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Prevention Impacts Simulation Model (PRISM)Core Contributors
System Dynamics Modelers• Jack Homer• Kris Wile
Economists• Justin Trogdon• Amanda Honeycutt
Project Coordinators• Bobby Milstein• Diane Orenstein
CDC partnered with the Austin (Travis County), Texas, Dept. of Health and Human Services. The model is calibrated to represent the overall US, but is informed by the experience and data
of the Austin team, which has been supported by the CDC’s “STEPS” program since 2004.`
CDC partnered with the Austin (Travis County), Texas, Dept. of Health and Human Services. The model is calibrated to represent the overall US, but is informed by the experience and data
of the Austin team, which has been supported by the CDC’s “STEPS” program since 2004.`
CDC & NIH Subject Matter ExpertsBishwa Adhikari, Nicole Blair, Kristen Betts, Peter Briss, David Buchner, Susan Carlson, Michele Casper, Tom Chapel, Janet Collins, Lawton Cooper, Michael Dalmat, Alyssa Easton, Joyce Essien, Roseanne Farris, Larry Fine, Janet Fulton, Deb Galuska, Kathy Gallagher, Judy Hannon, Jan Jernigan, Darwin Labarthe, Deb Lubar, Patty Mabry, Ann Malarcher, Michele Maynard, Marilyn Metzler, Rob Merritt, Latetia Moore, Barbara Park, Terry Pechacek, Catherine Rasberry, Michael Schooley, Nancy Williams, Nancy Watkins, Howell Wechsler
External Subject Matter ExpertsCynthia Batcher, Margaret Casey, Phil Huang, Kristen Lich, Karina Loyo, David Matchar, Ella Pugo, John Robitscher, Rick Schwertfeger, Adolpho Valadez
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Prevention Impacts Simulation Model (PRISM)• Represents multiple interacting risks and interventions for heart
disease, stroke, and related chronic diseases: medical, behavioral, social, environmental
• Begun in 2007 (now version 2i) and it remains a work-in-progress
• Engaged subject matter experts from 12 organizations (N~30), and 100s of policy officials, including a deep collaboration with local leaders in Austin, Texas
• Integrates best available information in a single testable model to support prospective planning and evaluation
• Explores the likely effects of “local interventions” (i.e., changes in local options/exposures/services that affect behavior and/or health status)
– To what extent might adverse events and costs be reduced?
– How can policymakers balance interventions for best effect with limited resources?
References: Homer J, Milstein B, Wile K, Trogdon J, Huang P, Labarthe D, Orenstein D. Simulating and evaluating local interventions to improve cardiovascular health. Preventing Chronic Disease, 2009 (in press).
Homer J, Milstein B, Wile K, Pratibhu P, Farris R, Orenstein D. Modeling the local dynamics of cardiovascular health: risk factors, context, and capacity. Preventing Chronic Disease 2008;5(2). Available at <http://www.cdc.gov/pcd/issues/2008/apr/07_0230.htm
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Tobacco
Air Pollution
Stress
Healthy Food
Sodium
Trans fat
PhysicalActivity
WeightLoss
MentalHealthServices
PrimaryCare
Emergency & Rehab Care
BloodPressure
Cholesterol
ObesityHeart Disease & Stroke
Cancer
Health CareCost
Diabetes
The Popular (and Professional) View of Chronic Disease Challenges is Largely One Headline after Another
Alcohol
Sleep Arthritis
JunkFood
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PRISM Situates Multiple Medical, Behavioral, and Environmental Factors into a Single Set of Causal Pathways
Cardiovascularevents
Air pollutionexposure(PM 2.5)
Use of qualitypreventive care
SmokingObesity
-Hypertension-High cholesterol
-Diabetes
Uncontrolledchronic disorders
Secondhandsmoke
Heart-unhealthy diet
Physicalinactivity
Distress
Excesscalorie diet
CVD deaths,disability,and costs
