Erectile Dysfunction

ERECTILE DYSFUNCTION smoking

Last Updated October 23rd, 2019

Overview

Having occasional difficulties in getting an erection is fairly common and could be prompted by fatigue or stress. This does not necessarily indicate a serious disorder. However, some men face this problem consistently. It can affect their self-esteem and relationships and may even be associated with other health problems. In common parlance, this is referred to as impotence. It can be a highly distressing condition and men suffering from it are often reluctant or embarrassed to discuss their problems and seek medical help.

Because sexual dysfunction is often treated as a taboo subject, patients tend to fall prey to advertisements of ‘magical’ herbal treatments and ‘instant’ remedies. Those suffering from impotence must be encouraged to approach certified medical practitioners instead of resorting to ‘natural’ remedies suggested by quacks or dubious email advertisements. This will ensure that the problem is responsibly and effectively diagnosed and treated. It should also be borne in mind that ‘natural’ does not always equate with ‘safe’.

Definition

ERECTILE DYSFUNCTION manErectile dysfunction or impotence refers to the persistent inability of the penis to achieve an erection and remain erect and firm enough to allow sexual intercourse.

Occasionally, a man may experience difficulty in achieving an erection because of stress or anxiety. This is very normal and does not qualify as impotence.

Erectile dysfunction is the consistent and continuous difficulty in achieving and maintaining an erection.

This condition is highly prevalent worldwide and it can affect men at any point during their lifetime following puberty. However, the likelihood of developing erectile dysfunction increases with advancing age. In fact, it is estimated that nearly half of all men over the age of 75 suffer from impotence.

Sexual arousal is a complex process and is made possible by a combination of factors. This includes sensory and emotional stimuli that trigger nervous and hormonal signals eliciting specific vascular and muscular responses. Problems can occur at any of these stages. In most cases, there is a physical cause but emotional and psychological factors may also be involved.

Causes

In order to engage in sexual intercourse, it is necessary for the male penis to become erect and firm. The penis is a highly vascular organ. When a man is aroused, the penis goes from a flaccid state to an erect state, becoming engorged and firm. This happens because of nervous stimulation which signals the muscles of the penis to relax, allowing its arteries to be flooded with blood. Simultaneously, the veins of the organ become constricted in order to keep this blood trapped in the penis. As long as this condition is maintained, the penis remains firm and erect. There can be several reasons for the failure to get and maintain an erection.

Formerly, impotence was blamed on emotional or psychological difficulties but it is now understood that the cause is more likely to be a physical one. Under this category, there can be four main scenarios in which the penis fails to achieve or maintain erection:

  • ERECTILE DYSFUNCTION smokingNot enough blood flowing into the penis. This can occur as a result of heart disease, diabetes or even narrowing of the arteries supplying blood to the shaft of the penis, preventing it from becoming firm enough.
  • Inability to retain blood. The veins may fail to constrict sufficiently to keep blood trapped in the penis. This is known as a venous leak.
  • The inability of blood to drain out from the penis. This painful condition is known as priapism and it is characterized by erections that can last for hours. Over time this can lead to complete loss of erectile function.
  • Disruption in the transmission of nerve signals to the penis. This may occur as a result of conditions such as stroke, paralysis or damage to the nerves of the organ itself.

A fuller list of specific causes appears below:

  • Cardiovascular disease such as atherosclerosis and hypertension.
  • Endocrine disorders causing abnormal levels of hormones such as testosterone and prolactin. Thyroid disorder is one possible cause.
  • Obesity.
  • Diabetes.
  • Chronic kidney or liver disease.
  • Peyronie’s disease. This is a condition involving the formation of scar tissue in the penis, causing it to curve and making intercourse difficult or painful.
  • Priapism
  • Metabolic syndrome.
  • Smoking.
  • Alcohol abuse or any other form of substance abuse. Drugs such as marijuana, cocaine and heroin can cause impotence.
  • Sleep disorders.
  • Treatment for enlarged prostate or prostate cancer.
  • Taking medications such as certain antidepressants, sleeping pills or blood pressure medications.
  • Injuries to the pelvic region.
  • Injuries to the spinal cord.
  • Parkinson’s disease.
  • Multiple sclerosis.
  • Reduced libido or indifference.
  • Stress.
  • Psychological problems such as depression and anxiety.
  • Emotional difficulties or relationship problems.

