MensHealth.de - Internet für Männer Leverkusenstraße 54 22761 Hamburg Telefon: 040/ 853303-0 Fax: 040/ 853303-933 e-mail: usermail@menshealth.de Men´s Health Website Weitere Themen Impressum- Redaktion www.MensHealth.de - Das Covermodel-Workout - Das Marathon-Training www.MensHealth.de/marathontraining www.BestFashion.de www.BestLife-Magazin.de © 2002 MensHealth.de – Alle Rechte vorbehalten. Die gewerbliche Nutzung darf nur mit der vorherigen Einwilligung des Verlages erfolgen. www.MensHealth.de/covermodelworkout ONLINE-SPECIAL AUGUST 2002 MENSHEALTH.DE 165 F I T N E S S Sie trainieren bis zum Umfallen, aber Ihr Bizeps wächst nicht weiter? Ihre Beine sind immer noch dünn wie Streichhölzer? Verschwenden Sie nicht Ihre Zeit mit uneffektiven Übungen. Trainieren Sie nur die besten! Wissenschaftler um Studienleiter Wend-Uwe Boeck-Behrens am Sportwissenschaftlichen Institut der Uni Bayreuth haben die Wirksamkeit von Kraftübungen objektiv gemessen: Sie ließen Sportstudenten mit geringem Unterhautfettgewebe alle Übungen durchführen und maßen dabei die elektrische Aktivität in den arbeitenden Muskeln (in Mikro- Volt). Oberflächenelektroden wurden auf die Haut geklebt, die Werte mit Hilfe der Elektromyografie (EMG) ermittelt. Eine Methode, die mit dem Elektrokardiogramm (EKG) vergleichbar ist, das die elektrische Aktivität des Herzens protokolliert. Je höher die EMG-Aktivität, desto intensiver die Muskelkontraktion und desto größer damit die erzeugte Muskelkraft. Von diesem Heft an stellen wir Ihnen in unserer neuen Serie die effektivsten Kraftübungen für alle wichtigen Muskelgruppen vor. Zum Sammeln und Nachtrainieren. Fotos: Arne Weychardt; Model: Kaspar/Body & Soul; Haare & Make-up: Stelli/m4 motion; Produktion und Text: Ute Witt; Dank an Elixia, Hamburg; Gym 80 International Vertriebsgesellschaft mbH, Gelsenkirchen (Hantelbank), Sport-Thieme GmbH, Grasleben (Hanteln); Wettach Elektronik Medizintechnik, Jockgrim (EMG-Messgerät) fiHier ausschneiden und abheften! Negativer Konzentrations-Curl Frontal (oder seitlich) hinsetzen, das freie Bein abspreizen. Der arbeitende Arm wird innenrotiert kurz oberhalb des Knies gegen den Oberschenkel gestützt, in der Ausgangsposition bereits leicht gebeugt. So, ohne die Schulter zu bewegen, den Arm beugen. Um ihn nah ans Kinn zu ziehen, hilft die freie Hand mit. Kammgriff (die Handfläche zeigt nach vorne) oder Hammergriff (Daumen und Zeigefinger zeigen nach oben). Senken ohne Unterstützung. Diese Übung mit supramaximalem Gewicht (20 bis 30 Prozent mehr als Ihr übliches Maximalgewicht) ist mit großem Abstand das intensivste Training für den Bizeps. *Erklärung nächste Seite („Messwerte“) DIE BESTEN UBUNGEN DER WELT NEU FOLGE 1 BIZEPS 3 ø μVolt* 1040 ø* 1,7 1. Platz Klassischer Konzentrations- Curl Wie die allerbeste Übung, aber mit erheblich weniger Gewicht. Die freie Hand hilft nicht mit, sondern wird abgestützt. Der arbeitende, bereits leicht gebeugte Arm wird innenrotiert kurz oberhalb des Knies am Oberschenkel fixiert. Den Arm Richtung Kinn beugen ohne die Schulter zu bewegen. Beim Herablassen den Unterarm nach innen drehen. Der Bizeps ist der meisttrainierte Muskel der Welt. Jeder Mann will ihn zeigen, jede Frau will ihn sehen. Obwohl seine Größe wenig über die tatsächliche Armstärke aussagt und seine Form genetisch bedingt ist. Schickt man allerdings eine Horde männlicher Wesen in geschlechtsreifem Alter in ein Fitness-Studio, so steuern 99 Prozent davon zielstrebig Freihanteln, Scottbank oder Bizepsmaschine an. Und sie haben Recht. Denn eine kleine Plauze lässt sich geschickt verbergen, Spargelbeine verschwinden unterm Schlabber- Look. Den Bizeps jedoch erkennt man immer. Wie er sich explosionsartig vergrößert? Klar, mit einem Workout aus den besten Übungen der Welt! Wichtig dabei: die Handgelenke stets aktiv stabilisieren. fiHier ausschneiden und abheften! Scott-Curl mit SZ-Stange Mit gestrecktem Rücken (im leichten Hohlkreuz) so hinsetzen, dass die Oberarme parallel fest aufliegen, die Lehne reicht bis unter die Achseln. Dann die Hantel greifen und langsam Richtung Kopf heben, dabei allerdings nicht mit den Ellenbogen ausweichen. Senken, bis die Arme wieder fast gestreckt sind. Die stabile Auflage der Oberarme ermöglicht es Ihnen, bei dieser Übung auch größere Gewichte zu bewegen. Messwerte Bei jeder Übung wurde die elektrische Aktivität des Muskels per Elektromyografie (EMG) gemessen (Angaben in Mikro- Volt, μVolt). Da sich die Werte von Person zu Person leicht unterscheiden können, wurde die Reihenfolge nach den Durchschnittswerten bestimmt, die wir Ihnen auch bei den einzelnen Übungen nennen. Zum Beispiel: 166 MENSHEALTH.DE AUGUST 2002 DIE BESTEN UBUNGENFUR DEN BIZEPS Variante: frontal sitzen. In der Streckphase des Arms das Ellenbogengelenk nicht ganz durchdrücken, dies würde die Intensität der Übung mindern. Buchtipp: W.-U. Boeck-Behrens/ W. Buskies: „Fitness-Krafttraining. Die besten Übungen und Methoden für Sport und Gesundheit“. Rowohlt-Taschenbuch, r 15,50. ø μVolt 763 ø 3,4 2. durchschnittlicher Rangplatz durchschnittliche elektrische Aktivität ø μVolt* 1040 ø* 1,7 1. Platz ø μVolt 738 ø 3,5 3. fiHier ausschneiden und abheften! Bizeps-Curl am Kabelzug, beidarmig und stehend Sie stehen in Schrittstellung vor dem Kabelzug, die Knie leicht gebeugt. Greifen Sie die Stange von unten, die Ellenbogen halten Sie dabei dicht am Körper. Dann ohne die Schultern hochzuziehen oder Schwung aus dem Rücken zu holen die Arme maximal beugen und wieder senken, bis sie beinahe durchgestreckt sind. Die dabei entstehende Spannung permanent halten. Die Anteversionskraft (der Zug nach vorn) bewirkt eine zusätzliche statische Anspannung des Bizeps. Wirksame Alternative: mit dem Theraband im Home-Gym (Band einfach unter der Tür befestigen). Bizeps-Curl mit Langhantel, stehend 1. Füße mehr als hüftweit auseinander, Bauch und Po anspannen. Hantel im breiten Untergriff nehmen und leicht anheben (bei Ermüdung oder extrem hohem Gewicht den Rücken anlehnen). 2. Ohne den Rumpf zu bewegen oder die Schultern zu heben die Arme beugen, das Gewicht zur Brust ziehen und wieder senken. Am tiefsten Punkt sofort mit der nächsten Aufwärtsbewegung beginnen. Der Arm wird geführt, dadurch können Sie der Belastung nicht mit dem Ellenbogen ausweichen. Maximales Beugen des Ellenbogengelenks mindert die Intensität. Bizeps-Curl mit abgelegtem Arm Vor die um 60 Grad gekippte Schrägbank stellen, Lehne unter der Achsel, Hantel im Untergriff gefasst. Beugen Sie den Arm und führen Sie die Hantel langsam Richtung Kinn ohne die Schultern hochzuziehen. Beim Absenken den Handrücken nicht ganz ablegen, sondern die Spannung stets halten. AUGUST 2002 MENSHEALTH.DE 167 Der vordere Teil des Deltamuskels und die Brustmuskulatur werden bei dieser Übung zusätzlich aktiviert. Wenn Sie die Hantel zu eng greifen, wirkt sich das leistungsmindernd aus.  ø μVolt 730 ø 3,5 4. ø μVolt 690 ø 4,4 5. ø μVolt 686 ø 4,8 6.   Fotos: Arne Weychardt Men´s Health muss Mann haben! Holen Sie sich die nächsten drei Ausgaben von Men´s Health mit über 25% Ersparnis portofrei nach Hause! Bestellung gleich ausfüllen und faxen an 0711/182-2250. Weitere Bestellmöglichkeiten unter www.MensHealth.de/abo, per Post oder an Men´s Health Aboservice, Postfach, 70138 Stuttgart oder telefonisch unter 0711/182-2590 Ihr JA, ich möchte die nächsten drei Ausgaben von Men´s Health für nur 7,40 Euro (A: 8,40 Euro; CH: 14,70 sfr; übriges Ausland auf Anfrage) mit über 25 % Ersparnis frei Haus beziehen. Wenn ich nach diesem Test das Magazin nicht weiterbeziehen möchte, sage ich nach Erhalt der 2. Ausgabe ab. Ansonsten erhalte ich Men´s Health weiter bis zur jederzeit möglichen Kündigung zum Vorzugspreis von nur 36,80 Euro (A: 41,30 EURO; CH: 72,50 sfr; übriges Ausland auf Anfrage) für ein ganzes Jahr. Name, Vorname Straße, Nr. PLZ Wohnort Geburtsdatum Telefon Ich bezahle bequem per Bankeinzug per Rechnung BLZ Konto-Nr. Geldinstitut Datum, Unterschrift 25.531 MA -Abo zum Superpreis Lesestoff den Mann nicht verpassen darf! Bestellung gleich ausfüllen und faxen an 07 11/1 82-17 56 Weitere Bestellmöglichkeiten unter www.MensHealth.de/shop, per Post oder an Men´s Health Bestellservice, Postfach, 70162 Stuttgart oder telefonisch unter 07 11/1 82-26 16 -Bücher Name, Vorname Straße, Nr. PLZ Wohnort Geburtsdatum Telefon Ich bezahle bequem per Bankeinzug BLZ Konto-Nr. Geldinstitut Datum, Unterschrift MHSPDF Von lüsternen Flüstern bis zu aufregenden Sex-Spielen – dieser Erotik-Guide verrät Kniffe und Taktiken, die jede Frau heiß machen. Euro 8,90 Man(n) kommt in Mode. Der meistgelesene Fashionund Stil-Autor Bernhard Roetzel zeigt in diesem topaktuellen Mode-Ratgeber, was Männer anzieht. Euro 9,90 Gesundheit und gutes Aussehen stehen ganz oben auf der Wunschliste jedes Mannes. Wie Sie beides erreichen, steht im Men´s Health Muskel-Manual. Euro 9,90 Kein Diätbuch, sondern der praktische Guide für die richtige Männerernährung, für Männer mit und ohne Gewichtsprobleme. Euro 9,90 Weitere Men´s Health-Bücher unter www.MensHealth.de/shop oder im Buchhandel Ich bestelle zum Stückpreis von Das Muskel-Manual Der Style-Guide So macht Mann... Weg mit der Wampe 35550000013 35550000012 35550000004 35550000014 Euro 9,90 MUSCLESTUFF.COM MUSCLE-FITNESS.COM 93 CYN MAG YEL BLK CYN MAG YEL BLK Trim Size 8" X 101⁄2" & ITNESS MUSCLE F 92 93 Mark 92 MUSCLE&FITNESS June 2003 THE 2003 M&F CHALLENGE MONTH 3 Blast through the final month to build your best body ever — and enter to win the grand-prize trip to California
By Mark Casselman, MS, CSCS, and Beth Sonnenburg, MPH, Staff Writer M&F Reader Challenge Hell, yeah. A few extra sinews of muscle flashed across the mirror as you toweled off after your shower today. Whenever you take off your shirt, your abs peek out from behind a layer of skin that’s considerably thinner than it was eight weeks ago. Your clothes fit better. You’ve met our challenge head-on and your efforts — every set, every rep and every drop of sweat — have contributed to your physique transformation to this point. But hold on, your metabolic metamorphosis is just getting under way. With just four weeks left to complete your transformation, you may feel as though you’ve already accomplished many of your goals. But the best is yet to come. This month, your intense training and strict attention to diet and recovery really start to pay off as you drop the hammer through the home stretch. In this final month of intense training, we’ll help you set the dial to BURN on your metabolic furnace. Rock-Hard Workout By Mark Casselman, MS, CSCS On the surface, this month looks quite similar to Month 2. After all, if it ain’t broke, why fix it? These workouts should give you a déjà vu feeling — like you’ve been there before. That’s good, but be sure that the amount of weight on the bar doesn’t elicit the same sentiment. Make every effort to consistently (and safely) increase the amount of weight you lift each workout. Check your log from last month to be sure you’re doing just that. Use as much weight as you can lift with good form so that you hit failure within the specific rep range for each set. For example, if you’re shooting for 6–8 reps, choose a weight heavy enough so that you’ll get at least six but no more than eight reps. Lifting relatively heavy weights as you try to get lean will allow you to maintain the mass you’ve built to this point; this is no time to start burning your muscle protein as fuel by going into high-rep, endurance mode. Take note: This month we’ve dropped in some more drop sets! On leg day, you’ll do drops on the leg press; on push day, you’ll drop-set the incline dumbbell press; on pull day, you’ll do drops on the bent-over barbell row. Each drop set should begin with a weight you can move for 4–5 good reps, then your partner will help you cut the resistance by about 10%–20% (depending on the exercise) and you’ll crank out five more reps without pause. The idea here is to start the set heavy to fire up those hard-to-hit fast-twitch fibers; then when you cut the weight and rep out, you’ll target the slower-twitch fibers as you complete the set. More bang for your workout buck. Be aware of the rep ranges you should work in for each week. During Weeks 9 and 11, bang out three sets of 6–8 This month, dreams become reality as you complete your Rock-Hard transformation. Photo by Robert Reiff CYN MAG YEL BLK 95 Mark MUSCLESTUFF.COM MUSCLE-FITNESS.COM 95 CYN MAG YEL BLK Trim Size 8" X 101⁄2" & ITNESS MUSCLE F 94 94 MUSCLE&FITNESS June 2003 MONTH 3 solid reps on the exercises that don’t feature a drop set. During Week 10, your range slides up a little to 8–10 reps, so reduce the amount of resistance you use by a few percentage points. Once you make the move back to lower rep ranges in Week 11, try to boost the amount of resistance you used in the initial week. Keep your eyes on the prize and stay focused as you drive through the home stretch. You’ll up your cardio volume slightly during each workout, so take a close look at the cardio key to note any changes from last month’s routine. This is your opportunity to reach all of your fitness goals, so don’t cheat yourself during the final month. Keep investing a solid effort on a daily basis and give your body the recovery and calories it needs to grow. The challenge now is staying power; the final four weeks are always the toughest. Enjoy the process and stick with it — your rock-hard body is just weeks away! Consult your physician before beginning or making changes in your diet, supplements or exercise program, for diagnosis and treatment of illness and injuries, and for advice regarding medications. Rock Hard: Month 3 WEEK 9 Monday Legs, Cardio B Tuesday Cardio A, Abs Wednesday Pushes, Cardio B Thursday Off Friday Pulls, Cardio B Saturday Cardio A, Abs Sunday Off WEEK 10 Monday Legs, Cardio B Tuesday Cardio A, Abs Wednesday Pushes, Cardio C Thursday