Excesssodium diet
Chronic Disorders
Trans fatconsumption
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Prevention Network
PRISM Situates Multiple Medical, Behavioral, and Environmental Factors into a Single Set of Causal Pathways
Cardiovascularevents
Air pollutionexposure(PM 2.5)
Use of qualitypreventive care
SmokingObesity
-Hypertension-High cholesterol
-Diabetes
Uncontrolledchronic disorders
Secondhandsmoke
Heart-unhealthy diet
Physicalinactivity
Distress
Excesscalorie diet
CVD deaths,disability,and costs
Excesssodium diet
Chronic Disorders
Other deaths and costsattributable to risk factors,
and costs of risk factormanagement
Total consequencecosts
Trans fatconsumption
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Weight lossservices for obese
JUNK FOODTax, restrict sales/mktg,
counter-marketing
Sodium in food
Trans fatIn food
HEART-HEALTHYFOOD
Access, promotionCardiovascular
events
Air pollutionexposure(PM 2.5)
Use of qualitypreventive care
SmokingObesity
-Hypertension-High cholesterol
-Diabetes
Uncontrolledchronic disorders
Secondhandsmoke
Heart-unhealthy diet
Physicalinactivity
PHYSICAL ACTIVITYAccess, promotion,
social support,school recs, childcare recs
Distress
Help servicesfor distress
Excesscalorie diet
CVD deaths,disability,and costs
Excesssodium diet
Reduce airpollution
Chronic Disorders
Other deaths and costsattributable to risk factors,
and costs of risk factormanagement
Total consequencecosts
Quality of acuteand rehab care
Quality and use ofpreventive care
Trans fatconsumption
Local Context for TobaccoLocal Context for DietLocal Context for Physical ActivityLocal Context for Air PollutionLocal Context for Health Care ServicesLocal Context for Weight Loss ServicesLocal Context for Mental Health Services
PRISM Also Includes Frontiers for Social Action
Tax, restrict sales/mktg,counter-marketing,
quit services
TOBACCOBan smoking in
public places
Primary Information Sources• Census
– Population, deaths, births, net immigration
• American Heart Association & NIH statistical reports
– Cardiovascular events, deaths, and prevalence
• National Health and Nutrition Examination Survey (NHANES)
– Risk factor prevalence by age and sex
– Diagnosis and control of hypertension, high cholesterol, and diabetes
• Medical Examination Panel (MEPS), National Health Interview (NHIS), Behavioral Risk Factor Surveillance System (BRFSS), Youth Risk Behavior Survey (YRBS)
– Medical and productivity costs attributable to risk factors
– Prevalence of distress in non-CVD and post-CVD populations
– Primary care utilization
– Extent of physical activity
• Research literature
– CVD risk calculator (Framingham)
– Relative risks from secondhand smoke, air pollution, obesity, poor diet, inactivity, distress
– Quality of diet (USDA Healthy Eating Index)
– Medical and productivity costs of cardiovascular events
– Effect sizes of behavioral interventions
• Expert judgment
– Effect sizes of behavioral interventions
Uncertainties are assessed through sensitivity testing
Uncertainties are assessed through sensitivity testing
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Mapping Information SourcesPhysical Activity Pathway
Cardiovascularevents
Air pollutionexposure(PM 2.5)
Quality of acuteand rehab care
Use of qualitypreventive care
Weight lossservices for obese
Help servicesfor distress
Ban smoking inpublic places
SmokingObesity
-Hypertension-High cholesterol
-Diabetes
Uncontrolledchronic disorders
Secondhandsmoke
Junk food options (N=3):Tax, restrict sales/mktg,
counter-market
Physical activity options (N=5):Access, promotion, social
support, school requirements,childcare requirements
Heart-unhealthy diet
Physicalinactivity
Distress
Quality and use ofpreventive care
Sodium in food
Trans fat infood
Excesscalorie diet
