Lycopene does not selec-
tively interfere with prostate-specific antigen (PSA)
levels, which is important to allow early detection of ALCOHOL
prostate cancer during long-term supplement intake Although only beer raises prolactin levels, higher
&&
[9 ]. alcohol intake may be associated with BPH. In a
17-year study of 6581 men in Hawaii, it was
noted that an alcohol intake of at least 25 oz/month
GREEN TEA was directly correlated with the diagnosis of BPH
Green tea has components that are attributed to [17].
potent antioxidants called catechins, known as epi- The association was most significant for beer,
gallocatechin-3-gallate (EGCG), which have been wine, and sake, and less for distilled spirits. Most
shown to destroy certain bacteria and viruses, other recent studies confirm a protective effect of
enhance the immune system, and combat several alcohol towards BPH but higher LUTS. A meta-
forms of cancer. EGCG seems to be useful for the analysis of 19 published studies, incorporating

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 Benign prostatic hyperplasia

120 091 men, observed up to a 35% decreased like- urinary tract symptom self-rating scores, and peak
lihood of BPH among men who drank daily, but an urine flow improvements compared with men
increased risk of LUTS [18]. receiving placebo [2]. This analysis also showed that
matched up with men receiving the DHT inhibitor
finasteride (Proscar), men treated with saw palmetto
VITAMIN D had similar improvements in urinary tract symptom
Kristal et al. [7] showed vitamin D supplementation scores with less adverse effects compared to the
was associated with reduced risk of BPH, but group on finesteride [2].
the dosage was imprecise. The association in this The mechanism of action is related to inhibition
4770-participant trial was observed only among of DHT binding to both the cytosolic and nuclear
men who used both multivitamins and single vita- androgen receptors, inhibition of 5-alpha-reductase,
min D supplements. There were no associations of and interference with intraprostatic estrogen recep-
supplement use with BPH risk, with the exception of tors. As a result of this multitude of effects, most
a trend for decreasing BPH risk with increasing dose of the results have been excellent in randomized
of supplemental vitamin D. Although this study trials.
lacked data on frequency, dose, and duration of A randomized, placebo-controlled, dose-escala-
vitamin D use, the results are intriguing enough tion trial indicates no benefit from saw palmetto
to support further research that will address consumption compared to placebo with 369 partici-
&
whether vitamin D alone will have any benefit for pants [3 ].
BPH [19].
Mechanism of how vitamin D may have a
favorable effect on BPH is by attaching the mole- RYE POLLEN EXTRACT (CERNILTON)
cule vitamin D receptors on the prostate and Cernilton is a water-soluble pollen fraction phyto-
bladder, and inhibiting prostate growth, lowering therapeutic product whose extract originates from
excessive contractility, and reducing inflammation rye grass pollen. One review analyzed the specific
[20]. effects of Cernilton and suggested that it improved
subjective symptoms including nocturia, but no
significant improvement in urodynamic measures
STARCH was observed when compared with placebo. The
A case-control study of 1369 patients with BPH and Cernilton studies are challenged by short duration,
1451 controls demonstrated a direct association low number of participants, and the lack of updated
&
between starch consumers and BPH [21]. The main data [4 ].
sources of starch in this population were white
bread, pasta, and rice.
Starch may be responsible for a glycemic BETA-SITOSTEROL
response that is compensated for by an increase Beta-sitosterol is one of the several phytosterols
in serum insulin and insulin-like growth (plant sterols) with chemical structures similar to
factor. Elevated insulin-like growth factor levels, that of cholesterol. Beta-sitosterol is widely distri-
possibly mediated by dihydrotestosterone [22], buted in the plant kingdom and found in pecans,
are thought to stimulate the development of saw palmetto, avocados, and pumpkin seeds. A
BPH. No association was found for sugars from review of beta-sitosterol studies included four
fruit, which have a lower glycemic index, than double-blind trials of 519 men, duration of which
does bread [22]. was between 4 and 26 weeks. Beta-sitosterol
improved symptom scores by 35%, peak flow rate
improved symptom scores by 35%, peak flow rate
SAW PALMETTO by 34%, and reduced postvoid residual volume by
The extracts from the berries of saw palmetto are the 24%. Their long-term effectiveness, safety, and
most popular herbal products used to treat sympto- ability to prevent BPH complications are not
matic BPH. Saw palmetto is native to Florida, and known [5].
has been shown to significantly improve the signs
and symptoms of BPH in numerous older clinical
studies. One examination of 21 randomized con- CONCLUSION
trolled trials involving a total of 3139 men (includ- In conclusion, nutritional modifications of less
ing 18 double-blind trials) demonstrated that men meat, simple starches, and more vegetables and
treated with saw palmetto experienced decreased fruits contribute substantially to the management
urinary tract symptom scores, less nocturia, better of BPH and LUTS. These nutritional patterns may