Off Friday Pulls, Cardio B Saturday Cardio A, Abs Sunday Off WEEK 11 Monday Legs, Cardio C Tuesday Cardio A, Abs Wednesday Pushes, Cardio C Thursday Off Friday Pulls, Cardio C Saturday Cardio A, Abs Sunday Off WEEK 12 Monday Compound-Exercise Tri-Sets Tuesday Cardio A, Abs Wednesday Compound-Exercise Tri-Sets Thursday Cardio A, Abs Friday Compound-Exercise Tri-Sets Saturday Off Sunday Off NOTE: On abs days, perform the same exercises you did for abs before starting this program. If you haven’t trained abs before, do crunches for two sets of 25 reps, reverse crunches for two sets of 20 reps, and twisting crunches for two sets, 10 reps to each side. The Rock-Hard Weight-Training Workouts Listed as: exercise sets x reps per set WEEK 9 WEEK 10 WEEK 11 Legs Workout Barbell Squat 3 x 6–8 Barbell Squat 3 x 8–10 Barbell Squat 3 x 6–8 Leg Press* 3 x 5 + 5 Leg Press* 3 x 5 + 5 Leg Press* 3 x 5 + 5 Hack Squat 3 x 6–8 Hack Squat 3 x 6–8 Hack Squat 3 x 6–8 Romanian Deadlift 3 x 6–8 Romanian Deadlift 3 x 8–10 Romanian Deadlift 3 x 6–8 Calf Raise** 3 x 6–8 Calf Raise** 3 x 8–10 Calf Raise** 3 x 6–8 DB Lunge/Leg Curl/Leg DB Lunge/Leg Curl/Leg DB Lunge/Leg Curl/Leg Extension Tri-Set 3 x 8–12 Extension Tri-Set 3 x 8–12 Extension Tri-Set 3 x 8–12 Push Workout Bench Press 3 x 6–8 Bench Press 3 x 8–10 Bench Press 3 x 6–8 Incline DB Press* 3 x 5 + 5 Incline DB Press* 3 x 5 + 5 Incline DB Press* 3 x 5 + 5 Seated DB Shoulder Press 3 x 6–8 Seated DB Shoulder Press 3 x 8–10 Seated DB Shoulder Press 3 x 6–8 Lying French Press 3 x 6–8 Lying French Press 3 x 8–10 Lying French Press 4 x 6–8 Dip/Cable Crossover/DB Dip/Cable Crossover/DB Dip/Cable Crossover/DB Lateral Raise Tri-Set 3 x 8–12 Lateral Raise Tri-Set 3 x 8–12 Lateral Raise Tri-Set 3 x 8–12 Pull Workout Pulldown to Front 3 x 6–8 Pulldown to Front 3 x 8–10 Pulldown to Front 3 x 6–8 Bent-Over Barbell Row* 3 x 5 + 5 Bent-Over Barbell Row* 3 x 5 + 5 Bent-Over Barbell Row* 3 x 5 + 5 Barbell Shrug 3 x 6–8 Barbell Shrug 3 x 8–10 Barbell Shrug 4 x 6–8 Standing Barbell Curl 3 x 6–8 Standing Barbell Curl 3 x 8–10 Standing Barbell Curl 4 x 6–8 Pull-Up/DB Pullover/Seated Pull-Up/DB Pullover/Seated Pull-Up/DB Pullover/Seated Cable Row Tri-Set 3 x 8–12 Cable Row Tri-Set 3 x 8–12 Cable Row Tri-Set 3 x 8–12 * Do all three sets as drop sets: Perform five reps heavy and then drop the weight for five more reps. ** Choose either seated or standing calf raise. Week 12 Compound-Exercise Tri-Sets In Week 12, you’ll do a whole-body workout on each training day. (Hit the gym when it’s pretty empty.) Take the first three exercises from each workout and perform them as tri-sets. Perform each tri-set three times and do two drops on each exercise on the third tri-set (except for squats, where you should not drop). The specifics: Start with the tri-set of barbell squats, leg presses and hack squats. Perform them in order, doing 8–12 reps per exercise and not resting within the tri-set as you go from exercise to exercise. Rest for two minutes, then do the tri-set again. Rest another two minutes before doing the third tri-set. On the last round, drop the weight twice on each exercise (except squats) — for instance, you may get 10 reps on the leg press, then drop the weight for five more, then drop the weight again for as many reps as you can do. (Don’t go to failure if you don’t have a spotter.) Go to the hack squat and do the same drop pattern. Next will be the pull tri-set: pulldown to front, bent-over barbell row and barbell shrug. Do the same 8–12 reps on the first two sets, then the final drop set. Finish with the push tri-sets: bench press, incline dumbbell press and seated dumbbell shoulder press, again in the same set-and-rep pattern.  1 2 Exercise photos by Rick Schaff at Dr. Perry’s International Sportsmedicine Institute, West Los Angeles, CA Rock-Hard Challenge INCLINE DUMBBELL PRESS LEG EXTENSION PULL-UP 1 2 CYN MAG YEL BLK 97 Mark MUSCLESTUFF.COM MUSCLE-FITNESS.COM 97 CYN MAG YEL BLK Trim Size 8" X 101⁄2" & ITNESS MUSCLE F 96 96 MUSCLE&FITNESS June 2003 Rock-Hard Challenge MONTH 3 Cardio Key A: Continuous, Moderate Intensity. Fiveminute warm-up, followed by 35–45 minutes of continuous cardiovascular exercise, then a fiveminute cool-down. B: Interval Training I. Five-minute warm-up, followed by 27–30 minutes of sprint intervals — sprint for one minute, jog to recover for two minutes, repeat. Cool down for five minutes. C: Interval Training II. Five-minute warm-up, followed by 25 minutes of sprint intervals — sprint for 30 seconds, jog to recover for one minute, repeat. Cool down for five minutes. NOTE: You can choose among many cardio activities: running outdoors, riding a bike, using a treadmill, elliptical machine, stair-stepper, etc., as long as you do the prescribed time and work at a level intense enough to break a sweat. Contest Information Trying to win the Rock-Hard Challenge and the trip to Venice, California? Here’s what you need to do: 1) Take your end-of-Month-2 photos in either a bathing suit or workout clothes — one facing forward and one side view (either side). Store those with your original “before” photos taken before you started the program and your end-of-Month-1 photos; you’ll need to send all those in at the end of this final month. 2) Use the training log on page 100 to keep track of your Month 3 training and nutrition goals. 3) When you complete the program, take your end-of-Month-3 photos, in either a bathing suit or workout clothes — one facing forward and one side view (either side). 4) Send in your Month 2 and Month 3 training logs, along with all your photos: those taken before you began, at the end of Month 1, at the end of Month 2 and at the end of Month 3 (make sure all are identified on the back). The envelope must be postmarked by June 11, 2003, to be eligible. (See rules on page 205 for complete details.) Nutrition By Beth Sonnenburg, MPH, Staff Writer Your resistance training is more intense and your cardio is wearing you down. To make those final physique adjustments for the Rock-Hard Challenge, should you cut your calories even further, or just continue eating at the calorie level you determined last month? Remember that you want to get stronger and leaner at the same time. Physically, if you drop your calories too low, you may end up wasting some of your hard-earned muscle. Mentally, training at such an intense level and depriving your body of much-needed carbohydrates and calories will result in a plain old bad mood. Since you don’t want either of those results, don’t drastically cut your calories. Do tweak your diet to improve the quality of food providing those calories. If you’re really feeling weak or lack the energy to complete your workouts, you may need to add a daily snack or an extra serving of protein. Here are the four strategies you’ll use to get your rear in gear for Month 3. 1) Get wet. In the first month, we asked you to ditch most of your caloric drinks and instead choose water, sparkling water, diet drinks and iced tea. Now it’s time to really emphasize your water intake. When you exercise, your metabolic rate increases, resulting in increased body heat. This heat needs to be regulated via sweat to maintain proper body temperature. The hotter it is outside, and the harder and longer you exercise, the more sweat you produce. “If this fluid isn’t replaced, the body becomes dehydrated,” explain Melinda Manore and Janice Thompson in their book Sport Nutrition for Health and Performance (Human Kinetics, 2000). “Since the body cannot adapt to dehydration, the loss of body water can severely affect physiological function, the ability to do work and overall health.” Be sure to drink water before, during and after training (both weights and cardio). To estimate how many ounces of water you should have during the day, use this rule of thumb from M&F Science Editor Jim Stoppani, PhD: Divide your bodyweight by two. If you weigh 180 pounds, that’s 90 ounces of water per day. 2) Eat at home. The more often you eat at restaurants, the harder it will be for you to drop weight. Even if you choose wisely when you go out to eat, the portions are usually large and there’s no telling how much oil or butter the cook slapped on the grill. Especially during this last month, make an extra effort to prepare meals at home and bring them with you to work or school. Continue cooking chicken, turkey and eggs in bulk for easy protein sources. A countertop grill (such as a George Foreman grill) makes it incredibly easy to cook a chicken breast to perfection. 3) Change your carbs. Eating a low-carb diet is a big mistake at this stage of the game. “Fat burns in a carbohydrate flame — energy from carbohydrate sources is necessary to oxidize [burn] fat stores,” explains Mark Casselman, MS, CSCS. “Plus, if you’re not eating enough carbs to replenish glycogen stores and STANDING BARBELL CURL STANDING CALF RAISE To burn calories efficiently, you need water! Photos by Robert Reiff CYN MAG YEL BLK 99 Mark MUSCLESTUFF.COM MUSCLE-FITNESS.COM 99 CYN MAG YEL BLK Trim Size 8" X 101⁄2" & ITNESS MUSCLE F 98 98 MUSCLE&FITNESS June 2003 Rock-Hard Challenge MONTH 3 fuel your training sessions, you’re going to have to tap into your muscle protein stores for energy. Since protein is a subpar source of fuel, you’ll be less able to hammer the weights and cardio at high intensities. Worse, you’ll be burning the very tissue you’re working so hard to build.” Instead of cutting carbs, you can manipulate them to clean up your physique. This month, strive to eat as many whole grains as possible instead of more “refined,” or overly processed, sources of carbohydrate. Examples of refined carbohydrate include processed cereal bars, sugary cereals or cheese crackers. At the store, buy whole-wheat pasta, crackers and bread; brown rice; and old-fashioned oats. If you don’t already have one, find a cereal that lists “whole wheat” as the first ingredient and has at least 4 grams of fiber per serving. Switching to whole grains will increase your fiber intake and slightly decrease your calorie intake, as well as improve the overall quality of your diet. If you’re struggling to lose those final few pounds, try swapping a grain serving for a fruit or vegetable serving each day. 4) Limit sodium intake. This strategy is especially geared toward Week 4, the countdown to your “after” photo. Excess salt can make you retain water and obscure the definition you’ve worked so hard to achieve. To limit sodium and prevent that full, bloated look, avoid these foods during Week 4: frozen meals, fast food, Chinese food, canned soup, boxed rice/pasta mixes, pickles, olives, chips, beef jerky, microwave popcorn and basically most processed ready-to-eat products. Obviously, don’t use the saltshaker. Concentrate on fruits, vegetables and whole grains, along with lean proteins such as egg whites, chicken, turkey and protein powder. If you tolerate dairy products well, include lowfat or fat-free cottage cheese, milk, cheese and yogurt. Some bodybuilders find that dairy makes them look bloated or soft; if you do, too, minimize your dairy intake this week. Eat super-clean and drink lots of water to get the best “after” photo you can! You might want to apply a self-tanner a couple of days beforehand to even out your skin tone. Congratulations on getting through these three intense months and creating your best body ever. Meal Plans Meal plans were designed by Susan Kundrat, MS, RD, nutrition consultant to the University of Illinois (Urbana-Champaign). Note: If you’re lactose intolerant, substitute 1 ounce lean protein for every 1 ounce dairy. Day 1 1,600-calorie plan: Breakfast 3 scrambled egg whites 2 slices whole-grain toast with 1 Tbsp. jam 1 cup 100% orange juice Snack 1 peach Lunch 2 cups chicken and vegetable lo mein 1 orange Snack 1 oz. string cheese 1 oz. (6 small) whole-grain crackers Dinner 3 oz. sautéed salmon cooked with low-sodium chicken broth, 1⁄2 cup chopped onion, 1⁄2 cup chopped green pepper 1 cup brown rice cooked with 1 tsp. olive oil 1 cup steamed broccoli For 1,800 calories add: Breakfast: 1⁄2 cup fresh fruit salad Dinner: 2 oz. salmon For 2,100 calories add the above plus: Morning snack: 1 protein bar (200 calories or fewer) Afternoon snack: 1 kiwi fruit Dinner: Spinach salad made with 1 cup fresh spinach, 1⁄2 cup chopped tomatoes, 1 Tbsp. reduced-fat salad dressing Day 2 1,600-calorie plan: Breakfast 2 6-inch pancakes with 1 Tbsp. light tub margarine and 1⁄4 cup light maple syrup 2 scrambled egg whites Lunch Roast beef sandwich on a whole-grain bun, with lettuce and tomato (no mayo) 1 cup minestrone soup 1 cup skim milk Snack 1 apple Dinner 5 oz. baked chicken breast 1⁄2 cup cooked brown rice Green salad with lettuce, cucumber, tomato and 2 Tbsp. fat-free salad dressing 1 cup red grapes For 1,800 calories add: Breakfast: 1 turkey sausage patty Afternoon snack: 1 oz. reduced-fat cheese For 2,100 calories add the above plus: Dinner: 2 oz. chicken breast Evening snack: ice cream bar (200–230 calories) Day 3 1,600-calorie plan Breakfast 3 scrambled egg whites 1 English muffin with 1 Tbsp. light tub margarine 1 tangerine Snack 1⁄4 cup dried mixed fruit Lunch Tuna salad sandwich on toasted whole-grain bread (made with light mayo) 1 cup baked potato chips 1 cup skim milk Snack 1 cup fresh baby carrots and green pepper slices Dinner 2 cups chicken ravioli with 1 cup marinara sauce 1 green salad with 2 Tbsp. fat-free salad dressing For 1,800 calories add: Afternoon snack: 1 oz. cheddar cheese Dinner: 1 cup skim milk For 2,100 calories add the above plus: Breakfast: 2 Tbsp. almonds Morning snack: protein bar (about 200 calories) Day 4 1,600-calorie plan Breakfast Shake made with 1 cup 1% chocolate milk, 1 frozen banana, 2 Tbsp. peanut butter Snack 3 whole-grain rye crackers spread with 2 Tbsp. low-fat cream cheese Lunch Spinach salad made with 4 oz. chopped turkey breast, 2 cups spinach, 1⁄4 cup sliced cucumber, 1⁄2 cup chopped tomato, 2 Tbsp. fat-free dressing 1 small roll Snack 1 protein/meal-replacement bar (under 200 calories) Dinner Skewers made with 4 oz. lean top sirloin, 1⁄2 cup sliced portabello mushrooms, 1 cup sweet yellow pepper slices 1 cup rice 1 cup steamed broccoli For 1,800 calories add: Lunch: 1 cup skim milk Dinner: 1 oz. top sirloin, 1⁄4 cup rice For 2,100 calories add the above plus: Breakfast: 1 small whole-grain bagel with 1 Tbsp. jam Lunch: 1 cup skim milk Day 5 1,600-calorie plan Breakfast 1 cup oatmeal made with 1 cup skim milk, 1⁄4 cup raisins and sweetened with Splenda/Equal/Sweet ’N Low Snack 1 cup cubed honeydew melon Lunch 1 turkey burger on a whole-grain bun made with fresh lettuce, two tomato slices, low-fat mayo 1⁄2 cup fresh fruit salad Snack 1 whole-grain granola bar Dinner 6 oz. meatloaf 1 cup baked winter squash made with 1 tsp. margarine and 1 Tbsp. walnuts 1 cup steamed fresh cauliflower 1 cup skim milk For 1,800 calories add: Breakfast: 2 egg whites, scrambled Lunch: 1 turkey patty For 2,100 calories add the above plus: Breakfast: 1⁄2 cup oatmeal, 1⁄2 cup skim milk Lunch: 1⁄4 cup fresh fruit salad Dinner: 1 roll with 1 tsp. butter M&F  QUICK TIP: When shopping for bread, choose a loaf that offers at least 2 grams of fiber per slice. Choose the oats over the cereal bar. THE 2003 M&F CHALLENGE Record your workouts and take this log to the gym to remind you of the day’s tasks. When you’re done with this third month’s program, mail it with your Month 2 log and all your photos. NUTRITION GOALS Week 1: Drink one-half ounce of water per pound of bodyweight per day. Week 2: Prepare and eat more meals at home. Week 3: Choose whole-grain carbs over refined carbs. Week 4: Limit your sodium intake. Training Log Monday Tuesday Wednesday Thursday Friday Saturday Week 9