CVD deaths,disability,and costs
Excesssodium diet
Reduce airpollution
Tobacco options (N=4):Tax, restrict sales/mktg,
counter-market, quitservices
Chronic Disorders
Other deaths and costsattributable to risk factors,
and costs of risk factormanagement
Total consequencecosts
Trans fatconsumption
Heart-healthy foodoptions (N=2):
Access, promotion
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Mapping Information SourcesPhysical Activity Pathway
Cardiovascularevents
Air pollutionexposure(PM 2.5)
Quality of acuteand rehab care
Use of qualitypreventive care
Weight lossservices for obese
Help servicesfor distress
Ban smoking inpublic places
SmokingObesity
-Hypertension-High cholesterol
-Diabetes
Uncontrolledchronic disorders
Secondhandsmoke
Junk food options (N=3):Tax, restrict sales/mktg,
counter-market
Physical activity options (N=5):Access, promotion, social
support, school requirements,childcare requirements
Heart-unhealthy diet
Physicalinactivity
Distress
Quality and use ofpreventive care
Sodium in food
Trans fat infood
Excesscalorie diet
CVD deaths,disability,and costs
Excesssodium diet
Reduce airpollution
Tobacco options (N=4):Tax, restrict sales/mktg,
counter-market, quitservices
Chronic Disorders
Other deaths and costsattributable to risk factors,
and costs of risk factormanagement
Total consequencecosts
Trans fatconsumption
Heart-healthy foodoptions (N=2):
Access, promotion
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Cardiovascularevents
Air pollutionexposure(PM 2.5)
Quality of acuteand rehab care
Use of qualitypreventive care
Weight lossservices for obese
Help servicesfor distress
Ban smoking inpublic places
SmokingObesity
-Hypertension-High cholesterol
-Diabetes
Uncontrolledchronic disorders
Secondhandsmoke
Junk food options (N=3):Tax, restrict sales/mktg,
counter-market
Physical activity options (N=5):Access, promotion, social
support, school requirements,childcare requirements
Heart-unhealthy diet
Physicalinactivity
Distress
Quality and use ofpreventive care
Sodium in food
Trans fat infood
Excesscalorie diet
CVD deaths,disability,and costs
Excesssodium diet
Reduce airpollution
Tobacco options (N=4):Tax, restrict sales/mktg,
counter-market, quitservices
Chronic Disorders
Other deaths and costsattributable to risk factors,
and costs of risk factormanagement
Total consequencecosts
Trans fatconsumption
Heart-healthy foodoptions (N=2):
Access, promotion
Mapping Information SourcesPhysical Activity Pathway
Physical Inactivity Prevalence52% - 65% (by age)
• NHANES, BRFSS, & YRBS • Troiano RP, et al. Med Sci Sports Ex 2008;
40(1):181-188.
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Cardiovascularevents
Air pollutionexposure(PM 2.5)
Quality of acuteand rehab care
Use of qualitypreventive care
Weight lossservices for obese
Help servicesfor distress
Ban smoking inpublic places
SmokingObesity
-Hypertension-High cholesterol
-Diabetes
Uncontrolledchronic disorders
Secondhandsmoke
Junk food options (N=3):Tax, restrict sales/mktg,
counter-market
Physical activity options (N=5):Access, promotion, social
support, school requirements,childcare requirements
Heart-unhealthy diet
Physicalinactivity
Distress
Quality and use ofpreventive care
Sodium in food
Trans fat infood
Excesscalorie diet
CVD deaths,disability,and costs
Excesssodium diet
Reduce airpollution
Tobacco options (N=4):Tax, restrict sales/mktg,
counter-market, quitservices
Chronic Disorders
Other deaths and costsattributable to risk factors,
and costs of risk factormanagement
Total consequencecosts
Trans fatconsumption
Heart-healthy foodoptions (N=2):
Access, promotion
Mapping Information SourcesPhysical Activity Pathway
Effective Interventions Increase PA by 40-55%
(by age and strategy)
• Kahn EB, et al. Am J Prev Med 2002; 22:S73-102.