Symptoms

Erectile dysfunction is characterized by an inability to attain erection or the inability to maintain one long enough to engage in sexual intercourse. The patient may be able to achieve an erection but it may not be firm enough. This may be accompanied by a reduced sex drive or libido. Sometimes the erection may be painful, as in the case of patients suffering from Peyronie’s disease or priapism.

Clinical Complications

Men who experience erectile dysfunction develop self-esteem issues and may also become frustrated and depressed. Because of the inability to engage in sex, a man with erectile dysfunction will find it difficult to get his partner pregnant. All of these factors can have adverse effects on intimate relationships.

Diagnosis

ERECTILE DYSFUNCTION treatmentTo begin with, the patient will be asked about their medical history in order to get a sense of any diseases, medications or treatments that may have a bearing on the difficulty to achieve an erection. The patient will be asked to describe their sexual life. Tests for assessing erectile dysfunction include:

  • A physical examination of the penis and testicles.
  • Blood and urine tests to check for endocrine or metabolic disorders or conditions such as diabetes.
  • Blood test to check for the level of testosterone
  • Erection is induced before performing ultrasound tests in order to assess blood flow.
  • Monitoring nocturnal erections by means of a special device. If the patient is able to achieve erections during sleep then it indicates that, rather than physical problems, it may be psychological ones that are responsible for failure to achieve an erection in the conscious state.

Treatment and prevention

Treatment – The first thing that your doctor will do is make sure that you are getting the right treatment for any health condition that may be causing or worsening the erectile dysfunction.

  • Oral medication – These are a very successful treatment for erectile dysfunction for many men. These medications increase the effects of nitric oxide; a natural chemical that your body produces that relaxes muscles in the penis.
  • Alprostadil self-injections – In this method, a fine needle is used to inject alprostadil on the side or base of the penis. This injection is dosed to create an erection that lasts for one hour.
  • Alprostadil urethral suppository – Here a tiny alprostadil suppository is placed inside the penile urethra.
  • Testosterone replacement – Some cases of erectile dysfunction are due to low levels of testosterone. Testosterone therapy might be recommended as the first step or given in combination with other therapies.
  • Penis pump.
  • Penis surgery.
  • Penis implants.

Prevention 

  • Leading a healthy lifestyle –It is important to make sure that the arteries and nerves are healthy; to maintain good circulation and prevent damage later on. Poor diet, exercise, and unhealthy behavior can increase your chances of developing erectile dysfunction.
  • Controlling chronic illnesses – Chronic diseases are some of the major causes of erectile dysfunction. Cardiovascular diseases and diabetes significantly increase the risk of erectile dysfunction development in older men.
  • Don’t neglect your mental health – Mental and emotional health can contribute to ED. In some cases, it can be the underlining cause of erectile dysfunction.

Facts

  • Studies show that 90% of those who suffer from erectile dysfunction (ED) never go for treatment.
  • ED can occur in men of any age. Although it is common among men over the age of 75.

Facts

  • Regular sex (at least once per week) can help prevent ED.
  • ED is linked to dental health.
  • Japan has the highest self-reported incidents of erectile dysfunction. China is second and USA is third.

Facts

  • Erectile dysfunction can be an underlining symptom of a medical condition. These conditions include high blood pressure and heart diseases.

Related Conditions

Want to live a healthy lifestyle?

Subscribe to free FactDr newsletters.

REVAMP YOUR

If you're enjoying our website, we promise you'll absolutely love our new posts. Be the first one to get a copy!

Get factually correct, actionable tips delivered straight to your inbox once a week.

I want the latest scoop on :

We hate spam too. We will never share your email address with anyone. If you change your mind later, you can unsubscribe with just one click

By clicking Subscribe, I agree to the FactDr Terms & Conditions & Privacy Policy and understand that I may opt out of FactDr subscriptions at any time.

 

Dos and Don'ts

Dos
  • Address health problems leading to ED. Get a physical exam done to see what the exact cause of your erectile dysfunction is.
  • Stick to a sex-healthful diet. Studies find that obesity and high cholesterol are linked to impotence problems.
  • Get enough exercise. Routine exercise for 20-30 minutes a day will enhance the general wellbeing and may become a libido enhancer.
Don'ts
  • Indulge in smoking. Nicotine constricts the vessels when you want to get an erection, and it leads to the arteries hindering that may make impotence possible.
  • Have high alcohol consumption. As it is not an aphrodisiac, libido enhancer, but a depressant. Excessive ingestion can hinder the capacity to get an erection.
  • Over medicate.