Legs
Cardio A
Pushes Rest
Pulls
Cardio A • Barbell Squat
Abs • Bench Press • Pulldown to Front
Abs • Leg Press • Incline DB Press • Bent-Over Row • Hack Squat • Seated DB Press • Barbell Shrug • Romanian Deadlift • Lying French Press • Standing Barbell Curl • Calf Raise • Dip/Cable Crossover/ • Pull-Up/DB Pullover/ • DB Lunge/Leg Curl/ Lateral Raise Tri-Set Seated Cable Row Tri-Set Leg Extension Tri-Set
Cardio B
Cardio B
Cardio B Week 10
Legs
Cardio A
Pushes Rest
Pulls
Cardio A • Barbell Squat
Abs • Bench Press • Pulldown to Front
Abs • Leg Press • Incline DB Press • Bent-Over Row • Hack Squat • Seated DB Press • Barbell Shrug • Romanian Deadlift • Lying French Press • Standing Barbell Curl • Calf Raise • Dip/Cable Crossover/ • Pull-Up/DB Pullover/ • DB Lunge/Leg Curl/ Lateral Raise Tri-Set Seated Cable Row Tri-Set Leg Extension Tri-Set
Cardio C
Cardio B
Cardio B Week 11
Legs
Cardio A
Pushes Rest
Pulls
Cardio A • Barbell Squat
Abs • Bench Press • Pulldown to Front
Abs • Leg Press • Incline DB Press • Bent-Over Row • Hack Squat • Seated DB Press • Barbell Shrug • Romanian Deadlift • Lying French Press • Standing Barbell Curl • Calf Raise • Dip/Cable Crossover/ • Pull-Up/DB Pullover/ • DB Lunge/Leg Curl/ Lateral Raise Tri-Set Seated Cable Row Tri-Set Leg Extension Tri-Set
Cardio C
Cardio C
Cardio C Week 12
Compound Tri-Sets
Cardio A
Compound Tri-Sets
Cardio A
Compound Tri-Sets Rest • Barbell Squat/Leg
Abs • Barbell Squat/Leg
Abs • Barbell Squat/Leg Press/Hack Squat Press/Hack Squat Press/Hack Squat Tri-Set Tri-Set Tri-Set • Pulldown to Front/ • Pulldown to Front/ • Pulldown to Front/ Bent-Over Row/Barbell Bent-Over Row/Barbell Bent-Over Row/Barbell Shrug Tri-Set Shrug Tri-Set Shrug Tri-Set • Bench Press/Incline DB • Bench Press/Incline DB • Bench Press/Incline DB Press/Seated DB Press Press/Seated DB Press Press/Seated DB Press Tri-Set Tri-Set Tri-Set Sunday is rest day. Cardio Key: A: Continuous, moderate intensity; B: Interval Training I (1-minute sprint intervals/2 minutes jog); C: Interval Training II (30-second sprint intervals/1 minute jog) Name:_______________________________________________ Address:_____________________________________________ _____________________________________________________ City:________________________ State:______ Zip:__________ E-mail:_______________________ Phone:_________________ Age:_______ Are you
male or
female? Please submit Month 2 and Month 3 Log and before, Month 1, Month 2 and after photos to: Muscle & Fitness Rock-Hard Challenge 21122 Erwin Street Woodland Hills, CA 91367 Postmarked by June 11, 2003. Please see the Official Contest Rules on page 205. CYN MAG YEL BLK Mark MUSCLESTUFF.COM MUSCLE-FITNESS.COM tk CYN MAG YEL BLK Trim Size 8" X 101&#8260;2" & ITNESS MUSCLE F 100 MONTH 3 AD 19LE CINQUE CHIAVI DELLA SALUTE E DELLA FELICITA L'uomo non èfigliodelle circostanze,ma sono le circo-stanze le creature dell'uomo. BENJAMIN DISRAEu Ormai possedete le risorse indispensabili per farvi assoluto ca-rico della vostra esistenza. Avete la capacità di formare le rappre-sentazioni interne e di instaurare gli stati d'animo che condu-cono al successo e al potere. Ma avere la capacità non sempreequivale a servirsene, e ci sono esperienze che di continuo met-tono gli esseri umani in condizioni di impotenza. La strada dapercorrere presenta curve, il fiume su cui si naviga ha rapide incui di continuo l'uomo incappa; ci sono esperienze che impedi-scono agli individui di essere tutto ciò che potrebbero essere. Inquesto capitolo intendo fornirvi una mappa indicativa dei peri-coli e di ciò che è necessario sapere per evitarli. Sono quelle che chiamo le cinque chiavi della salute e della fe-licità. Se intendete servirvi di tutte le capacità che ormai posse-dete, se volete essere tutto quello che potete essere, è necessarioche vi rendiate conto delle chiavi in questione: prima o poi, devefarlo ogni persona di successo. Chi le conosce può fare della pro-pria vita un'inarrestabile serie di riuscite. Qualche tempo fa mi trovavo a Boston. Al termine di un se-minario serale, verso la mezzanotte, ho fatto una passeggiata inCopley Square.Osservavo gli edifici circostanti, che vanno daimoderni grattacieli a case vecchie quanto gli Stati Uniti, quandoho notato un uomo che veniva alla mia volta con passo incerto.Sembrava che avesse dormito per le strade da settimane; puzzavadi alcool, aveva l'aria di non essersi rasato da mesi. Ho immaginato che volesse chiedermi l'elemosina. Mi è ve-nuto vicino e mi ha chiesto: "Signore, potrebbe prestarmi unquarter?"La mia prima reazione è stata di chiedermi se era bene che gli offrissi una ricompensa per il suo atteggiamento, poi misono detto che non volevo certo trattarlo male e che comunqueventicinque cent non avrebbero fatto molta differenza. Sonogiunto dunque alla conclusione che la cosa migliore che potevofare era cercare di impartirgli una lezione: "Venticinque cent? Èproprio questo che vuole, unquarter?"E lui: "Già, proprio unquarter."Allora mi sono frugato in tasca ne ho cavato unquartere gli ho detto: "La vita ci dà tutto quello che le si chiede."L'uomo mi ha lanciato un'occhiata sbalordita, e quindi si é allon-tanato barcollando. Seguendolo con lo sguardo, ho meditato sulle differenze tracoloro che riescono e coloro che falliscono. Mi chiedevo: in checosa consiste il divario tra lui e me? Perché la mia esistenza ètanto gioiosa, e posso fare tutto ciò che voglio, tutto ciò che de-sidero, ovunque lo voglia, con chiunque intenda farlo e in qua-lunque misura? L'uomo doveva essere sulla sessantina, vagabon-dava per le strade, chiedeva l'elemosina. Forse che Dio era scesodal cielo a dirmi:"Anthony Robbins,tu sei stato buono e avraila vita che ti sei sempre sognato?" Assai poco probabile. Forseche qualcuno mi ha conferito risorse e vantaggi superiori? Nonlo credo. Un tempo ero venuto a trovarmi in una condizione ap-pena un po' migliore della sua, sebbene non bevessi come lui nédormissi per le strade. Ritengo che, almeno in parte, la differenza consista nella ri-sposta che gli ho dato, cioè che la vita ti darà qualsiasi cosa tu lechieda. Chiedi unquarter,e unquarteravrai.Chiedi gioia e suc-cesso, e avrai anche quelli. Tutte le mie ricerche mi persuadonoche se si impara a controllare i propri stati d'animo e i propricomportamenti, si può tutto cambiare, imparando per esempioche cosa chiedere alla vita, con la certezza di ottenerlo. Nei mesiche seguirono, ho incontrato altri "barboni", e ho chiesto lorocome vivessero e come si fossero ridotti in quello stato. E ho co-minciato così a scoprire che avevamo in comune, loro e io, osta-coli da affrontare assai simili, e che la differenza consisteva nelcome lo facevamo. Qualeche sia la parola che pronunci, una simile ne udrai. PROVERBIO GRECO Vi indicherò ora le cinque cose che possono servire da segnalistradali lungo la via del successo. In esse non c'è nulla di pro-fondo e di astruso, eppure sono assolutamente decisive. Se le do- minate, non ci sono limiti alle vostre possibilità. Se non ve neservite, i limiti ve li siete posti voi stessi. Un modo di pensare af-fermativo e positivo costituisce certo un punto di partenza, manon è tutto; anzi, se manca la disciplina si andrà incontro alla de-lusione,mentre un atteggiamento positivo unito alla disciplinaproduce miracoli. Ecco dunque la prima chiave della creazione di ricchezza e fe-licità.Bisogna imparare a governare la frustrazione.Se vuoi diven-tare tutto ciò che vuoi diventare, se vuoi fare tutto ciò che puoifare, udire tutto ciò che puoi udire, vedere tutto ciò che puoi ve-dere, devi imparare a governare la frustrazione, la quale può ucci-dere i sogni. Capita molto spesso. La frustrazione può trasfor-mare un atteggiamento positivo in negativo, uno stato di graziain una condizione paralizzante. L'aspetto peggiore di un atteg-giamento negativo consiste nel fatto che può rendere impossibilel'autodisciplina; e, scomparsa questa, scompaiono anche i risul-tati cui si aspira. Sicché, per assicurarti un successo a lungo termine devi impa-rare a disciplinare la tua frustrazione. Vi svelerò un segreto: lachiave del successo consiste in una massiccia dose di frustrazione.Date un'occhiata agli uomini che si sono realizzati in pieno e co-staterete che quasi sempre lungo la loro strada sono incappati ingrosse frustrazioni. Chiunque vi dica il contrario, non sa nulla direalizzazioni e di successo. Ci sono due tipi di individui: coloroche la frustrazione l'hanno superata e coloro che avrebbero desi-derato farlo. C'è un'azienda americana di spedizioni che si chiama FederalExpress.A fondarla è stato un tale Fred Smith che ha creatoun'impresa multimiliardaria partendo da un cumulo di frustra-zioni.All'inizio, quando ha fondato l'azienda mettendoci dentrofin l'ultimo centesimo, sperava di riuscire a consegnare circa cen-tocinquanta carichi al giorno; invece i carichi furono sedici, cin-que dei quali inviati a casa di un suo dipendente. E da quel mo-mento le cose andarono sempre peggio. Di continuo i dipen-denti dovevano farsi cambiare dai bottegai gli assegni con cuierano pagati perché in banca non c'erano fondi sufficienti, piùvolte gli aerei della ditta hanno corso il rischio del sequestro, espesso si sono dovuti alienare beni per continuare l'attività. OggilaFederal Express, come ho detto, è multimiliardaria, e lo sideve esclusivamente a Fred Smith che è stato in grado di supe-rare una frustrazione via l'altra. Ci sono persone profumatamente pagate per superare le fru-strazioni. Se siete senza un soldo in tasca, probabilmente lo do-vete al fatto di non essere riusciti molto bene a vincerle. Vi dite:"Be', sono al verde, e per questo sono frustrato." Ma la situa-zione è esattamente l'opposto: se foste riusciti a superare unmaggior numero di frustrazioni, sareste ricchi. Una delle diffe-renze principali tra individui agiati e individui che non lo sono,consiste nel modo in cui hanno affrontato la frustrazione. Nonsono così cinico da affermare che la povertà non comportaenormi frustrazioni; dico che la maniera per non essere povericonsiste nell'affrontare una frustrazione dopo l'altra fino al mo-mento in cui la si spunta. La gente dice: "Chi ha quattrini nonha nessun problema." Ma se ci danno dentro, probabilmente diproblemi ne hanno, eccome; ma sono persone che sanno comeaffrontarli, come ricorrere a nuove alternative. Tenetelo presente:essere ricchi non significa solo avere denaro. Un magnifico rap-porto umano comporta problemi e sfide e, se di problemi non nevolete, tanto vale che una relazione non l'abbiate. Lungo lastrada di ogni grande successo - in campo finanziario come amo-roso - sono in attesa grandi frustrazioni. Ilmaggior dono che leTecnologie della Prestazione Ottimalecifanno consiste nell'insegnarci il modo di affrontarelefrustra-zioni in maniera efficace. Si possono prendere cose da cui untempo ci sentivamo frustrati e trasformarle in modo da esserneeuforizzati. Strumenti comeI'NLPnon sono soltanto un modo dipensare in positivo. La difficoltà, per quanto attiene un modo dipensare del genere, è che bisogna pensarci, e che quando ci side-cidea farlo molto spesso è ormai troppo tardi per raggiungere ipropri scopi. Ciò che1'NLPoffre è un modo di trasformare lo stress in op-portunità.Già sapete come sfumare le immagini che un tempovi deprimevano al punto da farle scomparire oppure da trasfor-marle in immagini che vi riempiano di entusiasmo. Non è difficile; il sistema ormai lo conoscete. C'è una formulain due tempi per superare Io stress. Fase1:non concentratevisulle piccole cose. Fase2:tenete presente che non ci sono chepiccole cose. Le persone di successo sanno che questo è nascosto al di làdella frustrazione. Purtroppo, c'è chi al di là non arriva mai; co-loro i quali non riescono a raggiungere i loro scopi, di solito silasciano bloccare dalla frustrazione. Per superare questo blocco,non resta che esaminare a fondo la frustrazione, servendosi di ogni intralcio come di unfeed-backdal quale trarre una lezione,continuando ad andare