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Cardiovascularevents
Air pollutionexposure(PM 2.5)
Quality of acuteand rehab care
Use of qualitypreventive care
Weight lossservices for obese
Help servicesfor distress
Ban smoking inpublic places
SmokingObesity
-Hypertension-High cholesterol
-Diabetes
Uncontrolledchronic disorders
Secondhandsmoke
Junk food options (N=3):Tax, restrict sales/mktg,
counter-market
Physical activity options (N=5):Access, promotion, social
support, school requirements,childcare requirements
Heart-unhealthy diet
Physicalinactivity
Distress
Quality and use ofpreventive care
Sodium in food
Trans fat infood
Excesscalorie diet
CVD deaths,disability,and costs
Excesssodium diet
Reduce airpollution
Tobacco options (N=4):Tax, restrict sales/mktg,
counter-market, quitservices
Chronic Disorders
Other deaths and costsattributable to risk factors,
and costs of risk factormanagement
Total consequencecosts
Trans fatconsumption
Heart-healthy foodoptions (N=2):
Access, promotion
Mapping Information SourcesPhysical Activity Pathway
RR for obesity onset = 2.6
• Haapanen N, et al. Intl J Obesity 1997: 21:288-296
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Prevention Network
Cardiovascularevents
Air pollutionexposure(PM 2.5)
Quality of acuteand rehab care
Use of qualitypreventive care
Weight lossservices for obese
Help servicesfor distress
Ban smoking inpublic places
SmokingObesity
-Hypertension-High cholesterol
-Diabetes
Uncontrolledchronic disorders
Secondhandsmoke
Junk food options (N=3):Tax, restrict sales/mktg,
counter-market
Physical activity options (N=5):Access, promotion, social
support, school requirements,childcare requirements
Heart-unhealthy diet
Physicalinactivity
Distress
Quality and use ofpreventive care
Sodium in food
Trans fat infood
Excesscalorie diet
CVD deaths,disability,and costs
Excesssodium diet
Reduce airpollution
Tobacco options (N=4):Tax, restrict sales/mktg,
counter-market, quitservices
Chronic Disorders
Other deaths and costsattributable to risk factors,
and costs of risk factormanagement
Total consequencecosts
Trans fatconsumption
Heart-healthy foodoptions (N=2):
Access, promotion
Mapping Information SourcesPhysical Activity Pathway
RR for distress = 1.3
• Netz Y, Wu M-J, et al. Psyh Aging 2005; 20(2):272-284. .
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Cardiovascularevents
Air pollutionexposure(PM 2.5)
Quality of acuteand rehab care
Use of qualitypreventive care
Weight lossservices for obese
Help servicesfor distress
Ban smoking inpublic places
SmokingObesity
-Hypertension-High cholesterol
-Diabetes
Uncontrolledchronic disorders
Secondhandsmoke
Junk food options (N=3):Tax, restrict sales/mktg,
counter-market
Physical activity options (N=5):Access, promotion, social
support, school requirements,childcare requirements
Heart-unhealthy diet
Physicalinactivity
Distress
Quality and use ofpreventive care
Sodium in food
Trans fat infood
Excesscalorie diet
CVD deaths,disability,and costs
Excesssodium diet
Reduce airpollution
Tobacco options (N=4):Tax, restrict sales/mktg,
counter-market, quitservices
Chronic Disorders
Other deaths and costsattributable to risk factors,
and costs of risk factormanagement
Total consequencecosts
Trans fatconsumption
Heart-healthy foodoptions (N=2):
Access, promotion
Mapping Information SourcesPhysical Activity Pathway
RR of inactivity if distressed: 1.6
• Whooley MA, et al. JAMA 2008; 300(20):2379-2388.