 

 

 

Related Conditions

Trending Topics

diverticulitis diet
Diverticulitis diet: The right way to eat if you suffer from the disease Are you suffering from diverticultis but clueless about your diet ? Read this complete plan for diverticulitis diet…
passion fruit juice
Passion fruit: How one exotic fruit can help you fight infections and cancer! Passion fruit: Why does this exotic fruit have such an enticing name? And how can it protect you…
Maltitol: Things you must know about this artificial sweetener Sugar alcohols are produced by fruits and vegetables. Maltitol is an artificially produced sugar alcohol and is used…
The science behind daith piercing: Can it really cure migraine? Since the ear has several pressure points, it is believed that daith piercing activates the vagus nerve and…
Top 6 remedies to treat a razor burn at home Symptoms of razor burn include bumps on the skin, redness, and irritation of the skin. Find easy and…
Chromium Picolinate: An essential mineral supplement for faster weight loss Did you know that about 1.6 million deaths were directly linked to diabetes globally? How is it linked…
maltodextrin sugar
Maltodextrin: What are the hidden health benefits of this food additive? Maltodextrin is one of the few food additives that has been relatively deemed safe. Many experts now have…
The real reason why you shouldn’t be eating ramen noodles Instant ramen noodles might be your go-to snack for your hunger pangs. But with each spoonful you are…
nature health benefits
Green Healing: The amazing health benefits of being in nature You have no idea what sitting in a closed room does to your body and mind.Can a stroll…
CLA: A breakthrough weight loss supplement with minimal side effects Tried every weight loss supplement in the market with no substantial gain? Why not try CLA supplements, derived…
Vitamin K2: 8 reasons why you need this bone-building & cancer-fighting nutrient Vitamin K2 is claimed to be essential for your bone health, for reducing the risk of cancer, and…
BRAT Diet: What is the right way to follow this diarrhea-relieving diet? BRAT diet, a simple diet consisting of just bananas, rice, applesauce, and toast, can help you combat the…
diabetes symptoms in women
FBS Test – Fasting Blood Sugar FBS or fasting blood sugar test is a blood test that is used to determine the level of…
rubella IgG test
Rubella IgG Test The rubella IgG test is a blood test that checks for the rubella virus IgG antibodies present in…
ASTtest-liver
AST- Aspartate Aminotransferase Test AST test is a blood test that is used to measure the level of a particular liver enzyme…
Stye : The best natural home remedies to ease the pain Styes developing inside the eyelid tend to be more painful whereas external styes are less painful and ooze…
ketoacidosis diabetes
HB1Ac Test HB1Ac test is an important blood test that is used to measure the levels of glycated hemoglobin in…
Colloidal silver benefits
Colloidal silver: An essential dietary supplement or yet another pharmaceutical hoax? Colloidal silver is hailed as an effective home remedy for infections. Many believe it can treat HIV and…
Piaget stages: Do they accurately describe the way the human brain develops?  A common assumption was that children are less competent thinkers as compared to adults, but this was refuted…
occupational hazards types
Occupational Hazards: How to vouch for your health at your workplace Occupational hazards affect millions worldwide. Chemical spills, faulty wires, deadly pathogen, and work-stress can happen anytime. Follow these…
Lectin: The common link of proteins between peas and people Lectins are a type of protein that are found majorly in legumes. Most people are find it easy…
anti-thyroglobulin antibody
Anti-Thyroglobulin Antibody test Anti-thyrogloubin antibody test measures the level of antibodies that attack the thyroid gland cells and are hence indicative…
eating disorder anorexia
Eating Disorders: Lifestyle choice or a psychological condition? Is eating disorder just a harmless bad habit? Or does it represent grim psychological disorders? Do you want…
yoga health benefits
How to practice yoga for astounding health benefits Can a 5000-year-old system be the ultimate body healer? Did you know yoga can make you smarter and…
Milk Thistle skin
Milk Thistle: Find possible cures for fatal diseases in these purple blooms Milk thistle is well-known for treating liver conditions. However, did you know that it comes with a plethora…
How do neutrophils protect you from fatal bacterial attacks? During an infection, certain enzymes alert the mature neutrophils.  Neutrophils then travel through the bloodstream to the affected…
