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ACHIEVING A HEALTHY FUTURE FOR OUR CHILDREN, OUR SCHOOLS, OUR HEALTH SYSTEM & OUR STATE Contact: Scott Turner [email protected] 602-513-0028 11/02/2017 A Win-Win Agenda 2 Prevent 1/3 Children Diabetic Adults With Proven Programs & Policies K-12 Investing Health $$ Savings into Schools Notes: Google images: OTC Wholesale. School Book. Slide 3 Better Health More K-12 Funding (or the opposite) Notes: Google images: OTC Wholesale. School Book. Slide Preventive Ed New $300-500M/yr for AZ K-12 4

Immediate Savings *>$33-100M/year 1.1 Million K-12 students in AZ x $30-90/year per child health cost savings + Long-term Savings *$2.5-5B/year 500,000 less adults with diabetes** + x $5-10K/year per adult health cost savings Note: Immediate Savings: see other slides; rangeamount of savings depends on amount invested with fidelity in moderate-to-vigorous activity (MVPA) & other highly-effective evidence-based approaches, e.g., in Empower Youth Health Program (EYHP) alone, or adding Fit Kids & other programs. Immediate Savings must be reinvested to pay for on-going annual K-12 investments & to develop fitness & healthy habits for long-term savings. Long-term Savings: see other slides/references including: Crump, Sundquist, et al, 2016 [1/2 - 2/3 reduced risk of diabetes when fit @age 18] & Zhuo et al, 2014, The Lifetime Cost of Diabetes and Its Implications for Diabetes Prevention [lifetime cost of $100K-300K+ per diabetic, depending on year of on-set; typically $7500/year savings for each year on-set is delayed. ] & Kaiser Family Foundation, 2012: The Role of Medicaid for Adults with Chronic Illnesses: diabetics Medicaid costs approaching $15K/year vs. $5K/year no chronic diseases. **diabetes & other preventable chronic disease savings: from postponed on-set & less severity in adulthood, as well as from many adults never getting diabetes while nonelderly (pre-Medicare), or never getting diabetes at all. ***Reference: DeVol, Ross, & Armen Bedroussian, An Unhealthy America: The Economic Burden of Chronic Disease, Milken Long-term Productivity/Tax Rev.*** >$200M/year >$2B more GDP x 10% state tax revenue AZ Stakeholder Input from: 5 Superintendents/Principals/Arizona School Administrators (ASA) Debbi Burdick, Calvin Baker*, Michael Cowan*, Deb Duvall, Roger Freeman, Chad Gestson, Betsy Hargrove*, Mark Joraanstad, Chris Lineberry, [Paul McDonald], Melissa Sadorf, Jeff Smith, Paul Stanton*, Paul Tighe* AZ School Boards Association (ASBA), AEA, AZ Health & Physical Education (AZHPE), SHAPE America, FTF Carly Braxton, Steve Jeffries, Chris Kotterman*, Paul Kulpinski*, Matt Mixer, Andrew Morrill*, Tim Ogle*, Trish Robinson, Keri Schoeff, Hans van der Mars

Arizona State Board of Education (SBE) (& SBEs A-F School Accountability Ad Hoc Advisory Committee) Catcher Baden, Calvin Baker*, Reg Ballantyne, Tim Carter, Roger Jacks, Michele Kaye*, Janice Mak*, J.D. Rottweiler*, Chuck Schmidt*, Karol Schmidt*, Jared Taylor*, Tom Tyree, Patricia Welborn*; (A-F: April Coleman*, Whitney Chapa*, Michael Henderson*, Mitra Khazai*, Foster Leaf*, Paul Tighe*) Nonprofits/NGOs/Misc. (AforAZ, ABEC, AHA, AzAAP, AZ Chamber, AZ for Recess, AzPHA, CFA, Fit Kids, GS, GPL, Playworks, SALC, SVPAZ), Triadvocates Amanda Burke, Ernie Calderon, Terri Wogan Calderon, Ellis Carter*, Whitney Chapa*, Patrick Contrades, Lattie Coor, Christine Davis, Pearl Chang Esau, Dick Foreman, Sybil Francis, Mike Gardner, [Rebecca Gau], Neil Giuliano, Stuart Goodman, Becky Hill*, Will Humble, Lisa Graham Keegan, John Kelly, Bert McKinnon, Jaime Molera, [Stacey Morley], Dana Wolfe Naimark, Nicole Olmstead, John Pedicone*, Brandy Petrone, Jon Ragan, Anne Stafford, Marissa Theisen, Adrienne Udarbe, Chuck Warshaver, Jim Zaharis Health Care Providers, Plans, Assocs. (AHIP, AzAHP (AHCCCS), AzHAA, Banner, BCBSAZ, HSAA (Alliance), Mercy Care/MMIC/Aetna, Tenet/Abrazo, United HC) Tony Astorga, Reg Ballantyne, Chuck Bassett, Jason Besozo*, Jennifer Carusetta, David Childers, Katrina Cope, Greg Ensell, Peter Fine*, Mark Fisher, Tad Gary, Joe Gaudio, Deb Gullett, Suzanne Hensing, Debbie Hillman, Debbie Johnston, Christi Lundeen, Andy K. Petersen, Karrie Steving, Trisha Stuart, Greg Vigdor Governors Office (including GOYFF) Kirk Adams*, Christina Corieri, Governor Ducey*, Katie Fischer, Debbie Moak, Danny Seiden*, Kristine FireThunder, Dawn Wallace State & County Agencies (ACA, ADE, ADHS, AHCCCS) ADE (AZ Department of Education): School Health/PE, ADHS (AZ Dept. of Health Services): AzHIP Obesity & Cross-Cutting Strategies/School Health Workgroups & BNPA, AHCCCS, AZ Commerce Authority*, Maricopa/Pima*/Pinal*/Gila* County Dept. of Public Health Legislators & Legislative Staff Sylvia Allen, Mark Anderson, Catcher Baden, Nancy Barto, David Bradley, Kate Brophy-McGee, Paul Boyer, Heather Carter, Regina Cobb, Randall Friese, Gail Griffin, Katie Hobbs, Michael Hunter, Josh Kredit*, Jay Lawrence, Debbie Lesko, Emily Mercado, JD Mesnard*, Lynne Pancrazi, Frank Pratt, Jesus Rubalcava, TJ Shope, Matt Simon, Steve Smith, Reed Spangler, Melissa Taylor, Kelly Townsend*, Bob Worsley, Steve Yarbrough*, Kimberly Yee* Foundations/Grantmakers (Arizona Community Foundation/ACF, AGF, AZSTA, BHHS Legacy, Helios, Piper, Rodel, United Way, Vitalyst); Others Jacky Alling, Carlyle Begay, Don Budinger, Shelley Cohn, Robbin Coulon, Kim Covington, Jeff Dial, Jon Ford, Charles Hokanson, Kimberly Kur, Robin Lea-Amos, Laurie Liles, Jayson Matthews, Melanie Mitros, Jackie Norton, Janice Palmer, Sue Pepin, Andy Kramer Petersen, Marilee Dal Pra, Suzanne Pfister, Roy Pringle, Steve Seleznow, Brian Spicker, Penny Allee Taylor, Mary Thomson, Merl Waschler, Glenn Wike, Jerry Wissink, HFAZ Coalition 6 Healthy Future US/Arizona Education, health, public-private, statewide coalition to dramatically improve health in AZ & USA, starting in schools. Healthy Future US is the nonprofit organization leading the Healthy Future Arizona initiative (HFAZ), including the coalition, plan, & implementation, with accountability for delivering health outcome results @ high ROI to sustain funding into schools. Scott Turner, PhD, MA, MBA; President & CEO. Business exec, 30 years; giving back pro bono last 7