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Prevention Network
Cardiovascularevents
Air pollutionexposure(PM 2.5)
Quality of acuteand rehab care
Use of qualitypreventive care
Weight lossservices for obese
Help servicesfor distress
Ban smoking inpublic places
SmokingObesity
-Hypertension-High cholesterol
-Diabetes
Uncontrolledchronic disorders
Secondhandsmoke
Junk food options (N=3):Tax, restrict sales/mktg,
counter-market
Physical activity options (N=5):Access, promotion, social
support, school requirements,childcare requirements
Heart-unhealthy diet
Physicalinactivity
Distress
Quality and use ofpreventive care
Sodium in food
Trans fat infood
Excesscalorie diet
CVD deaths,disability,and costs
Excesssodium diet
Reduce airpollution
Tobacco options (N=4):Tax, restrict sales/mktg,
counter-market, quitservices
Chronic Disorders
Other deaths and costsattributable to risk factors,
and costs of risk factormanagement
Total consequencecosts
Trans fatconsumption
Heart-healthy foodoptions (N=2):
Access, promotion
Mapping Information SourcesPhysical Activity Pathway
RR for High BP = 1.15RR for High Cholesterol = 1.4
RR for Diabetes = 1.4
• Ann Med 1991;23(3):319–327.• Intl J Epidemiology 1997; 26(4):739-747.
• Canadian Med Assoc J 2000;163(11):1435-1440.• Lancet 1991; 339:778-783.
• Arch Intern Med 2001; 161:1542-1548.
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Prevention Network
Cardiovascularevents
Air pollutionexposure(PM 2.5)
Quality of acuteand rehab care
Use of qualitypreventive care
Weight lossservices for obese
Help servicesfor distress
Ban smoking inpublic places
SmokingObesity
-Hypertension-High cholesterol
-Diabetes
Uncontrolledchronic disorders
Secondhandsmoke
Junk food options (N=3):Tax, restrict sales/mktg,
counter-market
Physical activity options (N=5):Access, promotion, social
support, school requirements,childcare requirements
Heart-unhealthy diet
Physicalinactivity
Distress
Quality and use ofpreventive care
Sodium in food
Trans fat infood
Excesscalorie diet
CVD deaths,disability,and costs
Excesssodium diet
Reduce airpollution
Tobacco options (N=4):Tax, restrict sales/mktg,
counter-market, quitservices
Chronic Disorders
Other deaths and costsattributable to risk factors,
and costs of risk factormanagement
Total consequencecosts
Trans fatconsumption
Heart-healthy foodoptions (N=2):
Access, promotion
Mapping Information SourcesPhysical Activity Pathway
Modification of theFramingham Risk Calculator
• Ex Rev Pharm Out Res 2006;6(4):417-24.• Am Heart J 1991;121(1 Pt 2):293-8.
• Am Heart J 2007;153(5):722-31, 31 e1-8.• JAMA 2001;286(2):180-7.
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Base Case & Illustrative Intervention Scenarios
Base Case (a simple scenario for comparison)
• Assume no further changes in the contextual factors that affect risk factor prevalences
• Any changes in prevalences after 2004 are due to “inflow/outflow” adjustment process and population aging
• Result: Past trends level off after 2004, after which results reflect only slow adjustments in risk factors
– Increasing obesity, high BP, and diabetes
– Decreasing smoking
– Increases in risk factors and population aging lead to eventual rebound in attributable deaths
Example Intervention Scenarios (max plausible effects, sustained)
• Four clusters of interventions layered to show their partial contribution and combined effects
• Services (health care, weight loss, smoking quit, distress)+ Diet & Physical Activity+ Tobacco + Air Pollution & Sodium & Trans fat
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Illustrative Intervention Scenarios: Maximum Plausible StrengthIndividual Services + Diet & PA + Tobacco + Air Pollution & Sodium & Trans
fat
Work in Progress, Please do no cite or distribute.
Smoking Prevalence (Adults) Obesity Prevalence (Adults)
Cardiovascular Events per 1000(CHD, Stroke, CHF, PAD)
Deaths from All Risk Factors per 1,000
0.4
0.3
0.2
0.1
0
1990 2000 2010 2020 2030 2040
0.4
0.3
0.2
0.1
0
1990 2000 2010 2020 2030 2040
30
22.5
15
7.5
0
1990 2000 2010 2020 2030 2040
8
6
4
2
0
1990 2000 2010 2020 2030 2040
Draft Model Output Draft Model Output
Draft Model Output Draft Model Output
**if all risk factors=0**
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Illustrative Intervention Scenarios: Maximum Plausible StrengthIndividual Services + Diet & PA + Tobacco + Air Pollution & Sodium & Trans
fat
Work in Progress, Please do no cite or distribute.