avanti. Dubito che troverete molte per-sone di successo che non abbiano avuto quest'esperienza. Ed ecco la seconda chiave.Bisogna imparare a superare il ri-fiuto;quando lo ripeto nel corso di un seminario, avverto chiara-mente il cambiamento che si verifica nella fisiologia dei presenti.Nel linguaggio umano, non c'è nulla che abbia una capacità diferire come la piccolissima parola "no". Se fate il venditore, qualè la differenza tra guadagnare 10.000e25.000 dollari? La diffe-renza principale consiste nell'apprendere ad affrontare il rifiutoin modo che la paura di doverlo subire non vi impedisca di intra-prendere un'azione. I migliori venditori sono quelli che piùspesso si imbattono in rifiuti: coloro che sono in grado di ser-virsi di ogni "no" come di uno sprone per continuare fino a otte-nere un "sì". La massima difficoltà con cui i membri della nostra societàsono alle prese, è la loro incapacità di affrontare la parola "no".Vi ricordate della domanda che ho posto in precedenza? Checosa fareste se sapeste di non poter fallire? Rifletteteci. Se lo sa-peste, questo cambierebbe il vostro comportamento?Vipermet-terebbe di fare esattamente quel che volete fare? E dunque, checos'è che ve lo impedisce? Appunto quella paroletta "no". Perriuscire, dovete imparare ad affrontare il rifiuto, a privare ogni ri-pulsa del suo potere. Una volta mi sono trovato a lavorare con un saltatore in alto;era un ex olimpionico, ormai però giunto al punto da non potersaltare una spanna, e immediatamente mi sono . reso conto diqual era il suo problema quando l'ho visto in azione. Inutile direche ha abbattuto l'asticella ed è caduto in preda alla spirale emo-zionale: ogni insuccesso veniva trasformato in un evento di di-mensioni colossali. L'ho chiamato a me e gli ho detto che, se vo-leva che mi occupassi di lui, non doveva più farlo, doveva smet-tere di registrare la situazione come un enorme fallimento, smet-terla di inviare al proprio cervello il messaggio che rafforzaval'immagine del fallimento, che quindi si verificava puntualmenteal salto successivo. Ogniqualvolta lo tentava, il sua cervello erapiù preoccupato dall'eventualità del fallimento che non dal met-tersi in quello stato produttivo che è foriero di successo. Gli ho detto che, se toccavi nuovamente l'asticella, dovevadire a se stesso: "Ah, un'altra differenza," e non già: "Accidenti,un altro fallimento!" Doveva rimettersi in uno stato d'animo produttivo e ritentare.Dopo tre salti, aveva ottenuto risultatimigliori che nei due anni precedenti. Non ci vuoi molto percambiare. La differenza tra un metro e novanta e due metri è solodel 10%: non grande quanto ad altezza, ma enorme quanto aprestazioni.Allo stessomodo, piccoli cambiamenti possonocomportare un grande mutamento quanto a qualità della vita. Tutti conosconoRambo,cioèSylvesterStallone. Credete forseche si sia presentato a qualche agente cinematografico e si siasentito dire: "Ehi, sa che lei ha un gran bel fisico? Bene, le fa-remo fare un film." No, le cose non sono andate proprio così.SylvesterStallone è diventato una grande star perché è stato ca-pace di resistere a una ripulsa via l'altra; e all'inizio gliene sonotoccate più di mille. Bussava all'uscio di ogni agente che riuscivaa scovare a New York, e tutti gli dicevano di no. Ma lui ha con-tinuato a tener duro, a tentare, finché ha fatto un film intitolatoRocky.Sylvesterera capace di sentirsi dire di no mille volte, equindi bussare alla milleunesima porta. Quanti "no" siete disposti a sentirvi dire? Quante volte aveteprovato l'impulso di avvicinare una persona che trovavateattraente, e poi avete deciso di non farlo perché non volevateudire la parola "no"? Quanti di voi hanno deciso di non tentaredi farsi assegnare una mansione o di non visitare un potenzialecliente per non sentirsi opporre un rifiuto? Vi rendete conto cheponete a voi stessi dei limiti solo perché avete paura di quellaparolina di due lettere? La parola in sé è priva di potere, nelsenso che noti può infliggervi una ferita, tagliarvi le gambe. Ilsuo potere deriva dal modo con cui la rappresentate a voi stessi,dai limiti che voi stessi create attribuendoli a essa. E che cosacreano i pensieri limitati? Esistenze limitate. Sicché, se imparate a governare il vostro cervello, potete im-parare anche a superare il rifiuto. Potete eventualmente anco-rarvi, in modo che la parola"no"agisca su di voi come uno sti-molo.Qualsiasi ripulsa potete trasformarla in un'opportunità.Ricordate che il successo sta nascosto dall'altra parte del rifiuto. Non ci sono veri successi senza ripulse. Quante più ne rice-vete, tanto meglio per voi, perché vuoi dire che avete imparatodi più, che siete maggiormente vicini alla vostra meta. La pros-sima volta che qualcuno vi oppone un rifiuto, dovreste abbrac-ciarlo.Questo cambierebbe la sua fisiologia. Ebbene, i "no" tra-sformateli in abbracci; se siete in grado di dominare la ripulsa,imparerete a ottenere tutto ciò che volete. E ora, la terza chiave della ricchezza e della felicità.Bisognaimparare a superare ledifficoltàfinanziarie.L'unica maniera pernon avere difficoltà finanziarie consiste nell'essere assolutamenteprivi di finanze. E di difficoltà finanziarie ce ne sono di molti ge-neri, e hanno distrutto molte persone. Esse possono originareavarizia, invidia, delusione, paranoia; possono privarvi della vo-stra sensibilità o allontanare da voi i vostri amici. Ma tenete pre-sente che ho detto "possono", non che Io faranno di sicuro. Su-perare le difficoltà finanziarie significa sapere come ottenere ecome dare, sapere come guadagnare e come risparmiare. Quando ho cominciato a far quattrini, mi sono trovatoadaf-frontare critiche feroci. I miei amici mi stavano alla larga. Dice-vano: "Adesso sei ricco, che altro vuoi?" E io: "Non sono ricco,ho semplicemente un po' di quattrini." Ma loro non la vedevanoallo stesso modo: all'improvviso, io apparivo un individuo di-verso perché godevo di una condizione finanziaria diversa; e c'erachi provava risentimento nei miei confronti. Ecco qui dunque ungenere di difficoltà finanziarie.Ma anche non avere abbastanzadenaro è una brutta condizione in cui si trova moltissima gente.Che di quattrini ne abbiate molti o pochi, sarete comunque alleprese con difficoltà finanziarie. Tenete presente che tutte le nostre azioni sono guidate dallenostre filosofie, intendendo per queste le rappresentazioniin-terneche d guidano nell'azione fornendoci modelli di comporta-mento.GeorgeS. Clason ha fornito un validissimo modellodisuperamento delle difficoltà finanziarie con il suo libroThe Ri-chestMan inBabylon.L'avete letto? Se l'avete letto, rileggetelo.In caso contrario, correte a comprarlo, perché si tratta di un'o-pera che può rendervi ricchissimi, felicissimi, pieni di entusia-smo. Per quanto mi riguarda, la cosa più importante che insegnaè di prelevare ildiedper cento di tutto ciò che guadagnate e diregalarlo. Proprio così. E perché? Uno dei motivi è che bisognarestituire quel che si prende; un altro, che così facendo valoriz-zate voi stessi e altri; ma l'aspetto più importante è che questoatto dice, al mondo e al vostro subconscio, che re n'è sempre piùche abbastanza, ed è un credo formidabile, da coltivare con cura.Se ce n'è più che abbastanza, ciò significa che potete avere quelche volete e che possono averlo anche altri. E se quest'idea lafate vostra, la fate diventare realtà. Quando dovete cominciare a dar via quel dieci per cento?Forse quando siete ricchi o famosi? Niente affatto. Dovete farloquando siete appena agli inizi, perché quel che date via è come se fosse grano che seminate: grano che investite, non che man-giate, e il modo migliore di investirlo consiste nel regalarlo inmodo che produca valore per altri. Né avrete difficoltà a trovareilmodo di farlo. Ovunque c'è gente bisognosa; e uno degli ef-fetti più produttivi che ne otterrete consiste nello stato d'animoche produrrà in voi. Se siete di quel genere di persone che sipreoccupano delle necessità altrui, donare quel dieci per cento vifarà sentire diversi, vi darà un'altra opinione di voi stessi. E gra-zie a questi sentimenti o stati d'animo, vivrete circondati dallagratitudine, grati voi stessi. Giorni fa ho avuto la fortuna di tornare al mio liceo a Glen-dora, in California. Mi occupo di un programma per insegnanti,e desideravo incontrarmi con quelli di loro che avevano eserci-tato un'influenza sulla mia vita. Arrivato sul posto, mi sono resoconto che un programma di insegnamento dell'inglese grazie alquale avevo imparato a esprimermi bene era stato abolito permancanza di fondi e che c'era chi pensava che non fosse abba-stanza importante, ragion per cui ho provveduto io a fornire inecessari fondi. Ho cioè restituito una parte di quello che mi erastato dato, e non l'ho fatto perché io sia uno che ci tiene a farbella figura,ma semplicemente perché ero in debito. E non èbello sapere che, quando dovete dare qualcosa, potete finalmenteripagarlo? E questo l'aspetto positivo dell'aver denaro. Tutti ab-biamo debiti: la vera ragione di far quattrini consiste nell'esserein grado di restituire quel che si deve. Quando ero bambino, i miei genitori sgobbavano duro permantenerci. Per una serie di motivi, eravamo sempre in gravi ri-strettezze economiche. Ricordo in particolare un Giorno del Rin-graziamento, quando di denaro in casa non ce n'era affatto; la si-tuazione non era certo delle migliori, finché qualcuno non habussato all'uscio portando una scatola di conserve e un tacchino.Si trattava di uno sconosciuto il quale disse che a mandarciquella roba era un altro, e che questi sapeva che non avremmochiesto nulla,ma civoleva bene e voleva che festeggiassimocome si deve il Giorno del Ringraziamento. Non ho mai dimen-ticato quell'episodio, e così, in occasione di ogni sua ricorrenzafaccio quello che altri ha fatto allora per me: vado ad acquistarecibarie bastanti al consumo settimanale di una famiglia in diffi-coltà economiche, e le consegno fingendomi un fattorino o undipendente, non già presentandomi come il vero donatore. E nonmanco mai di lasciare un biglietto che dice: "Da parte di un taleche si preoccupa di voi e spera che prima o poi tutto vi vada così bene da potervi permettere di ricambiare il favore a qualcun altroin stato di necessità." Questo ha finito per essere, per me, uno dei momenti piùbelli dell'anno. Vedere volti che s'illuminano quando coloro aiquali dono sanno che c'è qualcuno che di loro si preoccupa, cheè in grado di rendere la situazione diversa, è la cosa più bella checi sia nella vita. Un anno m'è venuto il desiderio di andare a di-stribuire tacchini a Harlem, ma non avevamo a disposizione unfurgoncino, neppure un'automobile, e tutto era chiuso. Quellidelmio staff mi hanno detto: "Lasciamo perdere per que-st'anno."Ma io: "No, voglio assolutamente farlo." E loro: "Macome? Se non hai neppure un furgoncino con cui fare le conse-gne!" Ho replicato che di furgoncini per le strade ce n'eranotanti, e che dovevamo soltanto trovarne uno che ci desse un pas-saggio. E ho cominciato a fare l'autostop, espediente che nonoserei raccomandare a nessuno a New York, perché molti guida-tori si sentono in territorio di guerra, e il fatto che fosse ilGiorno del Ringraziamento non cambiava un bel nulla. E così, eccomi fermo a un semaforo, a bussare ai finestrini difurgoni e a dire ai guidatori che ero disposto a dar loro centodollari se ci portavano a Harlem. Senza riuscire a cavare un ra-gno dal buco. E allora ho cambiato leggermente il mio messag-gio.Ho detto ai guidatori che avrei voluto rubare un'ora emezzo del loro tempo per consegnare cibarie a persone indigentiin un "quartiere disagiato"della città, e ho ottenuto almeno difarmi ascoltare. Avevo già deciso che mi occorreva un furgone abbastanzagrande per consegnare un bel po' di roba e, guarda caso, un auto-mezzo del genere, color rosso fuoco, si è avvicinato, ed era lun-ghissimo, proprio quello che mi occorreva. Uno dei miei ha at-traversato di corsa la strada, lo ha fermato al semaforo, ha bus-sato al finestrino, ha offerto all'autista cento dollari per portarcidove volevamo andare. Risposta dell'autista:"No, non occorreche mi paghiate, sono felice di portarvici." E così dicendo ha al-lungato la mano, ha preso il berretto che stava accanto a lui sulsedile, se lo è messo in testa. Sopra recava la scritta "SalvationArmy", Esercito della Salvezza. Era, ha spiegato l'uomo, il capi-tano John Rondon, e voleva accertarsi che le cibarie le conse-gnassimo a persone davvero bisognose. E così, anziché limitarci a distribuire tacchini ad Harlem,siamo andati anche nel South Bronx, che è uno dei luoghi piùdesolati d'America, passando tra case in rovina e terreni in ab- bandono; in un negozio abbiamo acquistato alimenti che ab-biamo distribuito a immigrati illegali, vagabondi, famiglie alleprese con le dure necessità quotidiane. Non credo che abbiamo cambiato l'esistenza di quella gente,ma stando al capitano Rondon abbiamo almeno mutato le loroopinioni circa i buoni sentimenti del prossimo. Non c'è denaroche possa procurarvi quel che ottenete quando date del vostro,né programma finanziario che possa fare di più per voi. Vi inse-gna ciò che il denaro può fare e ciò che non può fare, e sono duedelle più importanti lezioni che si possano apprendere. Pensavoche la maniera migliore per aiutare i poveri fosse di essere uno diloro, ma ho costatato che forse è vero il contrario, che la manieramigliore consiste nell'offrir loro un modello di altre possibilità,la dimostrazione che è disponibile un'altra gamma di scelte, enell'aiutarli a sviluppare le risorse necessarie a raggiungere l'au-tosufficienza. Una volta dato via il dieci per cento dei vostri introiti, desti-nate un altro dieci per cento al pagamento dei debiti e un altrodieci per cento ancora per costituirvi un capitale da investire.Dovete riuscire a campare con il settanta per cento di quello cheintascate.Viviamo in una società