years; Boards, Social Venture Partners Arizona and Arizona Business & Education Coalition (ABEC); ADHS AzHIP Obesity & School Workgroups. Terri Wogan Calderon, Board of Directors. ED, Social Venture Partners Arizona. Formerly in Governors Office of Children, Youth & Families. Expect More Arizona Public Engagement Task Force. MCESA Opportunities for Youth Board. Laurie Liles, Board of Directors. ED, Arizona Grantmakers Forum. Former President & CEO and SVP of Public Affairs, Arizona Hospital & Healthcare Association (AzHHA). Arizona Health & Physical Education AZHPE, established 1931, is the Arizona affiliate of SHAPE America (the national Society of Health And Physical Educators). Close to 1000 members, representing ~2600 certified physical & health educators of AZ. Hans van der Mars, PhD. Professor & Program Director, PE Teacher Ed & MPE Programs, ASU; AZHPE Director of Advocacy; >60 papers/book chapters/textbooks; ex-Boards, SHAPE America and Presidents Council on Fitness, Sport & Nutrition Science Slide @11/01/2017 HFAZ Coalition (contd/partial) 7 American Academy of Pediatrics, Arizona Chapter (AzAAP) Committed to improving the health of Arizona children and supporting the pediatric professionals who care for them. Anne Stafford, Executive Director. Formerly ED of Community Health Charities, Arizona Market. Arizona Association of Health Plans (AzAHP) AzAHPs members serve the nearly 2M Arizonans enrolled in the states Medicaid plan, AHCCCS. Deb Gullett, Executive Director. (HFAZ state advisory council.) Former member, AZ House of Representatives, incl. Chair of Health Committee. Former Chief of Staff, Sen. John McCain. Former Special Assistant to President George HW Bush & Director of White House Office of Media Relations. Greg Vigdor

(HFAZ state advisory council) Arizona Hospital & Healthcare Associations (AzHHA) members are devoted to collectively building better healthcare & health for the patients, people and communities of Arizona, with a vision of making Arizona the healthiest state in the nation. Greg Vigdor, President & CEO. Former CEO, Washington Health Foundation (state of WA). Arizona Public Health Association (AzPHA) AzPHAs members include public health professionals & organizations across Arizona. Will Humble, MPH, Executive Director. (HFAZ state advisory council). Former Director, Arizona Dept. of Health Services (ADHS). Mark Anderson (HFAZ state advisory council) Mark served in the Arizona House of Representatives & Senate for 14 years (R Mesa). He sponsored the law banning junk food from elementary and middle schools. Mark also worked as Director of Rules & Procedures for the Arizona Department of Education. Slide HFAZ Coalition (contd/partial) 8 Debra Duvall, EdD (HFAZ state advisory council) Former ED, Arizona School Administrators (ASA). Former Superintendent, Mesa Unified School District (largest school district in Arizona). Arizona Superintendent of the Year, 2007. Former Special Advisor, Governor Jan Brewer. Former administrator & teacher in Arizona, California, Virginia, & North Carolina. Has been active in ABEC, Mesa United Way, GPEC, and Mesa Family YMCA. Melissa Sadorf, Superintendent & Chris Lineberry, Principal, Stanfield ESD (HFAZ state advisory council) Low-income rural school district with no M&O override, yet national leader in increasing physical activity & healthy nutrition & integrating health in standards-based curriculum; first AZ school: USDA Healthier US Schools Challenge Gold w/Distinction Award. Melissa Sadorf, EdD, Superintendent. All Arizona Superintendent of the Year for Small Size Districts; AZ Middle Level Principal of Year; https://vimeo.com/200605985 Chris Lineberry, EdD, Principal. Co-author, Recess Was My Favorite Subject: Where Did It Go?; CoFounder, Core Purpose Consulting;

http://www.raisingarizonakids.com/2017/08/chris-lineberry-recess-advocate-principal/#.WZ5bxPsgFQE.fac ebook Jeffrey Smith, Superintendent, Balsz School District council) (HFAZ state advisory Dr. Smith has served as Superintendent of Balsz SD, a very-low-income high-ELL school district in south Phoenix, since 2008. Jeff was awarded All AZ Superintendent, & has served as President of Arizona School Administrators (ASA). He helped found & is President of Educare AZ. Balsz SD has led in extended school year, school health incl. gardens, & Promise Neighborhoods. Paul McDonald, Futures Education (HFAZ state advisory council) Executive Vice President for Futures, a national consulting firm in special education. Paul has Slide served as HFAZ Coalition (contd/partial) 9 & EYHP Leadership Dirk DeHeer, PhD, NAU Dept. of Health Sciences; Evaluator: Fit Kids of Northern Arizona Associate Professor, Dept. of Health Sciences, NAU. Research & evaluation focused on community-based physical activity & health promotion programs for high-risk populations, e.g., Fit Kids, & integrating them into health care systems. Evaluating Northern Arizona Healthcare (NAH)-funded Fit Kids of Northern Arizona physical activity & healthy habits education programs for ~9,000 students in more than 20 schools in northern AZ. Empower Youth Health Program (EYHP) Highly-effective, evidence-based program, nationally-recognized by CDC & PYFP, that dramatically improves physical education & activity, fitness, school wellness policies & practices, and nutrition education & behavior @$10/student/year at-scale. EYHP state leadership team includes: Jason Gillette, Chief, Office of Tobacco Prevention, Cessation & Secondhand Smoke, ADHS; former School Health Director, ADE (3 years). Co-Chair, Arizona Cancer Coalition. Jen Reeves, MEd. Associate Research Scientist, UofA (18 years): >$200M in grants; Principal Investigator, EYHP; former PE teacher, Avondale, Tucson (20 years); Spanish-speaking; national

SHAPE America Award. Keri Schoeff, Physical Education/Physical Activity Coordinator, ADE (5 years); former PE Teacher, Dysart USD; Glendale Union HSD (14 years). Scott Turner, PhD, MA, MBA; President & CEO, Healthy FutureYouth US; Fitness co-founder, Healthy Future Note: PYFP = Presidential Program. PA=physical activity Key Milestones incl. Plan, Coalition, Programs, A-F, AzHIP, Recess 10 2007; 2010 strategy) Scott Turner started PhD program; founded Edunuity (SEAS Change 2010-13 ST PhD research expands school-based evidence, kicks off planning 2012+ Empower Youth Health (EYHP) & Fit Kids programs started in Tucson (UofA), Flagstaff (FK/NAH) 2014 forming Edunuity full-time pro bono advocacy begins, including networking/coalition-