Juice Plus: Can you really replace actual fruits with pills?  Juice Plus supplements intend to fill nutritional gaps present in our daily diet. But how successful have they…
TBHQ: A carcinogen lingering in your child’s favorite snacks TBHQ - Why you should shun the practice of eating instant noodles or microwave popcorn to get rid…
Chlorella: Therapeutic powers of the billion-year-old algae now within your reach Chlorella - A billion year old nutrient-rich algae that can potentially ward off cancers and high cholesterol; the…
nutritional yeast bread
Nutritional Yeast : How can a fungi culture be good for your body? Nutritional yeast: How a simple culture of fungi can transform your skin, digestion, immunity , and much more.…
low fodmap plan
Troubled with IBS? Here’s a complete roadmap to the low FODMAP diet Leaky & inflammatory gut troubling you? No medicine bringing you relief from the pain? Why not try the…
Tamarind: The top health benefits of this staple Asian ingredient Did you know this sweet and sour pulpy fruit does more than just add a tangy flavor to…
How accurate is the hair follicle drug test? Hair follicle drug test is one of the best ways to identify drug use in professional circles. But…
Poop chart: Top things you didn’t you your poop could reveal about you Bristol poop chart was designed during the 1990s in order to help doctors identify various types of poops…
bilirubin-test-result
Bilirubin Test Bilirubin is a substance produced in the body as a result of red blood cell breakdown. A bilirubin…
Jicama: A fiber-rich tuber for your weight loss goals Pronouced as HEE-kah-ma, Jicama is the "new kid on the block" that has taken the world by the…
Silicon Dioxide: How can a component of sand be essential to your wellbeing? Silicon is one of the most abundant elements in the nature. Find out how silicon dioxide can prove…
What is the right way to take a pregnancy test? A pregnancy test is undertaken to determine if you have conceived. A home pregnancy test is the most…
Eustachian Tube : Functions and top home remedies to prevent its infection Pressure equalization, mucus drainage and protecting the middle ear from bacteria and viruses are the three important functions…
Quinine: How gin and tonic came to be known as a potent health elixir The discovery of quinine-containing tree bark is sometimes considered the most serendipitous medical discovery of the 17th century.
lifestyle diseases
The Big 5 lifestyle diseases: How your everyday living might be killing you You'd be shocked to know how unhealthy and potentially fatal your everyday routine could be. Has the modern…
Salt dangers
Sodium chloride: The wonders and dangers of the simple table salt Sodium chloride is a salt containing sodium and chlorine ions at a 1:1 ratio. It is edible and…
liver detox facts
7 liver detox facts and why ignoring these could kill you! Are you taking care of this organ that handles over 500 different vital functions in your body? Your…
ashwagandha brain
Ashwagandha: The best-kept secret of Ayurveda now revealed! Ashwagandha literally means "smell of horse". Don't get bogged down by that one tiny detail because this ayurveduic…
green poop causes
Green poop : What are the reasons and how can you correct it Ever sneak a peek down the toilet only to shockingly find green poop? Why does our poop turn…
waterchestnut
Water Chestnuts: The tastiest ways to include this healthy tuber in your diet Water chestnut is not a nut after all. It is a tuber (much like the potatoes) growing close…
Hydroquinone: Is it the best topical treatment for hyperpigmentation? Darkening of the skin due to high melanin levels is called hyperpigmentation.  Hydroquinone interferes with melanin production thus treating…
Oxalates: How healthy greens can sometimes be bad news for your kidneys Oxalates are compounds present in a majority of healthy foods. However, at times an overconsumption of these could…
Urologist: When should you visit one and why? A urologist can treat not only genitourinary problems of both men and women but also can treat various…
reflexology massage
Top reasons why you should go for a reflexology massage today Reflexology involves the application of pressure to your feet and hands to encourage self-healing. Could this be beneficial…
IGE test
IgE test – Immunoglobulin E IgE or immunoglobulin E test is a test that measures the level of IgE in the blood and…
Helicobacter pylori IGA
Helicobacter Pylori – IgA Test The H.pylori IgA test is a blood test used to identify the level of IgA antigen in the…
hidden benefits walking
9 benefits of walking we bet you didn’t know! Did you know walking can be the miracle pill for eternal youth? Everyone knows walking is good for…
kefir bottle