40 www.co-urology.com Volume 23  Number 1  January 2013

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 Nutrition and BPH Espinosa

4. MacDonald R, Ishani A, Rutks I, Wilt TJ. A systematic review of cernilton for the
modulate metabolic pathways that lead to obesity & treatment of benign prostatic hyperplasia. BJU Int 2000; 85:836–841.
and diabetes – two conditions that contribute to the Rye pollen extract (Cernilton) has been studied with 444 men in two placebo-
controlled and two comparative trials lasting from 12 to 24 weeks. These trials are
development of BPH and LUTS. Dietary supple- older and limited by short duration, limited number of enrolees, gaps in reported
ments must be used cautiously. Saw palmetto as a outcomes, and unknown quality of the preparations utilized. The comparative trials
lacked a proven active control. However, Cernilton is of some interest since it was
single agent may not help, whereas beta-sitosterol well tolerated and modestly improves overall urologic symptoms including noctur-
and rye pollen extract may. Newer clinical trials ia. Additional randomized placebo and active-controlled trials are needed to
evaluate the long-term clinical effectiveness and safety of Cernilton.
with a larger study population are needed for 5. Wilt TJ, McDonald R, Ishani A. Beta-Sitosterol for the treatment of benign
efficacy of these herbal products to be conclusive. prostatic hyperplasia: a systematic review. BJU Int 1999; 83:976–983.
6. Suzuki S, Platz EA, Kawachi I, et al. Intakes of energy and macronutrients and
Most of the available data on nutrition as it relates to the risk of benign prostatic hyperplasia. Am J Clin Nutr 2002; 75:689–697.
BPH are observational and should serve primarily as 7. Kristal AR, Arnold KB, Schenk JM, et al. Dietary patterns, supplement use, and
the risk of symptomatic benign prostatic hyperplasia: results from the prostate
a guide for informing patients on healthy lifestyle cancer prevention trial. Am J Epidemiol 2008; 167:925–934.
interventions. Such lifestyle modifications may 8. Barnard RJ, Aronson WJ. Benign prostatic hyperplasia: does lifestyle play a
role? Phys Sportsmed 2009; 37:141–146.
assist in weight loss and stabilizing insulin levels, 9. Schwarz S, Obermüller-Jevic UC, Hellmis E, et al. Lycopene inhibits disease
which modulate the effects of BPH and LUTS and && progression in patients with benign prostate hyperplasia. J Nutr 2008; 138:49–
53.
have a positive impact on cardiovascular health as a Lycopene is a promising nutritional component for chemoprevention of prostate
side benefit. cancer but the studies in regards to prostate cancer have been mixed. This pilot
study is of interest because it investigates the effects of lycopene supplementation
in a total of 40 elderly men diagnosed with BPH in a placebo-controlled rando-
mized clinical trial. The 6-mo lycopene supplementation decreased PSA levels in
men (P < 0.05), whereas there was no change in the placebo group. Prostate
Acknowledgements enlargement occurred in the placebo group as assessed by trans-rectal ultra-
None. sonography and digital rectal examination; the prostate did not enlarge in the
lycopene group. Symptoms of the disease, as assessed via the International
Prostate Symptom Score questionnaire, were improved in both groups with a
significantly greater effect in men taking lycopene supplements.
Conflicts of interest 10. Liao S. The medicinal action of androgens and green tea epigallocatechin
gallate. Hong Kong Med J 2001; 7:369–374.
G.E. is Chief Scientific Officer of Prostate Research Labs 11. Li XM, Zhang L, Li J, et al. Measurement of serum zinc improves prostate
and Chief Medical Officer of XY Wellness, LLC. cancer detection efficiency in patients with PSA levels between 4 ng/mL and
10 ng/m. Asian J Androl 2005; 7:323–328.
12. Gómez Y, Arocha F, Espinoza F, et al. Zinc levels in prostatic fluid of patients
with prostate pathologies. Invest Clin 2007; 48:287–294.
13. Om AS, Chung KW. Dietary zinc deficiency alters 5 alpha-reduction and
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