2015 Edunuity selected EYHP* for scaling: evidence-based, highly effective, replicable, very low cost 2015-16 Expanded advocacy from education to health, political sectors; assembled health ROI evidence 2016 Identified Fit Kids**: role model example of health organization win-win investing in schools 2015-17 Edunuity school-based strategies critical part of ADHS AZ Health Improvement Plan (AzHIP) 2016-17 Notes: StateEdunuity Board= pronounced of Ed agrees to add physical, health & arts education indicators as in Edu-cation with inge-Nuity. SEAS = Scalable; Effective; Affordable; Selfto state A-F formula funding. FK = Fit Kids of Northern Arizona. NAH = Northern Arizona Healthcare. ADHS = AZ Dept. of Health Services. *EYHP increased the % of K-12 students with cardiovascular fitness 4x. **Fit Kids cut the growth of child Changing All 4 Moves the 11 Needle Financi Progra ng ms transforming statewide, & eventually national, health behavior/outcomes/costs together Policy Implemen tation Notes: Healthy Future US works with others to take on any major obstacle in the way of improving Americans health behavior related to physical activity and nutrition, initially focusing on K-12 schools--whether it involves public policy, programs, financing,

implementation, or other areas. There have been a number of initiatives, which have improved certain elements--including healthier food in schools, and programs to increase activity and wellness policies in schools. They have been necessary--but because of other key missing elements, they have not yet been sufficient--to dramatically improve whole population health habits at statewide or national levels. We will partner with others to address whatever aspect necessary--& ultimately sufficient--to make fundamental sustainable behavior change happen. Starting in schools, we will partner to reverse in the foreseeable future the main preventable chronic conditions epidemics caused largely by physical inactivity & unhealthy nutrition--as measured by actual health Example #1: Higher Fitness @$10/Student = Up to 2/3 % Fit Less Diabetes! 12 Notes: Highly-effective/high-ROI program #1: Empower Youth Health Program (EYHP) increased % students with cardio-vascular aerobic fitness 4x, from 17% to 78%; also, >6x increase in % of students with good nutrition: 11% 73% consuming recommended fruit & vegetable servings; % of students at normal weight increased by 12.5% from 48% to 54%. Measured by objective aerobic capacity (PACER), BMI, & muscular strength & endurance metrics, + CDC-validated nutrition questions. Results from very-low-income 79-98% FRL AZ public schools incl. 90% Hispanic, 5% Native-American, 3% White, 2% African-American. By Year 3: 20 schools in EYHP, 16,000 students, Sunnyside USD, Tucson. References: Reeves, 2016: US Department of Education Grant Performance Report (ED 524B): Jennifer Reeves, Associate Research Scientist, UofA, Principal Investigator; fall 2012 - spring 2015. Crump, Sundquist, et al, 2016: These findings suggest that interventions to improve aerobic and muscle fitness levels early in life could help reduce risk for type 2 diabetes mellitus in adulthood. Example #2: Health $ WinWin $K-12 13 $1M/yr by physical activity Child obesity growth rate cut by * $60-90/student/yr) in K-8 (saving Note: Highly-effective/high-ROI program #2. *50% reduction in the incidence of being overweight from what would be expected based upon school district data NAH investment paid back each year, based on Fit Kids of Northern Arizona physical activity program cost of $60-70/student/year. $1M/yr invested by Northern Arizona Healthcare (NAH), since 2012 =~$100/student/yr invested in physical activity

(PA) etc., in 20 elementary/middle schools, 5 districts, >9000 students/year in greater Flagstaff+. Evidence-based evaluation: 2350 children, 4x BMI measurements over first 2 years. Mandatory 1 class/week moderate-to-vigorous physical activity (MVPA) & nutrition ed, led by trained Health Aides. Based on 7.5-10% of students not being obese, who would have otherwise been obese @$600 health cost/obese student/year, NAH is estimated to be saving $45-60/student/year in obesity-related costs alone; ADHD/asthma/depression & other mental health savings associated with moderate-to-vigorous physical activity could add savings of up to $30-50/student/year. References: Child obesity health costs: Buescher et al, 2008; Hampl et al, 2007; Kuhle et al, 2011; see MVPA-related annual child health (If statewide: >$100M/year into K-12 + much lower AZ obesity) What would You Do if Your Child = 1/3 chance of Diabetes ?? 1/ 14 3 MexicanAmericans Americans (all) 1/30 1 2 Notes: 1 out of 3 children are projected to become diabetic as adults. 23% teens, 35% of adults are already pre-diabetic. Approaching 500,000 w/diabetes in AZ now. Much higher-than-average diabetes rates among Mexican-American, Native-American, & lower-income populations. $245B = USA diabetes costs 2012, increased 41% in 5 years, & still growing fast. Annual medical expenditures per nonelderly (ages 18-64) adult enrollee in Medicaid, 2009: No chronic conditions=$4,342/year; CVD (cardiovascular disease) =$9,414/yr; Diabetes=$13,313/year; after out-of-pocket costs; per Kaiser FF. References: Pediatrics, 2012 in USNews, 5/21/2012 (youth prediabetes); Diabetes. org (adults; USA); Boyle et al, 2010 (middle-ground projections); CDC, 2014: Long-term Medicaid: Annual Medical Expenditures per Adult, 2009 15 Chronic Conditions 2-3x Higher

Health Costs $14,000 $12,000 $10,000 $8,000 $6,000 $4,000 $2,000 $- o N ic n ro h C s n o ti i d n o C D V C ( r) a l u sc a -v

o di r ca s e et b ia D Note: Annual medical expenditures per nonelderly (ages 18-64) adult enrollee in Medicaid, 2009: No chronic conditions=$4,342/year; CVD (cardiovascular disease)=$9,414/year; Diabetes=$13,313/year; after out-of-pocket costs. References: Kaiser Family Foundation, 2012: The Role of Medicaid for Adults with Chronic Illnesses / Cardiovascular Diseases: 56,274,369 nonelderly adult Medicaid enrollees, of which 28% with CVD=15.8M individuals; 9% with diabetes=5.1M. AZ AHCCCS Population Highlights, October 2015: 1,818,445 individuals. US Census, Arizona population, 2014 estimate, 6,731,484. Chronic Need Min. 60 Minutes/Day Physical Activity for Child Health Not happening at home (screen time!), cant do at pediatricians office Must do at school 16 Institute Of Medicine, 2012: comprehensive 462 page NAS report based on all medical & research evidence Reference: Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation, Institute of Medicine of National Academy of Sciences (NAS), 2012. The bottom line: this report recommends >=60 minutes daily moderate-to-vigorous physical activity (MVPA) for children to stay healthy. (462 page report analyzed all medical & research evidence to-date.) Physical activity (PA) should be moderate to vigorous for full academic and health benefits: MVPA = for example, after several minutes of MVPA, children are panting, starting to sweat, & having trouble conversing while moving. Adequate physical activity is no longer happening outside Yet We Slashed PE/Health Ed/Recess Time many schools increased ELA/Math time above recommendations, yet this did not improve test scores K-8 PE/HE & Recess Minutes, Recommended* vs. Actual 17 Schools cut