capitalistica, gran parte deimembri della quale non sono capitalisti e di conseguenza nongodono dello stile di vita che desiderano. Ma perché vivere inuna società capitalistica, tra mille opportunità, e non trarre van-taggio dal sistema che i nostri antenati hanno tanto lottato percreare? Imparate a servirvi del vostro denaro come di un capitale;se lo spendete, un capitale non lo accumulerete mai, mai avrete adisposizione le risorse di cui avete bisogno. Si dice che inCali-forniail reddito medio annuo è sui venticinquemila dollari procapite, ma la spesa media si aggira sui trentamila dollari. Il diva-rio è alla base di quelle che si usano chiamare "difficoltà finan-ziarie". Spero che non vogliate rientrare nella categoria di chicosì si comporta. Ilpunto è che il denaro è come qualsiasi altra cosa. Potetefarlo lavorare a vostro pro o contro di voi. Dovreste essere ingrado di trattare il denaro come qualsiasi altra cosa che sia nellavostra mente, con la stessa determinazioneedisinvoltura. Impa-rate a guadagnare, a risparmiare e a donare; se ci riuscite, impare-rete a superare le difficoltà finanziarie. Il denaro non costituiràpiù uno stimolo a mettervi in uno stato d'animo negativo che virenderà infelici o vi indurrà a trattare altri attorno a voi in ma-niera inaccettabile. Se avete in pugno le prime tre chiavi, comincerete a renderviconto che la vostra esistenza è straordinariamente ricca di suc-cessi. Se siete in grado di superare frustrazioni, rifiuti e difficoltàeconomiche, non ci sono limiti a quello che potete fare. Avetemai visto TinaTurnermentre canta? Ecco una che sa maneg-giare perfettamente tutte e tre le chiavi. Divenuta una star, havisto fallire il suo matrimonio, ha perduto tutto il suo denaro, hapassato otto anni nel purgatorio dello show business, esibendosiin saloni di alberghi e in night da quattro soldi. Telefonava apersone che si facevano negare, nessuno le offriva un contrattoper una registrazione.Ma lei ha continuato a tener duro,adi-menticare i "no", ha continuato a lavorare per pagare i debiti emettere ordine nelle sue finanze, e alla fine eccola di ritorno sullavetta del mondo dello spettacolo. Sicché, tutto si può fare. Ed è a questo punto che entra inscena la quarta chiave.Bisogna imparareasuperare l'autocompiad-mento.Avete certamente visto uomini celebri o grandi atleti che,dopo aver raggiunto un certo grado di successo, li si sono fer-mati. Cominciano a godersi le loro comodità, e perdono quellequalità che hanno permesso loro di arrivare fin lassù. La massimadellerealizzazioni ha ancoraun futuro tuttoda readizzan Iato Tzs,TaoTehKing Il comfort può essere una dellepiadisastrose situazioni emo-zionali in cui può venire a trovarsi un organismo. Che cosa ac-cade a una persona che goda di eccessivo comfort? Smette di cre-scere, di lavorare, smette di creare valori ar iunti. Non bisognagodere di eccessivo comfort, perché in tal caso è probabile che sismetta di crescere.Ha detto BobDylanche "colui che non sisforza di nascere, si sforza di morire". O si ascende o si precipitaavalle.RayKroc, il creatore della catena di ristorantiMcDo-nald,a chi un giorno gli chiedeva un consiglio per assicurarsiuna lunga vita di successi, ha detto che bastava tenere presentequesta massima: "Quando sei verde, cresci; quando sei maturo,marcisci." Finché si rimane verdi, si cresce. Si può approfittare diqualsiasi esperienza per farne un'occasione di crescita o farne in-vece un motivo di declino. Nel fatto di andare in pensione sipuò vedere l'inizio di un'esistenza più ricca oppure la fine dellapropria vita attiva; si può considerare il successo un trampolino per realizzazioni ancora maggiori, oppure come un luogo in cuiadagiarsi a riposare. E in questo secondo caso, è probabile chenon ce lo si conservi a lungo. Una forma di autocompiacimento è legata al confronto. Dirsicioè: ritengo di aver agito come si deve perché l'ho fatto megliodi altre persone.Ma è uno dei più grossi errori che si possanocommettere, perché forse significa semplicemente che i nostriamici non se la cavano molto bene.Imparate a giudicare voi stessiin base aivostri obiettivi anziché sul metro di ciò' che fanno i vostri co-noscenti.E perché? Perché è sempre possibile trovare qualcunoche serva a giustificare quello che state facendo. Da bambini, tutti l'abbiamo fatto. Chi di noi, non ha detto:"Pierino ha fatto questo e quello, perché io non potrei farlo?"Vostra madre probabilmente replicava: "A me non interessaquello che fa Pierino." E aveva perfettamente ragione. Non cura-tevi di ciò che fanno Pierino, Maria e Giovanni, preoccupatevi diciò di cui siete capaci, di ciò che create e di ciò che volete fare. Eagite proponendovi una serie di obiettivi dinamici, in continuaevoluzione, produttivi, che vi aiuteranno a raggiungere ciò chevolete, non ciò che qualcun altro ha già raggiunto. Ci sarà sem-pre qualcuno che ha più di voi e sempre qualcuno che ha meno,ma che importa? Dovete autogiudicarvi sulla scorta dei vostriobiettivi, di nient'altro. Lepiccole case colpiscono le piccole menti.BENj®MIN DISiunu Un altro modo di evitare l'autocompiacimento consiste nellostare alla larga da quelle che chiamo le "chiacchiere da caffè": leriunioni in cui tutti parlano di tutto, dalle abitudini di lavoroalla sessualità e alla situazione economica, e ogni cosa sembra ri-solta.Ma le "chiacchiere da caffè" sono come un suicidio, vi in-tossicano il cervello, inducendovi a focalizzare la vostra atten-zione su ciò che altri fanno nella vita privata, anziché su ciò chevoi potete fare per allargare la vostra esperienza esistenziale. E fa-cile cadere in queste trappole, ma ricordatevi che in esse aveteache fare con persone che mirano solo a trovare motivi di distra-zione dalla noia frutto dell'incapacità di produrre i risultati chepure desidererebbero. C'è una frase che Tuono Rotolante, il saggio indiano, amavaripetere, ed era: "Parla solo se hai qualcosa di buono da dire."Ricordatevi che ciò che diamo ci viene restituito, per cui vi in- vito a starvene lontani dalle chiacchiere inutili.Non date impor-tanzaa cose prive di importanza.Se aspirate a essere compiaciuti divoi stessi e mediocri, perdete. pure il vostro tempo a parlare dichi va a letto con chi; ma se volete essere diversi, abbiate cura diporvi di fronte a sfide, di mettervi alla prova, di fare della vostraesistenza qualcosa di particolare. E ora, l'ultima chiave:Date sempre più diquanto vi aspettatediricevere. Puòdarsi sia la chiave più importante di tutte, perché inpratica garantisce la vera felicità. Ricordo che una sera stavo rincasando in auto dopo una riu-nione; cascavo dal sonno, e a riscuotermi ogni tanto erano i sob-balzi sulle gobbe della strada. E, in quello stato di dormiveglia,cercavo di capire che cosa è a dare significato alla vita;eall'im-provviso, una vocina dentro la mia testa ha detto: "Il segretodella vita consiste nel dare." Se volete avere una vita degna di tal nome, cominciate dalcome dare. Gran parte delle persone iniziano chiedendosi sol-tanto come ricevere.Ma ricevere non è un problema, anche ilmare riceve. E invece dovete preoccuparvi di dare, in modo dacominciare da una posizione dinamica più che passiva. La diffi-coltà è che moltissimi prima di dare vogliono avere. Per esem-pio, ecco una coppia che viene da me e il marito dice che la mo-glie lo tratta male, e lei replica che lo fa perché lui non sa mo-strarle affetto. Sicché, ciascuno dei due aspetta che l'altro facciala prima mossa, che fornisca la prova iniziale. Ma che razza di rapporto di coppia è mai questo? E quantopotrà durare? La chiave di ogni relazione consiste nel fatto chebisogna innanzitutto dare e continuare a dare, senza fermarsi inattesa di ricevere. Se si comincia col calcolo del dare e avere, ilrapporto va in fumo. Ve ne state li a dire: "Ho dato, adesso è ilsuo turno", e tutto è finito, lei o lui se ne va. Bisogna esserepronti a piantare il seme e quindi a curarne la crescita. Che cosa accadrebbe se andaste dalla terra a dirle: "Dammifrutti, dammi piante"? Probabilmente, la terra vi risponderebbe:"Scusi, caro signore, ma lei dev'essere un tantino fuori strada;evidentemente è un novellino. Non è così che il gioco funziona."Poi la terra vi spiegherebbe che è necessario che gettiate il seme,che ne abbiate cura, innaffiandolo e zappando, concimando ilsuolo, proteggendo e nutrendo le nuove piantine; e se lo fatebene, prima o poi ne avrete frutto. La richiesta alla terra potreterivolgerla in eterno senza che la situazione cambi di un ette. Do- vete continuare -a dare, a nutrire e curare il suolo perché diafrutto, e lo stesso vale per la vita tutta quanta. Potete fare un sacco di cose; potete essere il signore di vastiregni o a capo di enormi aziende, ma se lo fate solo per voi stessiilvostro non potrà dirsi un vero successo. Non avrete un effet-tivo potere, non avrete una ricchezza vera. Se "la montagna delsuccesso" la scalate da soli, probabilmente ne precipiterete. E sapete qual è la massima illusione circa il successo? Che siaqualcosa di simile a una cima da scalare, a una cosa da possedere,a un risultato definitivo da raggiungere. Se volete riuscire, se vo-lete raggiungere tutti i vostri obiettivi, dovete pensare al suc-cesso come a qualcosa in continuo farsi, a un modo di vivere, aun'abitudine mentale, a una strategia esistenziale. E di questoche abbiamo parlato nel presente capitolo. Dovete sapere cosasiete, conoscere i pericoli sulla vostra strada, essere in grado diservirvi del vostro potere in maniera responsabile e amorosa, sevolete godere di vera ricchezza e di vera felicità. Se sarete capacidi servirvi di queste cinque chiavi, sarete in grado di utilizzare lecapacità e i poteri insegnati in questo libro per giungere a risul-tati stupefacenti. E adesso, un'occhiata al modo di cambiare le attività su unpiano più elevato, quello dei gruppi, comunità e nazioni. Preventive Medicine and Public Health PreTest® Self-Assessment and Review PRE TEST® NOTICE Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. 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DOI: 10.1036/0071376399 Terms of Use CONTENTS Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix BIOSTATISTICS AND METHODS OF EPIDEMIOLOGY Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Answers, Explanations, and References . . . . . . . . . . . . . . . . . . . . . . 34 EPIDEMIOLOGY AND PREVENTION OF COMMUNICABLE DISEASES Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Answers, Explanations, and References . . . . . . . . . . . . . . . . . . . . . . 92 ENVIRONMENTAL AND OCCUPATIONAL HEALTH Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Answers, Explanations, and References . . . . . . . . . . . . . . . . . . . . . 135 EPIDEMIOLOGY AND PREVENTION OF NONCOMMUNICABLE AND CHRONIC DISEASES Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Answers, Explanations, and References . . . . . . . . . . . . . . . . . . . . . 174 PROVISION OF HEALTH SERVICES Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 Answers, Explanations, and References . . . . . . . . . . . . . . . . . . . . . 205 LEGAL AND ETHICAL ISSUES Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217 Answers, Explanations, and References . . . . . . . . . . . . . . . . . . . . . 223 Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235 Terms of Use This page intentionally left blank. vii PREFACE Many changes have been made in this book from the last edition. I hope it will be helpful in providing a good review of public health and preventive medicine. I also hope you will appreciate how applicable this field is in everyday clinical practice (even biostatistics principles!) and what an important impact prevention can have on the health of a population. Many thanks to the medical students, Lucy Chie, Megan Schwarzman, and Natalie Holt, for their thoughtful comments. This book is dedicated to my husband, Alain Campbell, M.D., M.S., and my daughter, Myriam. Very special thanks for supporting me throughout this project. SYLVIE RATELLE, M.D., M.P.H. This page intentionally left blank. INTRODUCTION Preventive Medicine and Public Health: PreTest® Self-Assessment and Review, Ninth Edition, has been designed to provide medical students and physicians with a comprehensive and convenient instrument for self-assessment and review within the field of epidemiology and public health. The 500 questions provided have been designed to parallel the format of the questions contained in Step 2 of the United States Medical Licensing Examination (USMLE). Each question in the book is accompanied by an answer, a paragraph explanation, and a specific page reference to either a current journal article, a textbook, or both. A bibliography that lists all the sources used in the book follows the last chapter. Perhaps the most effective way to use this book is to allow yourself one minute to answer each question in a given chapter; as you proceed, indicate your answer beside each question. By following this suggestion, you will be approximating the time limits imposed by licensing examinations. When you practice your examination-taking skills with this PreTest®, one way to maximize your score is to go through, answer all the questions you find easy, and skip over the more difficult ones initially. We do recommend, however, that once you come back to the more difficult questions, you spend as much time as you need. You will then be more likely to retain the information. Do note: When it comes to your examination for the board, you will do better to answer each question as you come to it and not skip around. Do not spend too much time on any one problem. Make a guess, circle the question, and come back to it. Otherwise, you can waste time looking for the questions you skipped or—the ultimate tragedy—you may discover time is running out. When you have finished answering the questions in a chapter, you should then spend as much time as you need verifying your answers and carefully reading the explanations. Although you should pay special attention to the explanations for the questions you answered incorrectly, you should read every explanation. The author of this book has designed the explanations to reinforce and supplement the information tested by the questions. If, after reading the explanations for a given chapter, you feel you need still more information about the material covered, you may wish to consult the references indicated. ix BIOSTATISTICS AND METHODS OF EPIDEMIOLOGY Questions DIRECTIONS: Each item below contains a question or incomplete statement followed by suggested responses. Select the one best response to each question. 