Years of Life Lost from Attributable Deaths
Consequence Costs per Capita(medical costs + productivity)
30 M
22.5 M
15 M
7.5 M
0
1990 2000 2010 2020 2030 2040
6,000
4,500
3,000
1,500
01990 2000 2010 2020 2030 2040
**if all risk factors=0**
Draft Model Output Draft Model Output
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Example of Sensitivity TestingEstimated impacts of a 15-component intervention,
with uncertainty ranges
1990 2000 2010 2020 2030 2040
Total Consequence Costs per capita (2005 dollars per year)
3,000
2,000
0
1,000
Combined 15 interventionswith range of uncertainty
Base Case
Costs if all risk factors = 0
1990 2000 2010 2020 2030 2040
Deaths from CVD per 1000
4
2
0
Combined 15 interventionswith range of uncertainty
Base Case
Deaths if all risk factors = 0
Homer J, Milstein B, Wile K, Trogdon J, Huang P, Labarthe D, Orenstein D. Simulating and evaluating local interventions to improve cardiovascular health. Preventing Chronic Disease, 2009 (in press).
Model Output (v2008)Model Output (v2008)
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How are Practitioners Using PRISM?
A Few Local Versions
• Re-calibrate to areas with different demographics, histories, and current conditions
Planning• Engage a wider circle of stakeholders
• Situate silos within a system
• Prioritize interventions (given tradeoffs/synergies)
• Set plausible short- and long-term goals
Evaluating
• Trace intervention effects through direct, secondary, and summary measures
• Extend the time horizon for evaluative inquiry
• Establish novel referents for comparison (self-referential counter-factuals)
Users (~500)Customized Versions
• East Austin, Texas
• Mississippi Delta
• New Zealand Ministry of Health
• U.S. economic stimulus health initiative
Nat’l & State Stakeholders
• CDC Staff
• National Association of Chronic Disease Directors
• Directors of Public Health Education
• National Institutes of Health (NHLBI, OBSSR)
Users (~500)Customized Versions
• East Austin, Texas
• Mississippi Delta
• New Zealand Ministry of Health
• U.S. economic stimulus health initiative
Nat’l & State Stakeholders
• CDC Staff
• National Association of Chronic Disease Directors
• Directors of Public Health Education
• National Institutes of Health (NHLBI, OBSSR)
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Conversations Around the Model
Other health
priorities
Available information
Health inequities
Local interventionopportunities and costs
Communitythemes and strengths
Political willStakeholder
relationships
• What’s in the model does not define what’s in the room
• Simulations intentionally raise questions to spark broader thinking and judgment
• Narrower boundaries tend to be more empirically grounded
• Wider boundaries may legitimize “invisible” processes
• Boundary judgments follow from the intended purpose and users
SYSTEMDYNAMICS MODEL
STRATEGICPRIORITIES
Cardiovascularevents
Air pollutionexposure(PM 2.5)
Quality of acute andrehab care for
cardiovascular events
Use of qualitypreventive care
Use of weightloss services
by obese
Use of help servicesfor distress
Bans on smokingin public places
SmokingObesity
-Hypertension-High cholesterol
-Diabetes
Uncontrolledchronic disorders
Secondhandsmoke
Junk foodinterventions
(N=4)
Physical activityinterventions
(N=6)
Heart-unhealthy diet
Physicalinactivity Distress
Efforts to promoteprovision and use of
quality preventive care
Sodiumreduction
Trans fatreduction
Excesscalorie diet
Fruit &vegetable
interventions(N=3)
CVD deaths,disability,and costs
Excesssodium diet
Air pollutionreduction
Tobaccointerventions
(N=4)
Chronic Disorders
Other deaths and costsattributable to risk factors,
and costs of risk factormanagement
Total consequencecosts
Researchagenda
Interactive ModelingBuilds Foresight, Experience, and Motivation to Act
Experiential Learning“Wayfinding”
Expert Recommendations