30-40+ minutes/day 80 70 60 50 40 30 20 Recess Health Education Physical Education 10 0 Recommended/ Traditional Actual (est.) Notes/References: Estimated typical reduction in PE, health ed instruction minutes & recess time ~40-50 minutes/day, over the last 25+ years, at many schools. In addition, 45 minutes/day is estimated by Edunuity as the traditional* amount of recess time during a full school day, based on a morning, lunch & afternoon recess. Actual instruction/recess time estimated by Edunuity based on ADE 2010 PE & Recess Survey & recent testimony etc. Total daily instruction time recommended by ADE in standards-based academic subjects (not including recess): Grades 1-3: 345 minutes; Grades 4-8: 335 minutes. Research evidence shows that instruction time reallocation from PE has not improved academic achievement, e.g., Trudeau & Shephard, 2008: Given competent providers, [up to 60 minutes] PA [physical activity] can be added to the school curriculum by taking time from other subjects without risk of hindering student academic achievement. On the other hand, adding time to academic or curricular subjects by taking time from physical education programs does not enhance grades in these subjects and may be detrimental to health. Lees & Hopkins, 2013: systematic review of RCTs: There was no documentation of APA [aerobic physical activity) having any negative impact on childrens cognition and psychosocial health, even in cases where school curriculum time was reassigned from classroom teaching to aerobic physical activity. Also, Dills, Morgan & Time Running Out from K to 12 18

a life sentence for diseases & costs K-12 begins with the vast majority of low-income students have unhealthy habits & health neglect at school are unfit + without effective physical & health education, they do not change their habits = vast majority of lower-income students remain unhealthy as adults Notes: It is very difficult & expensive to change adults health behavior, and even changed adult behavior often reverts. Initial measurements indicate that >80% of lower-income AZ students are unfit. National longitudinal data indicate that > 2/3 of lowerincome students will not change their health behavior, and will remain unfit & increasingly unhealthy as adults--unless their habits change K-8. Low-income student fitness data based on baseline Empower Youth Health Program (EYHP) FitnessGram results from representative sample of approx. 16,000 students in 20 lower-income schools in AZ, 2012-2015, indicated 83% with cardiovascular aerobic unfitness (i.e., not in aerobic Healthy Fitness Zone). Adult unfitness estimates are based on statistical 80+% persistence of overweight/obesity from adolescence into adulthood. References: Google images: 123RF.com; http:// www.clker.com/cliparts/y/R/v/V/H/k/red-syringe-hi.png; wupr.org. Reeves, 2016: US Department of Education Grant Performance Report (ED 524B): Jennifer Reeves, UofA, Principal Investigator; fall 2012 - spring 2015: AZ student fitness EYHP baseline A Peek at AZ State Spending: 2050 19 need to reverse trend of less educating, more medicatingby increasing healthy behavior 60% 53% 50% Education Health 48%

40% 37% 29% 30% 19% 20% 15% 10% 0% 2003 2013 2050 Notes/References: % of state budget. Azleg.gov: AZ Joint Legislative Budget Committee 2013: General fund operating budget spending. Fiscal years 1979-2014. JBLC, 2014: Other appropriated fund operating budget spending: Fiscal years 1989-2014. 2050: very rough Edunuity estimates. (Health: AHCCCS + ADHS + Veterans Services) (FYI: USA total national education public + private spending as % of GDP, per OECD: education @7% & health @18% of GDP.) Google images: School Book, clipartfest. Preliminary Early Detection: Preventing The Coming 20 Zero-Sum Budget War between Health & Education For the first time since I can remember, advocates for public K-12 education openly opposed higher education funding.

- Eileen Klein, ABOR Reference: Arizona Board of Regents op-ed in Arizona Capitol Times, June 14, 2017. Slide @10/16/2016 http://azcapitoltimes.com/news/2017/06/14/dont-fall-for-the-false-choice-between-k-12-and-higher-education/ How Can Health System Survive Pressure? 21 HFAZ improves whole-population health outcomes & lowers per-capita costs, by increasing physical activity & improving nutrition habits, starting K-12 Per-Person Max.$, Value-based, Lower Reimbursements, ACOs, etc. Now Margin$, Quality Healthier People/Outcomes by addressing Root Causes Helps Relieve Pressure on Health Costs & Quality Now Diabetes: >prevalence & >#years; Obesity: earlier & >severe; etc. Root Causes: inactivity, nutrition Potential Google images: clipartfest, eBay. Slide @10/16/2017 Our Leaders (i.e., Your) Choice 22 Current Trajectory If

Change Now Google images: Clockwise from top left: Google images: reuters.com; videoblocks.com; New Jax Gym; EYHP/Sunnyside USD, Tucson. [email protected]/24/2017 Hold Us Accountable for Improving Health with Education 23 Notes: The health sector invests in and outsources the in-school responsibility to Healthy Future Arizona/US. We want & expect to be held accountable for statewide physical activity & nutrition and related health outcomes & cost savings. This starts among K-12 students, by improving & expanding recess and physical & nutrition/health education including achieving ~60 minutes of moderate-to-vigorous physical activity (MVPA) daily, through schools, and thereby dramatically improving child fitness and reducing child obesity & teen prediabetes, etc. This also applies longer-term to HFAZ/HFUS work with young parents & ages 0-5 and adults generally, in starting early and continuing with lifelong healthy habits, and helping substantially reduce adult diabesity & preventable heart disease below current trends, + increasing $$ for K-12 schools from health cost savings, + from higher tax revenue due to higher productivity & profits. The Healthy Future Arizona initiative & its many partners can be early innovator-leaders in helping to reverse the preventable AZ & US chronic conditions epidemic. Google images: Shuttercock 414502585 [email protected]/09/2017 How We Get There 24 Notes: (clockwise from upper left): PE; classroom activity break; peer-led physical activity; PE teacher & student; parent involvement. References: top photos from mrvhpwb.weebly.com & georgiahealthnews.com from Google images; bottom from EYH AZ/Sunnyside USD. Health/K-12 Agenda 25 Unsustainable health crisis long-term education funding & business/economic (details) crises 1/3 children diabetic adults; declining funds for ed, tax cuts; pressure on profits, productivity; etc. 1st stage solution K-12 physical & health preventive education Its good for student achievement & engagement And a rapid payback & great ROI for health organizations How get there? Nonprofit leadership: Healthy Future Arizona initiative: coalition, policy co-advocacy, org. capacity K-12: Help schools increase recess/physical activity, implement PE/health ed A-F accountability Including scaling Empower Youth Health Program (EYHP)