Kefir: Top reasons why this probiotic drink should be consumed by you Yet another remarkable fermented food, kefir is a much healthier version of yogurt. These chewy white grains can…
Jackfruit: Slice your way into higher immunity, better digestion, & more… Native to the South East Asia, the jackfruit is a fruit brimming with thousands of health benefits. Discover…
Pescatarian Diet 101: What are the inherent health advantages of this diet? People opt to become a pescatarian in order to enrich their bodies with the essential health benefits that…
Bubble Tea: Bubbling with nutrition or a hidden sugar mine? The tapioca pearls present in the tea looks like bubbles and hence the name bubble tea became popular.…
dance health benefits
5 unbelievable effects of dance on your overall health! You enjoy dancing, but did you know what else it does to your body? Dancing is not only…
sleep deprivation
Don’t let your sleep deficit grow into memory loss or heart attack Why is sleep important for us? How could sleep deprivation harm you? We bet you didn't know about…
Cordyceps: How the Caterpillar fungus works as a proven cancer-shield Strange as it may sound, but cordyceps or "caterpillar fungus", a fungus variety native to the Himalayas may…
How chlorophyll is more than just a green pigment meant for photosynthesis Cholorphyll - you must know the usual function of this chemical in plants. But did you know that…
Astaxanthin: Why experts believe it could be 550x more potent than vitamin E! What is astaxanthin and why is this new supplement on the block touted as the most powerful antioxidant…
Mood swings
The real reasons for your mood swings and how to overcome them Are you prone to heated moods frequently? Do you also feel bouts of depressive feeling creeping up on…
Is bronchitis contagious? And how to prevent this infection? It is acute bronchitis that is contagious which means you can contract it from another person or you…
Balneotherapy jacuzzi
5 things you didn’t know about balneotherapy and how you can do it at home Sauna baths have been popular since a long time. But how much more beneficial can balneotherapy be as…
Chest X-Ray A chest x-ray is a diagnostic test that uses x-rays to visualize the structures inside your chest. It…
Max thalassemia profile
Max thalassemia Profile Max Thalassemia is the most severe form of Thalassemia where a person’s body is unable to produce the…
Pumpkin Seeds: Why pumpkins are more than just for pies! Pumpkins have been long associated with Halloween carvings and delicious pies. But did you know that pumpkin seeds…
vital organ diseases
Common diseases that could cripple your vital organs Brain, heart, kidney, lungs, and liver - these vital organs are indeed vital for your survival. However, these…
chia seeds weight loss
Chia seeds: How to consume this staple Aztec food to get a leaner body Chia seeds: What is the actual reason for its sudden popularity? Why are celebrities swearing by its amazing…
Garlic health benefits cloves
Garlic: Nature’s white pill as an effective home remedy What are the secrets hidden in these tiny white pills? Find out the immense health benefits of using…
Exercises or diet? Find out the healthiest way to gain weight Tired of being called skinny all the time? Looking for healthy ways to beef up? Why not try…
Experts reveal the safest ways to perform an enema at home The idea of pushing some up your rectal area might make you queasy but an enema could actually…
Coffee Enema: Turn your favorite morning beverage into a powerful colon cleanser The wonders of coffee are not just limited to waking you up every morning. You can now use…
liver cleanse detox
14 go-to foods that are best for a complete natural liver detox Liver cleanse can be achieved by just choosing or avoiding certain types of food. Liver itself is a detoxifying…
Ear pain model
Easy and safe tips for ear wax removal you can do at home Cerumen impaction generally occurs when an external object like cotton swabs are used to remove the ear wax.…
CBC blood test
CBC (Hemogram 6-part diff) blood test CBC (Hemogram 6-part diff) blood test refers to the test that measures the number of RBCs, WBCs, etc…
hidden causes obesity
8 hidden causes of obesity you probably didn’t know! Did you know that around 2 billion people worldwide are either overweight or obese? Are you too a…
iron food shellfish
Iron-Rich Foods: Eat these foods to keep fatigue and anemia away! How to ensure a muscles as strong as iron? Eat iron rich foods ! Iron is one of…
Moringa drink
Moringa: This could be the most nutrient-dense food known to us! Moringa is a lush green tree brimming with over 90 essential nutrients required for a healthy mind and…