1 1. Assuming that mammography has a sensitivity of 90% and a specificity of 98% and that consecutive tests are independent, what is the probability that a woman with breast cancer will have a negative yearly screening mammogram for two consecutive years? a. 1/10 b. 2/10 c. 4/10 d. 1/100 e. 4/100 2. The association between low birth weight and maternal smoking during pregnancy can be studied by obtaining smoking histories from women at the time of the first prenatal visit and then subsequently assessing and assigning birth weight at delivery according to smoking histories. What type of study is this? a. Clinical trial b. Cross-sectional c. Prospective cohort d. Case-control e. Retrospective cohort Terms of Use 3. An investigator wishes to perform a randomized clinical trial to evaluate a new beta blocker as a treatment for hypertension. To be eligible for the study, subjects must have a resting diastolic blood pressure of at least 90 mm Hg. One hundred patients seen at the screening clinic with this level of hypertension are recruited for the study and make appointments with the study nurse. When the nurse obtains their blood pressure two weeks later, only 65 of them have diastolic blood pressures of 90 mm Hg or more. The most likely explanation for this is a. Spontaneous resolution b. Regression toward the mean c. Baseline drift d. Measurement error e. Hawthorne effect 4. Which of the following measures is used frequently as a denominator to calculate the incidence rate of a disease? a. Number of cases observed b. Number of new cases observed c. Number of asymptomatic cases d. Person-years of observation e. Persons lost to follow-up 5. Among women aged 18 to 34 in a community, weight is normally distributed with a mean of 52 kg and a standard deviation of 7.5 kg. What percentage of women will have a weight over 59.5 kg? a. 2% b. 5% c. 10% d. 16% e. 32% 6. In nine families surveyed, the numbers of children per family were 4, 6, 2, 2, 4, 3, 2, 1, and 7. The mean, median, and mode numbers of children per family are, respectively, a. 3.4, 2, 3 b. 3, 3.4, 2 c. 3, 3, 2 d. 2, 3.5, 3 e. 3.4, 3, 2 2 Preventive Medicine and Public Health Biostatistics and Methods of Epidemiology 3 Hypertension Normal Blood Pressure Total >8 cups 6 4 10 No coffee 2 7 9 8 11 19 7. A study is undertaken to determine whether drinking more than eight cups of coffee a day is associated with hypertension. The blood pressure readings were taken of persons who drink more than eight cups and persons who drink no coffee. The results are as follows: Which of the following is the most appropriate test to analyze the data? a. Chi-square test b. McNemars test c. Fishers exact test d. Student t test e. Analysis of variance Items 810 The results of a study of the incidence of pulmonary tuberculosis in a village in India are given in the following table. All persons in the village are examined during two surveys made two years apart, and the number of new cases was used to determine the incidence rate. Category of Household Number of Number of at First Survey Persons New Cases With culture-positive case 500 10 Without culture-positive case 10,000 10 8. What is the incidence of new cases per 1000 person-years in households that had a culture-positive case during the first survey? a. 0.02 b. 0.01 c. 1.0 d. 10 e. 20 9. What is the incidence of new cases per 1000 person-years in households that did not have a culture-positive case during the first survey? a. 0.001 b. 0.1 c. 0.5 d. 1.0 e. 5.0 10. What is the relative risk of acquiring tuberculosis in households with a culture-positive case compared with households without tuberculosis? a. 0.05 b. 0.5 c. 2.0 d. 10 e. 20 11. In the study of the cause of a disease, the essential difference between an experimental study and an observational study is that in the experimental investigation a. The study is prospective b. The study is retrospective c. The study and control groups are of equal size d. The study and control groups are selected on the basis of history of exposure to the suspected causal factor e. The investigators determine who is and who is not exposed to the suspected causal factor Items 1213 About 1% of boys are born with undescended testes. To determine whether prenatal exposure to tobacco smoke is a cause of undescended testes in newborns, the mothers of 100 newborns with undescended testes and those of 100 newborns whose testes had descended were questioned about smoking habits during pregnancy. The study revealed an odds ratio of 2.6 associated with exposure to smoke, with 95% confidence intervals (CI) from 1.1 to 5.3. 12. Some reviewers are concerned that the study may overestimate the association between maternal smoking and undescended testes in the offspring because of potential a. Confounding b. Nondifferential misclassification c. Differential misclassification d. Selection bias e. Loss to follow-up 4 Preventive Medicine and Public Health 13. What is the most appropriate conclusion to be drawn from the study? a. There is no association between maternal smoking and undescended testes in the offspring b. The study results, if accurate, suggest that an offspring whose mother smoked is about 2.6 times more likely to be born with undescended testes than an offspring whose mother did not smoke c. The p value > 0.05 d. The 90% confidence interval for these results would probably include 1.0 e. A larger sample size would increase the confidence interval 14. The probability of being born with condition A is 0.10 and the probability of being born with condition B is 0.50. If conditions A and B are independent, what is the probability of being born with either condition A or condition B (or both)? a. 0.05 b. 0.40 c. 0.50 d. 0.55 e. 0.60 15. As an epidemiologist, you are asked to recommend the type of study appropriate to the needs of researchers who would like to study the causes of a rare form of sarcoma. They have discovered a registry of this form of cancer and have access to the largest database of patients with this form of cancer, which, unfortunately, is only a few years old. They have funding for only one year from the National Institutes of Health and note the budget will be tight. What type of study design do you recommend? a. Prospective cohort b. Retrospective cohort c. Cross-sectional d. Experimental e. Case-control 16. If rapidly progressive cancers are missed by a screening test, which type of bias will occur? a. Lead-time bias b. Length bias c. Selection bias d. Surveillance bias e. Information bias Biostatistics and Methods of Epidemiology 5 Items 17-19 Lou Stewells, a pioneer in the study of diarrheal disease, has developed a new diagnostic test for cholera. When his agent is added to the stool, the organisms develop a characteristic ring around them. (He calls it the Ring- Around-the-Cholera [RAC] test.) He performs the test on 100 patients known to have cholera and 100 patients known not to have cholera with the following results: 6 Preventive Medicine and Public Health 17. Which of the following statements is INCORRECT about the RAC test? a. The sensitivity of the test was about 91% b. The specificity of the test was about 12% c. The false negative rate was about 9% d. The predictive value of a positive result cannot be determined from the preceding information e. The predictive value of a negative result cannot be determined from the preceding information 18. Dr. Stewells next performs the test on 1000 patients with profuse diarrhea: Cholera No Cholera RAC test + 91 12 RAC test &#8722; 9 88 Totals 100 100 Cholera No Cholera RAC test + 312 79 RAC test &#8722; 31 578 Totals 343 657 Which of the following statements is correct? a. The predictive value of a positive result is 31/343 b. The predictive value of a positive result is 79/312 c. The predictive value of a negative result is 578/(578 + 31) d. The predictive value of a negative test is 578/657 e. The incidence rate of cholera in this population is 343/1000 19. The RAC test achieves widespread acceptance. However, with improvements in hygiene, the prevalence of cholera gradually falls from 35 to 5% of hospitalized diarrhea patients. Which statement about the effect of this fall in prevalence is true? a. The change in prevalence will reduce the predictive value of a negative result b. The predictive value of a positive result will decline c. The specificity of the test is likely to decline d. The specificity of the test will increase at the expense of its sensitivity e. It will have no impact on the predictive values of the test 20. A randomized clinical trial is undertaken to examine the effect of a new combination of antiretroviral drugs on HIV viral load compared to usual therapy. Randomization is used for allocation of subjects to either treatment or control (usual care) groups in experimental studies. Randomization ensures that a. Assignment occurs by chance b. Treatment and control (usual care) groups are alike in all respects except treatment c. Bias in observations is eliminated d. Placebo effects are eliminated e. An equal number of persons will be followed in the treatment and control group 21. In a study of the cause of lung cancer, patients who had the disease were matched with controls by age, sex, place of residence, and social class. The frequency of cigarette smoking was then compared in the two groups. What type of study was this? a. Prospective cohort b. Retrospective cohort c. Clinical trial d. Case-control e. Correlation Items 22-24 The incidence rate of lung cancer is 120/100,000 person-years for smokers and 10/100,000 personyears for nonsmokers. The prevalence of smoking is 20% in the community. 22. What is the relative risk of developing lung cancer for smokers compared with nonsmokers? a. 5 b. 12 c. 50 d. 100 e. 120 23. What percentage of lung cancer can be attributed to smoking? a. 52% b. 78% c. 80% d. 92% e. 99% Biostatistics and Methods of Epidemiology 7 24. If the prevalence of smoking in the community was decreased to 10%, the excess incidence rate of lung cancer that could be averted in that community would be a. 11/100,000 b. 22/100,000 c. 50/100,000 d. 60/100,000 e. 110/100,000 25. The Coronary Drug Project was a randomized trial to evaluate the efficacy of several lipid-lowering drugs. The five-year mortality of the men who adhered to the regimen of clofibrate (i.e., took 80% of their medicine or more) was 15%; among those assigned to the clofibrate group who were less compliant, it was 24.6%. The result was highly statistically significant (p < 0.0001). From this one can conclude a. Clofibrate was very beneficial to the patients who took it reliably b. Clofibrate is not effective unless patients take at least 80% of the recommended doses c. Either clofibrate or something associated with taking it reliably is strongly associated with reduced total mortality d. There was a problem with blinding in this study e. Only those who were compliant should be included in the data 26. The use of matching as a technique to control for confounding is most appropriate for which type of study? a. A large-scale cohort study b. A case-control study with a small number of cases c. A clinical trial with a factorial design d. A cross-sectional study with multiple variables e. A correlation study with a small number of countries Items 27-28 An investigator is designing a randomized, double-blind, placebocontrolled clinical trial to see whether vitamin E will prevent lung cancer. 27. Which technique is likely to maximize compliance with the allocated regimen? a. Using the placebo b. Performing a run-in phase c. Using intent-to-treat analysis d. Double blinding the study e. Limiting the number of subjects enrolled 8 Preventive Medicine and Public Health 28. Which is most likely to affect the validity (source of bias) of the study? a. Loss to follow-up b. Incidence of lung cancer c. Prevalence of smoking in the source population d. &#945; error e. &#946; error 29. The crude death rate in the United States is 150/100,000. The crude death rate in a smaller, developing country is 75/100,000. Based on these data, which one of the following statements best explains the data? a. The health care system of the developing country is far better than that in the United States b. More people die in the United States because it has a larger population c. Infant mortality in the first week is higher in developing countries, but it is not included in the crude death rate d. Death rates in the developing country are lower due to the emigration effect e. Crude death rates are usually higher in developed countries because of a higher proportion of older persons in the population Items 30-32 A research team wishes to investigate a possible association between smokeless tobacco and oral lesions among professional baseball players. At spring training camp, they ask each baseball player about current and past use of smokeless tobacco, cigarettes, and alcohol, and a dentist notes the type and extent of the lesions in the mouth. 