Partners co-invest & scale-up: Private-public pay-for-performance: health orgs, govt.; via HFAZ Long-term goals Grow to $300-500M+/year in new $$ to K-12 from public/private health cost savings, higher tax rev. - Voluntarily co-investing 0.X% of chronic costs in evidence-based K-12 programs proven to improve health & lower diabetes/other risks ROI=return on investment; A-F=A-F School Accountability (adding health ed indicators to A-F grading formula for each public ReverseNote: child obesity, diabetes, chronic epidemicformula trends in PE, AZ, USA school). EYHP=Empower Youth Health Program; HFAZ=Healthy Future Arizona. Slide @11/02/2017 Helping Schools Healthier Students 26 Overwhelming Evidence: Activity Academic Achievement Physical education & activity helps not hurts academic achievement* (State ed leadership recognizes, e.g., ASA, ASBA invited us to present evidence-based research at their conferences) School-Friendly Policies & Implementation Reasonable policy goals, e.g., A-F indicators as positive incentives, equitable school recess reqd (2/day) Providing training, support & funding for evidence-based programs with good school track records (e.g., assistance in introducing A-F fitness assessments, how to effectively allocate seat-time back to PE & recess, etc.) A Little Win-Win School Funding goes a Long Way

Notes: School Administrators association. ASBA=Arizona Boards Association. PA=physical activity. A-F=Arizonas A-F school accountability ASA=Arizona Educators very eager for new money intoSchool schools grading formula; State Board of Education agreed in May 2017 to add physical & health education indicators to the A-F formula. References: *Trudeau & Shephard, 2008: Given competent providers, [up to 60immediately minutes] PA can be& added to the school by taking time from other subjects without risk of Health orgs benefit financially long-term bycurriculum investing in more active, healthier hindering student academic achievement. On the other hand, adding time to academic or curricular subjects by taking time from physical education programs students** does not enhance grades in these subjects and may be detrimental to health. Lees & Hopkins, 2013: systematic review of RCTs: There was no documentation of APA [aerobic physical activity) having any negative impact on childrens cognition and psychosocial health, even in cases where school curriculum time was

reassigned from classroom teaching to aerobic physical activity. For evidence on how MVPA boosts academic achievement: Ahamed et al, 2007: Action School! BC; Donnelly et al, 2009: PAAC; Fedewa et al., 2011; Hillman, Castelli et al, 2007- ; Hollar et al, 2010; Kamijo et al, 2011, 2012; Sallis et al, 1999; Shephard, 1996. **High levels of MVPA (moderate-to-vigorous physical activity) reduce health costs by min. est. $30-50/child/year. Evidence-based Empower Youth Health Program (EYHP) plans for, trains, & assesses to ensure high levels of MVPA @scale cost of $10/student/year = <1year payback. See other slides, edunuity.org for detailed references. Google images: School Book. Slide @10/09/2017 Why Educators Support? Physical activity (PA) improves academics 27 Reallocating time from PE does not improve achievement Trudeau & Shephard, 2008; Wilkins et al, 2003 Keeping/increasing* time for PE/PA/recess does not harm achievement Dills et al, 2011; Kwak et al, 2009; Lees & Hopkins, 2013; Rasmussen & Laumann, 2013; RWJF, 2009; Shephard, 1996; Singh et al, 2012; Trost & v.d. Mars, 2010; Trudeau (& Shephard), 2010; USDHHS, 2010 Regular Physical Activity (PA) throughout day helps academic outcomes Ahamed et al, 2007: Action School! BC; Donnelly et al, 2009: PAAC; Sallis et al, 1999 Moderate-to-vigorous PA (MVPA) improves cognitive functioning & academic performance Fedewa et al, 2011; Hillman et al, 2007- ; Hollar et al, 2010; Kamijo et al, 2011, 2012; Shephard, 1996 PE, PA, Sports increase engagement & reduce drop-outs Desy et al, 2013; Rumberger, 2011 Notes: e.g., *Trudeau & Shephard, 2008: Given competent providers, [up to 60 minutes] PA can be added to the school curriculum by taking time from other subjects without risk of hindering student academic achievement. On the other hand, adding time to academic or curricular subjects by taking time from physical education programs does not enhance grades in these subjects and may be detrimental to health. Lees & Hopkins, 2013: systematic review of RCTs: There was no documentation of APA [aerobic physical activity) having any negative impact on childrens cognition and psychosocial health, even in cases where

school curriculum time was reassigned from classroom teaching to aerobic physical activity. Also, Dills, Morgan & Rotthoff, 2011: changing time spent in recess and PE is unlikely to affect student test scores. See other slides, edunuity.org for detailed references. Slide @08/24/2017 How So Effective @$10/Student/Year?: P-T-A: Plan + Train + Assess 28 Optimizing existing school staff with students, with available PE & recess time*, without added personnel* Plan: Develop Policy/Plan for School-based Health Promotion - Mutually agreed wellness policy plan by staff to improve health: incl. administration, food services, nurse, classroom & PE teachers - Prioritize plan with self-assessment of all school-based health-related elements; complete CDCs School Health Index (SHI) to identify & reduce health risk behaviors, including addressing gaps & weaknesses Develop Community Partnerships including School Health Advisory Councils (SHAC) - Plan includes before, during, and after school, as well as on weekends, holidays, and vacations (e.g., parents, school food service vendor, neighborhood associations, community-based organizations (CBO), park and recreation, YMCAs, after-school programs, Walking School Bus Programs, local businesses, and more), promoting youth & community physical activity & healthy nutrition etc.) - SHAC to help improve instructional programs, policies, & support services for the 8 components of a coordinated school health/ WSCC model; meet min. every other month, ensure wellness implementation for students, staff, & community Train: High-quality Standards-based Instruction to optimize Physical/Nutrition/Health Education - Professional development of K-12 teachers, other staff + on-going field support; including training to reach 60 minutes/day of moderate-to-vigorous physical activity (MVPA during classroom brain breaks, recess, PE, pre/post-school) Develop Student Leadership to assist with Physical Activity etc. - Student volunteer peer-led physical & wellness activities by trained older students--before, during, after school incl. lunch & recess Assess: Regular Assessment of Student Health Behavior FitnessGram (Presidential Fitnessstudents. Program/PYFP), CDC-validated questions, portfolio/health