Trisodium Phosphate: How a paint thinner made its way into your breakfast Ever thought how toxic chemicals find their way into our foods? How can they harm our body? And…
Love tea, hate tannins? Rooibos tea is just what you need The market is brimming with a multitude of herbal teas. But what makes rooibos tea (or red bush)…
How can Kegels help you overcome weak pelvic muscles & incontinence? Kegel exercises are pelvic floor strengthening exercises that can help you overcome incontinence issues that rise out of…
Top natural diuretics: The instant benefits you can get from nature’s water pills Since diuretic drugs are known to cause side effects, it is better to choose a natural diuretic that…
Appendix pain: Recent findings on this not-so vestigial organ The exact function of the appendix is still not clear. Some consider it as an organ that once…
Nipah Virus epidemic
Is shingles contagious? If yes, then how can you prevent this infection? What is shingles? How is different from chicken pox? Do adults get shingles? How contagious is it? Find…
How to scrub away stress and fatigue with an Epsom salt bath? Epsom salt is a popular home remedy for many skin ailments. Though there is a lack of scientific…
Hot cups for detox? Read all about the ancient technique of cupping Did you know inverted hot cups on your back can squeeze out and eject toxins from your body?…
Krill Oil: Does the solution to human illnesses really lie at the depths of the ocean? The word "krill" means “small fry of fish” in Norwegian. They are usually the primary food source of…
CT-scan-machine
CT – Computed Tomography Scan CT scan or computed tomography scan is an diagnostic imaging technique where cross-sectional images of body are obtained…
about mediterranean diet
Why you should be adopting a Mediterranean style of diet today Ever wondered why the Mediterranean diet is so healthy? One simple solution to lowering risk of several deadliest…
Panera bread steak arugula
Panera Bread: The truth behind this “healthy” restaurant chain What to order and what to avoid when dining at Panera Bread ? Know more about this popular…
autoimmune diseases facts
Autoimmune Diseases: Find out if your body is attacking you right now Did you know your body can harm itself? What are autoimmune diseases and why does it harm some…
Dragon Fruit – Blessing from Nature’s Basket The dragon fruit is packed with nutrients and yet low on calories and is the dream food that…
improve digestion weight loss
Power up your gut: 8 proven steps on how to improve your digestion Did you know you have a colony of bacteria in your gut that help you in digesting food?…
High Fiber Diet – Fire up your fiber intake for these health benefits! Regular bowels, healthy detox, higher immunity, and guaranteed weight loss - a high fiber diet can bring all…
bananas exercise
10 health reasons why you should go “bananas” over bananas! Bananas:The world's most popular fruit comes with a host of unbelievable health benefits. Find out how you can…
stevia side effects
Stevia: A healthy sugar substitute or yet another risky additive? Stevia is a plant native to South America.  It has been used as a natural sugar substitute and…
The right way to prepare Alfalfa sprouts at home Alfalfa or lusan ghas is not just a nutritious animal fodder. This flavonoid-rich herb has some amazing health…
Muscle relaxers: Think twice before popping prescription drugs for muscle pain The market is brimming with OTC muscle relaxers. But these come with a host side-effects. Find out the…
What to eat, what not to eat in the South Beach Diet? The South Beach Diet is one among the most popular weight loss programs that have been the talk…
Carb Cycling: Weighing the pros vs the cons of this diet routine Completely discarding carbs from your life will do you more harm than good. Read more about carb cycling,…
GERD heartburn
Heartburn: What are the exact symptoms and the best home remedies? There are easy home remedies for heartburn, which not only acts as a first aid when you experience…
The Vegan Diet: The benevolent way of eating that wins hearts (and tummies) The vegan diet involves fauna-friendly outlook towards food. Could the diet that hopes to balance everything based on…
The complete fitness guide on how to perform Tabata This fitness routine is called Tabata workouts, which is named after Dr. Izumi Tabata who developed this intensive…
TRX: Why is this total resistance workout the best choice for your body? TRX or total resistance exercise is a form of exercise where suspension belts are used to produce that…
PiYo (Pilates + Yoga): Bringing you the best of both the worlds PiYo exercise routine was formulated for people who find it tedious and grueling exercise regimens such as extensive…