30. What type of study is this? a. Case-control b. Cross-sectional c. Prospective cohort d. Clinical trial e. Retrospective cohort Biostatistics and Methods of Epidemiology 9 31. After the players have been questioned about use of smokeless tobacco and examined for lesions of the mouth, the data on the 146 players are tabulated as follows: 10 Preventive Medicine and Public Health Mouth No Lesion Lesion Total User 80 30 110 Nonuser 2 34 36 Total 82 64 146 In this study, which measure of disease occurrence can be calculated? a. Incidence rate b. Cumulative incidence rate c. Incidence density d. Prevalence e. Relative risk 32. Which of the following statements is true? a. The odds ratio is equal to (80/110) × (2/36) = 13.1 b. A temporal association between smokeless tobacco use and oral lesions can be established c. The statistical association can be calculated using the chi-square test d. Selection bias could overestimate the result e. There should be an equal number of exposed and nonexposed subjects 33. A randomized trial shows that a new thrombolytic agent reduces total mortality by 30% in the first 30 days after a suspected myocardial infarction compared with a placebo (p = 0.002). Which of the following questions would be the most important to have answered? a. Was the trial blinded? b. What was the power of the study? c. What happened to surviving patients in the next year? d. What percentage of patients in each group actually had a myocardial infarction? e. What was the effect on mortality from coronary heart disease? Items 34-36 In a study of the effectiveness of pertussis vaccine in preventing pertussis (whooping cough), the following data were collected by studying siblings of children who had the disease. Biostatistics and Methods of Epidemiology 11 Immunization Status Number of Siblings Number of Cases of Sibling Contact Exposed to Case among Siblings Complete 4000 400 None 1000 400 34. What was the secondary attack rate of pertussis in fully immunized household contacts? a. 0% b. 10% c. 25% d. 40% e. 75% 35. What was the protective efficacy of whooping cough vaccine? a. 25% b. 40% c. 75% d. 90% e. 99% 36. What was the relative risk of contracting whooping cough in the unimmunized children compared with the fully immunized children? a. 0.25 b. 0.5 c. 1.0 d. 2.0 e. 4.0 37. Decision analyses often include a patients utilities in the determination of the best decision. These utilities measure a. Whether a patient favors one decision over another b. Whether a physician favors one decision over another c. The difference between a patients decision and the physicians decision d. The relative value a patient places on a particular outcome e. The relative likelihood of a particular outcome 38. You have just finished conducting a case-control study to measure the association between alcohol use and lower respiratory tract infections. The most appropriate method to control for smoking as a confounder is a. Matching b. Restriction c. Randomization d. Stratification e. Multivariate modeling Items 39-41 Data from an investigation of an epidemic of rubella in a remote village in Brazil are given in the following table: 12 Preventive Medicine and Public Health Number Not III but with Age Number Number Antibody Group in Ill Rise Number Percent (years) Population (Symptomatic) (Asymptomatic) Uninfected Infected 09 204 110 74 20 90 1019 129 70 46 13 90 2039 161 88 57 16 90 4059 78 42 28 8 90 60+ 42 2 2 38 10 Totals 614 312 207 95 39. Which expression represents the calculation to determine the incidence of illness (symptomatic cases) for all age groups (as a percentage)? a. 95/519 × 100% = 18.3% b. 207/614 × 100% = 33.7% c. 207/519 × 100% = 39.9% d. 312/614 × 100% = 50.8% e. 519/614 × 100% = 84.5% 40. Which expression represents the calculation to determine the percentage of infection that is asymptomatic (subclinical)? a. 95/519 × 100% = 18.3% b. 207/614 × 100% = 33.7% c. 207/519 × 100% = 39.9% d. 312/614 × 100% = 50.8% e. 519/614 × 100% = 84.5% 41. Based on the age-specific infection rates, when did German measles previously occur in this village in relation to the current epidemic? a. 0 to 9 years ago b. 10 to 19 years ago c. 20 to 39 years ago d. 40 to 59 years ago e. 60 or more years ago Items 4244 A new test has been developed to screen for ovarian cancer. The following figure illustrates the distribution of values for this test among two populations. Biostatistics and Methods of Epidemiology 13 Normal population Population with cancer Frequency 0 10 15 20 25 30 35 40 45 50 55 60 70
g/dL 42. If the researcher chooses values under 30 &#956;g/dL as normal limits for the test, which of the following statements is true? a. The test will be 100% specific b. The test will be 100% sensitive c. Some persons without cancer will test positive d. There will be some false-positive tests e. All persons with cancer will have a positive test 43. If the researcher chooses values under 25 &#956;g/dL as normal limits for the test, which of the following statements is true? a. The test will be 100% specific b. The test will be 100% sensitive c. No false-negative tests will occur d. There will be some false-positive tests e. All persons with cancer will have a positive test 14 Preventive Medicine and Public Health 44. The researcher decides to use values under 20 &#956;g/dL as normal limits, and the test becomes commercially available. One of your patients has a test result of 27 &#956;g/dL. You conclude that a. The patient has cancer of the ovary b. The patient does not have cancer of the ovary c. This is a false-negative test d. A confirmation test will be needed as she may or may not have cancer e. This test is not sensitive enough to detect cancer 45. You are preparing a report to present to the Public Health Council on the declining rates of gonorrhea in your state in both men and women over the last 10 years. Which type of graph would best illustrate the data? a. Bar chart b. Histogram c. Pie chart d. Frequency polygon e. Line graph 46. Consider the following two distribution curves. Which numerical summary measure would allow you to discriminate between the two distributions? a. Median b. Mean c. Mode d. Standard deviation e. Sample size 47. Consider the following distribution curve. Which statement best applies to this curve? a. The mean is a more robust measure of central tendency b. The median is larger than the mean c. The data is skewed to the right d. This is a normal distribution e. This is a bimodal distribution Biostatistics and Methods of Epidemiology 15 1 2 Items 48-50 Five prospective cohort studies were undertaken to examine the association between bacterial vaginosis and delivery of a premature child. The results of these five hypothetical studies are illustrated in the following figure and are expressed as relative risks with 95% confidence intervals. 16 Preventive Medicine and Public Health 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 RR D C B A E 48. Which study appears to have the smallest sample size? a. A b. B c. C d. D e. E 49. Which study has a p value > 0.05? a. A b. B c. C d. D e. E 50. Which study appears to be the most precise? a. A b. B c. C d. D e. E Items 51-53 Five new herpes simplex virus type 2specific ser ologies are developed by different research laboratories. The test performance characteristics are used to create the receiver operator curve (ROC) illustrated in the following figure. 51. The x axis represents a. True negatives b. Prevalence of disease c. False-negatives d. False-positives e. Positive predictive values 52. The main purpose of the ROC curves in the preceding example is to a. Determine cut-off points for a new test b. Compare the diagnostic accuracy of the new tests c. Assess the utility of a new test in a low-prevalence population d. Determine the test performance characteristics e. Determine the cost-effectiveness of a new test Biostatistics and Methods of Epidemiology 17 C D E B A 1.0 x y 1.0 Sensitivity 53. Which of the five tests would be best to use as a diagnostic tool? a. A b. B c. C d. D e. E 54. A decision analysis is undertaken in an attempt to determine which approach, radiation therapy or surgery, is best for the management of prostate cancer. A sensitivity analysis is plotted on the graph shown in the following figure. The x axis represents the probability of death from surgery, and the y axis represents the life expectancy (expected utility) expr essed in quality-adjusted life years (QALYs). Based on this information, you conclude that a. Radiation therapy is always the best approach b. Surgery is always the best approach c. Radiation therapy is the best approach when mortality from surgery exceeds 11% d. Mortality from surgery does not affect the choice of approach e. Surgery is the preferred approach when mortality from the procedure exceeds 20% 18 Preventive Medicine and Public Health .05 3.797859 4.509957 Expected utility R R R R R R R R R R R R Radiation Surgery R R R S S S S S S S S S S S S S S S pDIE 0.1 .2 55. A prospective cohort study examining the association between passive smoking and cervical cancer reveals an odd ratio of 1.3 (95% confidence interval 0.85.6). The most appr opriate conclusion is that a. There is a significant association between passive smoking and cervical cancer b. The null hypothesis is rejected c. There is a type 1 error d. The &#945; was set at 0.10 e. A 90% confidence interval would result in a narrower confidence interval 56. Consider the following two-way scatter plot examining the relationship between glomerular filtration rate (GFR) on the y axis and the reciprocal of plasma creatinine (1/Cr) on the x axis. Biostatistics and Methods of Epidemiology 19 (Adapted, with permission, from Ingelfinger JA, Mosteller F,Thibodeau LA,Ware JH. Biostatistics in Clinical Medicine, 3rd ed. New York, McGraw- Hill, 1994: 205.) This is an example of a. A correlation analysis with a coefficient between 0 and 1 b. A logistic regression analysis c. A simple linear regression analysis d. A multiple regression analysis e. A correlation analysis with a coefficient between &#8722;1 and 0 57. Consider the results of two hypothetical intervention studies: 20 Preventive Medicine and Public Health Study A Study B Incidence of mortality in the control group 1.3% 20% Incidence of mortality in the intervention group 0.6% 9.2% What is the most useful measure of association in assessing the clinical relevance of these two studies? a. The relative risk (RR) b. The relative risk reduction (RRR) c. The odd ratio (OR) d. The attributable risk reduction (ARR) e. The numbers needed to treat (NNT) 58. A hypothetical study examining the association between serum cholesterol (>280) and cardiovascular disease (CVD) demonstrates a crude relative risk of 3.0. When the data is stratified by gender, the relative risk for men is 4.0 and the relative risk for women is 1.0. The adjusted risk is 3.0. The most appropriate interpretation of the results of this study is that a. Gender is both a confounder and an effect modifier b. Gender is a confounder only c. Gender is an effect modifier only d. Gender is neither a confounder nor an effect modifier e. Gender is a causal pathway 59. A clinical training program wishes to evaluate the reliability of selfassessment of clinical skills as a tool for measuring improvement. After a teaching session, students are asked to rank themselves (on a scale of 1 to 5) on 10 examination procedures. The preceptor also ranks the students according to the same scale. The results of the two assessments are then compared. The most appropriate test statistic to compare results is a. A Kappa statistics test b. A student t test c. A Wilcoxon rank sum test d. A chi-square test e. A correlation analysis 60. Which of the following tests can be used to study ordinal data from two independent samples from a population that is not normally distributed? a. The student t test b. The Wilcoxon rank sum test c. The chi-square test d. The one-way analysis of variance e. The Mantel-Haenszel method 61. Point prevalence studies tend to overestimate the occurrence of which of the following diseases? a. Diseases with a high incidence b. Diseases with a long duration c. Diseases with a high mortality d. Diseases with a short duration e. Diseases with a low incidence 62. Consider the following study assessing the proportion of patients presenting with urethritis who were tested for Chlamydia trachomatis (CT) at two different health centers: The data is analyzed using the chisquare distribution to determine if there is a significant difference in proportions between the two health centers. How many degrees of freedom should be used for this distribution? a. 1 b. 2 c. 3 d. 4 e. 6 Biostatistics and Methods of Epidemiology 21 Health CT Test Center Yes No A 220 100 B 150 80 63. Consider the following survival curve for women diagnosed with disease XYZ. This curve suggests that the five-year survival rate is a. 10% b. 20% c. 30% d. 40% e. 50% 22 Preventive Medicine and Public Health 0 1 2 3 4 5 Years since diagnosis 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 Proportion surviving Items 64-67 For each of the following descriptions, match the appropriate measure of frequency. a. Fetal mortality b. Infant mortality c. Perinatal mortality d. Neonatal mortality e. Postneonatal mortality f. Maternal mortality 64. Number of deaths in the first 28 days of life per 1000 live births in 1 year. (SELECT 1 RATE) 65. Number of fetal deaths plus deaths in the first week of life per 1000 total births in 1 year. (SELECT 1 RATE) 66. Number of deaths under the age of 1 year per 1000 live births in 1 year. (SELECT 1 RATE) 67. Number of deaths between the ages of 28 days and 11 months per 1000 live births in 1 year. (SELECT 1 RATE) Items 68-69 For each of the following questions, choose the appropriate epidemiologic term it refers to. a. Internal validity b. External validity c. Precision d. Power e. Statistical significance 68. A study demonstrates that the risk of cardiovascular disease among physicians can be reduced by aspirin intake. Can the results of this study be applied to the population at large? 