Notes/References:-EYHP $10/child/year cost at-scaleYouth of 50K-100K+ WSCC: Whole School Whole nutrition Communitysurvey Whole Child model. student *In addition, for schools withselflittle or no PE help at present: Schools with inadequate numbers of certified PE teachers &/or low PE & recess minutes can usually fund PE/recess expansion, by re-allocating their existing instructional time & funds back to PE & recess, without harming academic performance (Kwak et al., 2009; Lees & Hopkins, 2013; Rasmussen & Laumann, 2013; RWJF, CV; updated SHI, & other validated assessments for reliable, balanced, comprehensive review & continuous improvement 2009; Shephard, 1996; Singh et al., 2012; Trost & van der Mars, 2010; Trudeau & Shephard, 2010; et al); in fact, schools can increase academic success with rigorous PE/MVPA (Ahamed et al, 2007: Action School! BC; Castelli et al, 2007-12; Donnelly et al, 2009: PAAC; Hollar et al, 2010; Kamijo et al, 2011, 2012). Slide @10/13/2017 Min. 60 Minutes/Day Physical Activity for Child Health Schools can reach minimum MVPA needed by kids but need enough recess & PE minutes 29 Physical Activity (PA) Mins./day Mins./day offered activity Classroom activity brain breaks* during school (3/day x 7 mins. ea.) 21 16 Physical Education class (60 minutes/ week PE) 12 8

Recess #1 (one 15 minute/day) 15 12 Recess #2 (or PE #2: addl 60 mins./week PE, totaling 120 mins/week PE) Before/after-school program/morning/afternoon activity 12-15 12 15 12 Total Physical Activity 75-78 60 Notes: Institute of Medicine of National Academy of Sciences recommends >=60 minutes daily moderate-to-vigorous physical activity (MVPA) for children to stay healthy (Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation, 462 page report published in 2012 analyzed all medical & research evidence to-date). Physical activity (PA) should be moderate to vigorous for full academic and health benefits: MVPA = for example, after several minutes of MVPA, children are panting, starting to sweat, & having trouble conversing while moving. Adequate physical activity is no longer happening outside school; MVPA must occur at school or will not happen & childrens health will be at risk. References: Adapted from LMAS PAL training, 2015. *Next-to-desk classroom exercise break sample, GoNoodle example: https://www.youtube.com/watch?v=TbzFq7gH2Zw&list=PLX0p6gjOu3DWJIPWagUwbFS-Bgm8AQbXj&index=3 Slide @10/30/2017 MVPA: Health Payback <1 Year Investment: @$10/child/year (cost at-scale: EYHP) The Good News: rapid ROI for health sector from investment in moderate-to-vigorous physical activity 30 The Bad News: rapid payback, because many children are much sicker at younger ages than past Health Condition Treatment Prevalence in Reduced

Grade Average Cost (per treated student/year) (% students with condition) Incidenc e (% drop in students with condition) Levels with Most Reduced Costs Reduced Health Cost per Student/Year (all students) Asthma, ADHD, Roughly Obesity, $400spread 5-24% 14-33% Depression/ Other 1500 across K-12 Behavioral Health

Notes: High levels of MVPA (moderate-to-vigorous physical activity) reduce health costs by est. $30-50/child/year. Evidence-based Empower Youth Health Program (EYHP) $30-50 preventive ed-vaccination plans for, trains, and assesses to ensure high levels of MVPA @scale cost of $10/student/year = <1year payback. EYHP costs per student are higher at smaller scales: ~$15-30/student/year. It often only takes ~1-2 children per class becoming healthier to pay back EYHP investment within 1 year. Payback/ROI formula: Condition Cost x Condition Prevalence x Reduced Incidence of Condition = Treatment Cost Reduction per Average Student (across all students). K-12: Kindergarten through12th grade. ADHD: attention deficit/hyperactivity disorder. BH: behavioral/mental health. MS: middle school. HS: high school. MVPA is key to improving many of these conditions: MVPA=e.g., after several minutes of MVPA, children are panting, starting to sweat, & having trouble conversing while moving. Target total of 60 minutes/day of MVPA from before, during and after school activities. Utilized peer-reviewed journal articles, when available, and also population data from government statistics/reports. ADHD & depression can improve particularly quickly, though BMI has been improving within 1-2 years in both EYH and Fit Kids. Reduced incidence of obesity estimated based on reduced obesity compared to what would have been expected in that sociodemographic population at those ages. Longer-term ROI = >100x, as health condition on-set is delayed or averted & the severity in middle age & later is postponed and reduced. Rapid payback at all grade levels by particularly reducing: Elementary: ADHD, asthma; MS: ADHD, misc.; HS: obesity, depression/BH. ADHD & depression costs vary dramatically based on type of treatment, and can be much higher. Also, EYH payback/ROI is estimated based on changes in the 78% of students now in the Healthy Fitness Zone (HFZ); however, the 22% non-HFZ obesity rates did not likely improve as much. There is some possible double-counting of teen obesity/depression/BH savings, since obesity costs can include some depression/BH costs. Class size assumption: 30-35 students. References include: Domino et al, 2009; Fullerton et al, 2012; Hampl et al, 2007; Katz et al, 2010; Kuhle et al, 2011; MACPAC, 2015; Pelham et al, 2007; Schuch et al, 2016; Skinner et al, 2016; Thapar et al, 2012; Wang et al, 2005. Also, per Yamamoto, 2013: significant costs (& savings) can start early in life: Chronic conditions in the young (under age 30) take a higher relative toll on that population than they do for the older population. For commercial members under 30 identified with cancer or circulatory conditionstheir costs were much higher on average. More Notes & References: see Payback Details slide. Slide @10/06/2017. Preventive Power of Physical Activity Doses evidence-based rapid payback during childhood from MVPA 31 Health Condition Treatment Cost of Students Prevalence in Students Reduced Incidence among Students Grade Levels w/ Most Reduced Costs

Asthma $400 (Wang et al, 2005) 6% (Wang et al, 2005) 14% (Katz, Cushman et al, 2010) Elementary, MS ADHD $1,000-$1,500 (CDC, 2016; Fullerton et al, 2012; Pelham et al, 2007) 7-9% (Wolraich et al (CDC), 2012/2014; MACPAC, 2015) 33% (Katz, Cushman et al, 2010) Elementary, [MS] Obesity $600 (Buescher et al, 2008; Hampl et al, 2007; Kuhle et al, 2011) 12-24% (DeHeer, 2014; Reeves, 2016; YRBS AZ, 2013) 10-20% (DeHeer, 2014; Reeves, 2016; Skinner et al, 2016; Edunuity est.) [MS], HS $700 (Domino et al, 2009)