69. An intervention study demonstrates that attending a sexual historytaking skills-building workshop increases the level of comfort of providers in questioning patients about the number of sexual partners (RR = 1.4, 95% CI 1.2 33.8). Are the results of the study reliable? Biostatistics and Methods of Epidemiology 23 DIRECTIONS: Each group of questions below consists of lettered options followed by numbered items. For each numbered item, select the appropriate lettered option(s). Each lettered option may be used once, more than once, or not at all. Choose exactly the number of options indicated following each item. Items 70-73 For each of the studies below, choose the most appropriate statistical test to analyze the data. a. Chi-square analysis b. Student t test c. Paired t test d. Analysis of variance e. Linear regression f. Multiple regression g. Correlation analysis h. McNemar test 70. Comparison of systolic blood pressures in independent samples of pregnant and nonpregnant women. (SELECT 1 TEST) 71. Comparison of the prevalence of hepatitis B surface antigen (HBsAg) in medical and dental students. (SELECT 1 TEST) 72. Comparison of the level of blood glucose in male and female rats following administration of three different drugs. (SELECT 1 TEST) 73. Comparison of serum cholesterol before and after ingestion of hamburgers in a sample of fast-food patrons. (SELECT 1 TEST) Items 74-77 For each of the following descriptions, pick the appropriate epidemiologic term. a. Confounding b. Effect modification c. Differential misclassification d. Lead-time bias e. Selection bias f. Nondifferential misclassification 74. Elevated bilirubin levels in neonates are associated with brain damage only in babies who also have infections or severe hemolytic disease. (SELECT 1 TERM) 75. People who drink coffee tend to smoke more, and for this reason coffee drinkers have a higher risk of lung cancer. (SELECT 1 TERM) 76. Higher lead levels in hyperactive children may be due to increased consumption of paint in children who were already hyperactive. (SELECT 1 TERM) 24 Preventive Medicine and Public Health 77. A prospective cohort study with an imprecise measurement of exposure to radiation fails to demonstrate a significant association with cancer. (SELECT 1 TERM) Items 78-81 In each statement below, data are presented based on a cohort study of coronary heart disease. Choose the parameter that best describes each of these statements. a. Point prevalence b. Cumulative incidence c. Standardized morbidity ratio d. Relative risk e. Incidence density f. Odds ratio g. Case fatality rate 78. At the initial examination, 17 persons per 1000 had evidence of coronary heart disease (CHD). (SELECT 1 PARAMETER) 79. Among a cohort of heavy smokers, the observed frequency of angina pectoris was 1.6 times as great as the expected frequency during the first 12 years of the study. (SELECT 1 PARAMETER) 80. During the first eight years of the study, 45 persons developed coronary heart disease per 1000 persons who entered the study free of disease. (SELECT 1 PARAMETER) 81. At the end of the study, a total of 129 nonfatal myocardial infarctions per 54,560 person-years of observation occurred in the study population. (SELECT 1 PARAMETER) Items 82-86 Match the examples below with the appropriate epidemiologic terms. a. Lead-time bias b. Surveillance bias c. Recall bias d. Type 1 error e. Power f. Length time bias g. Confounding 82. Medical students who fail a physiology examination are more likely to report missing two or more physiology lectures than those who fail a neuroanatomy examination. (SELECT 1 TERM) 83. The chance of discovering the truth that twice as many of your friends are at the movies as are studying for their board examinations. (SELECT 1 TERM) 84. In a class of 150 medical students, there will likely be a few who can answer this question correctly without understanding the material. (SELECT 1 TERM) Biostatistics and Methods of Epidemiology 25 85. The likelihood of finding a lost biochemistry notebook in your apartment is higher in the month of June than in the month of March. (SELECT 1 TERM) 86. Medical students enrolled in a first-year anatomy class are more likely to remain at their same addresses for the next two years than medical students enrolled in fourthyear clerkships. (SELECT 1 TERM) Items 8790 Choose the rate that best describes each statement below. a. Secondary attack rate b. Case fatality rate c. Morbidity rate d. Age-adjusted mortality e. Crude mortality 87. Death occurs in 10% of cases of meningococcal meningitis. (SELECT 1 RATE) 88. Approximately 9 people die each year in the United States for every 1000 estimated to be alive. (SELECT 1 RATE) 89. Eighty percent of susceptible household contacts of a child with chicken pox develop this disease. (SELECT 1 RATE) 90. Children between the ages of 1 and 5 have an average of eight colds per year. (SELECT 1 RATE) Items 9194 Choose the term that best fits the description. a. Matching b. Stratification c. Age adjustment d. Multivariate statistical analysis e. Survival analysis 91. In a cohort study of hypertensive men, the proportions of subjects with high and low renin levels who survived for five years are compared separately among those aged 40 to 49, those aged 50 to 59, and those aged 60 to 69 at entry. (SELECT 1 TERM) 92. A sampling strategy is used to achieve comparability of the groups being studied. (SELECT 1 TERM) 93. A technique that takes into account variable length of followup is used. (SELECT 1 TERM) 94. Six different risk ratios are calculated: one for each sex at each of three social class levels. (SELECT 1 TERM) 26 Preventive Medicine and Public Health Items 95-98 For each of the studies described, select the reason for which the conclusion can be misleading or false. a. Lack of a control group b. Lack of proper follow-up c. Lack of adjustment for age d. Lack of denominators e. Lack of adjustment for race 95. Of 250 consecutive, unselected women in whom acute cholecystitis was diagnosed, 75 were under age 50 and 175 were over age 50. The investigator concluded that older women are at greater risk of acute cholecystitis than are younger women. (SELECT 1 ERROR) 96. In a review of 3000 patients in whom adult-onset diabetes was diagnosed, 2000 of these patients were obese at the time of diagnosis. The investigator concluded that there is an association between diabetes and obesity. (SELECT 1 ERROR) 97. Acute anxiety neurosis was diagnosed among 250 patients and follow-up data were available on 80% of these patients 10 years later. The mortality experience of this cohort was no different from that of the general population. The authors concluded that the diagnosis of acute anxiety neurosis is not associated with a decrease in longevity. (SELECT 1 ERROR) 98. Of 143 patients who died of bacterial endocarditis and on whom autopsies were performed, 2% were less than 10 years of age. The authors concluded that bacterial endocarditis is rare in childhood. (SELECT 1 ERROR) Biostatistics and Methods of Epidemiology 27 Items 99-102 Consider the following decision tree assessing radiation therapy versus surgery for the treatment of prostate cancer: The expected utility, life expectancy, is expressed in quality-adjusted life years, or QALYs. 28 Preventive Medicine and Public Health Death Life expectancy (QALYS) 3.15 0 4.50 3.50 5.00 Surgery 0.05 Survive 0.95 0.05 ? 4.4 4.8 Incontinence 0.10 Recurrence 0.90 No recurrence 0.10 Recurrence 0.40 Recurrence 0.40 Recurrence 0.90 No recurrence 0.60 No recurrence 0.60 No recurrence 0.95 No incontinence 3.15 4.50 3.50 5.00 Radiation 0.43 3.9 4.4 4.2 Proctitis 0.57 No proctitis 102. If radiation therapy was never associated with the complication of proctitis, the quality-adjusted life expectancy would be a. 5.0 b. 3.5 c. (3.5 + 5.0)/2 = 4.25 d. (3.15 × 0.4) + (4.5 × 0.6) = 3.96 e. (3.5 × 0.4) + (5.0 × 0.6) = 4.4 Items 103-106 The following 2 × 2 table represents the findings of a five-year cohort study in which the incidence of suicide in veterans who served in Vietnam was compared with that of veterans who served elsewhere. Match the name of the parameter below with the appropriate formula. a. ad/bc b. (a + b)/(a + b + c + d) c. (a + c)/(a + b + c + d) d. [a/(a + b)]/[c/(c + d)] e. [a/(a + b)] &#8722; [c/(c + d)] 103. The odds ratio. (SELECT 1 FORMULA) 104. The relative risk. (SELECT 1 FORMULA) No Suicide Suicide Served in Vietnam a b Served elsewhere c d 99. Which of the following statements is true concerning the creation of a decision tree used for clinical decision making? a. The first nodes in a tree are chance nodes b. Branches from the chance nodes must be mutually exclusive and collectively exhaustive c. The terminal nodes represent prevalence of disease d. The expected utilities are calculated by folding back the tree from left to right e. The numerical values of the expected utility are expressed in different units than the expected outcomes 100. The quality-adjusted life expectancy for surgery is a. (4.4 + 4.8) × 0.95 = 8.74 b. (4.4 × 0.95) + (4.8 × 0.05) = 4.42 c. [(4.4 × 0.05) + (4.8 × 0.95)] × 0.95 = 4.5 d. (4.4 × 0.95) + (4.8 × 0.95) = 8.74 e. (4.4 × 0.90) + (4.8 × 0.90) = 8.28 101. Based on the results of this decision analysis, which approach appears preferable? a. Surgery b. Radiation c. Surgery, only if there is no probability of death d. Radiation followed by surgery, if there is a recurrence e. No preferable approach can be identified Biostatistics and Methods of Epidemiology 29 105. The excess risk of suicide in Vietnam veterans. (SELECT 1 FORMULA) 106. The overall incidence (per five years) of suicide in the study. (SELECT 1 FORMULA) Items 107-110 Match each description of a sampling procedure with the correct term. a. Systematic sampling b. Paired sampling c. Simple random sampling d. Stratified sampling e. Cluster sampling 107. Each individual of the total group has an equal chance of being selected. (SELECT 1 PROCEDURE) 108. Households are selected at random, and every person in each household is included in the sample. (SELECT 1 PROCEDURE) 109. Individuals are initially assembled according to some order in a group and then individuals are selected according to some constant determinant; for instance, every fourth subject is selected. (SELECT 1 PROCEDURE) 110. Individuals are divided into subgroups on the basis of specified characteristics and then random samples are selected from each subgroup. (SELECT 1 PROCEDURE) Items 111-115 A new test for chlamydial infections of the cervix is introduced. Half of the women who are tested have a positive test. Compared with the gold standard of careful cultures, 45% of those with a positive test are infected with chlamydia, and 95% of those with a negative test are free of the infection. Match the epidemiologic terms below with the correct percentage. a. 25% b. 45% c. 63% d. 90% e. 95% 111. Sensitivity of the test. (SELECT 1 PERCENTAGE) 112. Specificity of the test. (SELECT 1 PERCENTAGE) 113. Prevalence of chlamydial infection in that community. (SELECT 1 PERCENTAGE) 114. Predictive value of a positive test. (SELECT 1 PERCENTAGE) 115. Predictive value of a negative test. (SELECT 1 PERCENTAGE) 30 Preventive Medicine and Public Health Items 116-119 For each result or conclusion described below, select the choice that might best explain it. a. Ecologic fallacy b. Type 1 error c. Type 2 error d. Selection bias e. Misclassification bias 116. A randomized blinded trial of aspirin to prevent myocardial infarction fails to find a difference between aspirin and placebo groups after five years (N = 500 per group; p = 0.11). (SELECT 1 ERROR) 117. A study of patterns of contraceptive use finds that counties with the highest per capita use of condoms also have the highest pregnancy rates (N = 100,000; p < 0.001) and concludes that condoms are ineffective as contraceptives. (SELECT 1 ERROR) 118. An investigator analyzes data from the National Health Interview Survey and finds that there is a positive association between consumption of turkey and degenerative joint disease in black women 50 to 59 years old (N = 50; p < 0.05). (SELECT 1 ERROR) 119. In a case-control study of lung cancer, cases spouses ar e chosen as controls. The odds ratio for smoking is 3.0, which does not quite reach statistical significance (N = 30 per group; p = 0.07). (SELECT 1 ERROR) Items 120124 For each variable described below, choose the type of measurement scale. a. Dichotomous scale b. Nominal scale c. Ordinal scale d. Interval scale e. Ratio scale 120. Survival of a particular patient for at least five years. (SELECT 1 SCALE) 121. Frequency of somnolence during biochemistry lectures: never, sometimes, usually, or always. (SELECT 1 SCALE) 122. Birth weight. (SELECT 1 SCALE) 123. Type of medical specialty. (SELECT 1 SCALE) 124. Year of birth. (SELECT 1 SCALE) Biostatistics and Methods of Epidemiology 31 Items 125-127 Dr. Vera Blues, a noted psychiatric epidemiologist, is interested in the diagnosis of depression. She develops a new test for its diagnosis, which she calls the Blues test. According to the gold standard, which involves meeting the DSMIV criteria, about 10% of adults in the United States are depressed. Dr. Blues applies her new test to 100 persons diagnosed as being depressed by the gold standard; 80 have a positive Blues test. She finds 400 persons who are not depressed; 60 have a positive test. She reports her findings in the Journal of the Society of Academic Psychiatrists (JSAP). Match the statements that Dr. Blues made in her article with the appropriate percentage. a. 85% b. 80% c. 60% d. 6% e. <10%