3-5% (MACPAC, 2015; Thapar et al, 2012) 26-33% (Shuch et al, 2016) [MS], HS Depression/BH [email protected]/13/2017 Notes: MVPA = moderate-to-vigorous physical activity. ADHD: attention deficit/hyperactivity disorder. BH: behavioral/mental health. [MS]: moderate cost reduction among middle school students. HS: high school. More Notes & References: see other Payback Details slides. References: Buescher, Whitmire, Plescia, 2008: Relationship Between Body Mass Index & Medical Care Expenditures for North Carolina Adolescents Enrolled in Medicaid in 2004. DeHeer, 2014: Fit Kids at School: Executive Report. Domino, Burns, Mario, et al, 2009: Service Use and Costs of Care for Depressed Adolescents: Who Uses and Who Pays? Fullerton, Epstein, Frank, Normand, Fu, McGuire, 2012: Medication Use and Spending Trends Among Children With ADHD in Floridas Medicaid Program, 1996-2005 Hampl, Carroll, Simon, Sharma, 2007: Resource Utilization and Expenditures for Overweight and Obese Children. Katz, Cushman, Reynolds, et al, 2010: Putting Physical Activity Where It Fits in the School Day: Preliminary Results of the ABC (Activity Bursts in the Classroom) for Fitness Program. Kuhle, Kirk, Ohinmaa, et al, 2011: Use and cost of health service among overweight and obese Canadian children. MACPAC, 2015: Behavioral Health in the Medicaid ProgramPeople, Use, and Expenditures. Pelham, Foster, Robb, 2007: The Economic Impact of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Reeves, 2016: US Department of Education Grant Performance Report (ED 524B) (report on early Empower Youth Health & related elements). Schuch, Vancampfort, Richards, et al, 2016: Exercise as a treatment for depression: A meta-analysis adjusting for publication bias. Skinner, Perrin, Skelton, 2016: Prevalence of Obesity and Severe Obesity in US Children, 1999-2014. Thapar, Collishaw, Pine, Thapar, 2012: Depression in Adolescence. Wang, Zhong, Wheeler, 2005: Direct & Indirect Costs of Asthma in School-age Children. Postponing Diabetes Onset Dramatically Reduces Costs Undiscounted lifetime incremental spending e.g., 32 less teens pre-diabetic; adults remaining pre-diabetic instead of becoming diabetic; adults becoming diabetic when elderly, not in middle-age; >100x lifetime payback/ROI for Empower Youth Health Program evidence-based preventive education $300,000 $250,000

Child inactivity/ obesity $200,000 Active children K-12 $150,000 $100,000 + Follow-on Policies with Adults $50,000 $- 30(est) Onset Age 35(est) 40 45(est) 50 55(est) 60 65 Notes: Lifetime cost varies enormously by age of diabetes onset. Typically $7500/year savings for each year on-set is delayed. Data includes both men and women. References: Zhuo et al, 2014, The Lifetime Cost of Diabetes and Its Implications for Diabetes Prevention: Table 2Life-years lost to diabetes and lifetime incremental medical spending attributed to diabetes (sources: linked data from the 20052008 National Health Interview Survey and the 20062009 Medical Expenditure Panel Survey and from published national vital statistics). Earlier and interval costs estimated by Edunuity: (est). Also: Reference: Crump, Sundquist, et al, 2016: Physical fitness among Swedish military conscripts and long-term risk for type 2 diabetes mellitus: These findings suggest that interventions to improve aerobic and muscle fitness levels

early in life could help reduce risk for type 2 diabetes mellitus in adulthood. [1/2 to 2/3 reduction in risk] Empower Youth Health (EYH) is an evidence-based program that improves aerobic/cardiovascular fitness and muscular strength, as verified by FitnessGram (Reeves, 2016). The level of fitness achieved by consistent moderate-tovigorous physical activity such as through Empower Youth Health and Fit Kids Programs could help reduce diabetes risk by to 2/3. Slide @10/09/2017. Strategies that Worked vs. Smoking Yet We Arent Doing Now to Promote Physical Activity & Healthy Nutrition [Report Card graded (A-F): if & how well we are re-using strategies that helped reduce smoking] 33 - Broad & profound awareness of seriousness of problem (D) - Strong physical/health-related education programs in schools (D) - Hard-hitting, pervasive public information campaigns (F) - Very strong government health warnings (D) - Large insurance premium discounts for healthy behavior (D) - Cost-effective behavior cessation/adoption products/programs (D) - Government restrictions on unhealthy product marketing/promotion (F) - Dramatically increased unhealthy product sales taxes* (F) Notes: Effective steps we can realistically start taking NOW are bold and/or underlined. Anti-smoking track record: 42% US adults smoked in 1965 17% US adults now. Listing of key strategies that helped to dramatically reduce smoking among Americans; followed by an (A-F) grade, indicating Edunuitys rating of how well AZ & the USA are using the particular strategy to prevent other unhealthy behaviors--particularly lack of physical activity and unhealthy nutrition--and thereby prevent or reduce chronic health conditions. Ranked by Edunuity in rough order of what is realistically implementable & politically achievable starting in 2017. Population-wide K-12 preventive education builds a foundation of support for other policies, including by raising consciousness of students & their parents & communities, including the general taxpaying & voting public, about the impact of health-related behavior. *Taxes could be imposed in revenue-neutral/no-net-new-taxes manner; & only after public & political support grows, due to greater recognition of the de facto government subsidies which are being provided for unhealthy behavior, e.g., by taxing unhealthy products & services that cause chronic conditions such as obesity, diabetes & heart disease, at the same rate as healthy products & services. In other words, the healthy-eating public is paying the costs of other peoples unhealthy nutrition through payroll, income, sales & other taxes for Medicaid, Medicare, A(H)CA/(BCRA), as well as through higher health insurance premiums & deductibles due to other peoples chronic conditions, etc. Also, healthier behavior increases productivity, boosts profits & income, & raises GDP, which increases tax revenue without tax increases. References: Google images alexiamuscat1.blospot.com; CDC, 2015 (NHIS, 1965; YRBSS 2013 data, AZ: HS student cigarette use); Ending the Tobacco Problem, Why Schools Indispensable for Health ? 34 biggest 21st century health issues from unhealthy behavior, not microbes preventive ed for healthy behavior Captive long-term audience: 180 days/year x 13 years - vs. 1 hour?/year with pediatrician

Developmentally ideal stages for learning: ages 5-17 Very low cost per person: Many effective, evidence-based approaches - PE, HE, recess, classroom, before/lunch/after-school; EYHP, Fit Kids, other programs, etc. Can influence parents & communities through children/schools Lays foundation for personal ownership of health as adults - Preparing each person K-12 to adopt future clinical & public health advice Nothing else comes close in affordable total population impact [Alternatives ??: Clinical settings not turning the tide & Improving adults behavior is very expensive & much less effective.] EYHP=Empower Youth Health Program. Slide @10/16/2017 - main school/staff fixed costs covered already by public K-12 funding What Next? 35 Google images: Proverbial frog in increasingly hot pot contemplating getting out, from RGB Blog. Slide @08/07/2017 HFAZ Intermediary Role Ensures Outcomes, ROI - Funders invest via HFAZ, not directly in schools or through public agencies - HFAZ implements & takes responsibility for health outcomes, reduced costs - Pay-for-performance/success: without results, the monies stop 36

FUNDERS INVESTMENT$ Foundations, Others Health Care Providers & Plans Legislature, Counties COLLABORATORS Govr Office, ADE, ADHS, AHCCCS Health & Education Associations & Nonprofits State & Regional Communit y Groups Medicaid/ CMS, CDC Business/ Leadership Orgs., Foundations, Others IMPLEMENTERS HEALTH OUTCOMES School Districts:

School Boards, Superintendents, Staff Schools: Principals, PE/HE & Classroom teachers, Food services directors, School nurses, Other school personnel, Parents, Community representatives Local Nonprofits , Others Healthy Future Arizona Initiative Overview 37 Follow-on Priorities too Vision Mission Values Health Tagline (draft) ROI-based Governance Funding Healthy Future Arizona (HFAZ) initiative [affiliated with Healthy Future US (501(c)(3))] Via fiscal sponsorship under ACF/Vitalyst [501(c)(3)pending] Scaling Empower Youth Health Program in AZ (& TBD) to trajectory of >20% reduction in chronic diseases & costs, using school-based approaches (PE/PA, nutrition ed, EYHP, etc.) Co-develop path to sustained statewide & USA ~50% reduction in chronic diseases & costs incl. outside of school settings TBD; dramatically improve other aspects of healthy behavior, Arizona becoming the healthiest state (& USA the healthiest country) Empowering individuals to substantially improve their health, in the broadest sense,

using school-based & other approaches to develop lifelong healthy habits High-integrity/transparency, accountable, move-the-needle-systemic, practical + scalable, school-friendly, ROI/hard-evidence-based, pay-for-performance/success, sustainably selffunding, sense of urgency/emergency, in partnership, & in local/community/social context Whole-person: physical, cognitive, social-emotional, mental, financial, civic, creative, etc. Healthy habits for life Highly results-oriented, hard-data-evidence-based, objectively quantified costs & outcomes, accountable & pay-for-performance/success; measuring & delivering short- & long-term financial, public + private, socioeconomic & quality-of-life returns Permanent statewide citizens/community oversight board/commission: shared governance; social, econ., political, geographic cross-section, incl. key funders e.g. health orgs, legislators Year 1-2 seed funding by leading Co-Founder-Partners Notes: PA=physical activity. Working title Org. Status First Priority Next Steps: HFAZ Initiative 38 Short-term Policy Advocacy, Implementation: Add PE/HE indicators (in progress): A-F School Grading Formula; School Report Card: ADE+ Min. 2/day recess K-5, whole-child resolution, recess/A-F/EYHP implementation appropriation EYHP Scaling: Empower Youth Health Program to 90+ low-income schools HFAZ Capacity Building: $$ for Healthy Future AZ/US launch incl. initial staff Foundations/Others: Help expand coalition, capacity$, program scaling $$ Health Sector Funding: Early champions with prevention seed $$ for EYHP scaling, etc. Measurable Pay-for-Performance Goals: First steps: $4-5M/year EYHP scaling to $11M/yr all-AZ EYHP ASAP, with quantified outcomes/ROI - Save health sector min. $30-50/student/year in child costs, $billions/year longer-term, compared to current trajectory Longer-term: AZ first state to clearly reverse child obesity & diabetes trends Longer-term: $300M+/yr new $$ K-12 + $200M+/yr new state tax revenues: K-12, tax cuts, TBD - From health cost savings & productivity/profit increases in GDP & tax rev. - Govt/public & private sources co-investing, with high ROI - Voluntarily co-investing 0.X% of chronic costs in evidence-based K-12 programs proven to improve health & lower diabetes/other risks Public Policy Agenda (2017-18+

draft) 39 Policy A-F School Grading K-5 Recess Bill Whole Child Resolution Year Legislature 201718+ 2017-18 2018 XXX XXX Govr Off. SBE ADE X XXX X Researching & negotiating first version w/State Board of Ed, then continuously improve PE, HealthEd indicators w/SBE. XX X X

Min. 2 recesses/full-day. May not withhold recess as punishment etc. Local control/flexibility in implementing. X X Start communicating the value of whole-child ed/health in broadest sense: cognitive, physical, mental, socialemotional, civic, creative, financial, social determinants, community, etc. X X [Only do in 2018 if key state political leadership supports.] To help expand Empower Youth Health Program, & to help support school-friendly implementation of recess bill & adding PE/HE to A-F formula (with funds from AZ health sector TBD). XXX Foundations? ADE needs funds to launch system to inform parents in choosing schools. More detailed data would be useful to support policy agendas, & help gain govt. & public support. X Appropriation: Expand EYH Program; Support: Recess Bill, PE/HE/Arts in A-F 2018?19+ XX

XXX School Report Card 2018-19 ? ? Medicaid Waiver Notes 2018?19 XX XXX X X AHCCCS/ Other XXX Comments [When Governors Office/AHCCCS supports.] Federal, state funds to expand EYHP & other evidence-based school programs to save substantial AHCCCS/health costs. Develop evidence base for large-scale long-term sustainable health sector investment for prevention through schools, funded by improved health outcomes & lower costs. # Xs = estimated importance of that group to approve law/policy. *TBD [Researching & getting feedback on this.]* Preliminary discussion draft slide @11/02/2017

Additional Details/Background Slides 40 Notes: (clockwise from upper left): PE; classroom activity break; peer-led physical activity; PE teacher & student; parent involvement. References: top photos from mrvhpwb.weebly.com & georgiahealthnews.com from Google images; bottom from EYH AZ/Sunnyside USD. Students Stay Engaged in School via Favorite Subjects 41 My daughter hated school when her recess was withheld. Rep. Kelly Townsend, R District 16 Recess was my favorite subject. Rep. Don Shooter, R District 13 References: Paraphrases from House Education Committee hearing, 01/30/2017: http://azleg.granicus.com/MediaPlayer.php?clip_id=18514 Desy, Paterson, & Brockman, 2013: Gender Differences in Science-related Attitudes and Interests Among Middle School and High School Students. See other slides, edunuity.org for detailed references. Google images: istockphoto.com/Getty Images; azsbe.az.gov. Slide @08/13/2017 ADE-Recommended Instructional Time--Ignored Physical & Health Education, Visual Arts & Music Education should total close to 20% of K-8 instruction time, but often <1/2 of that 42 RECOMMENDED MINUTES OF INSTRUCTION FOR ELEMENTARY SCHOOLS Upper Elementary Primary Grades (1-3) (4-6, including 7 & 8 if self contained) Daily Weekly Daily Weekly Developmental Reading Language Arts 90 Min.

60 min. 450 min. 300 min. 60 min. 60 min. 300 min. 300 min. Mathematics Social Studies 60 min. 30 min. 300 min. 150 min. 60 min. 40 min. 300 min. 200 min. 30 min. *30 min. 150 min. 120 min. 40 min. *30 min. 200 min. 120 min. **15 min. **15 min.

60 min. 60 min. **15 min. **15 min. 60 min. 60 min. **15 min. 345 min. 60 min. 1650 min. 15 min. 335 min. 60 min. 1600 min. Science Physical Education Art Music Health Total *It is recommended that this be scheduled and taught at least 120 minutes per week. **It is recommended that this be scheduled and taught at least 60 minutes per week. It is assumed the normal six hour day will provide for 360 minutes of instructional activities in which children are under the guidance and direction of teachers in the teaching process. The above recommendations provide 15 minutes for primary grades and 25 minutes for upper elementary grades that the teacher can schedule additional activities that are in the best interest of the youngsters. The school week should consist of 1800 minutes of instruction at both the primary and upper elementary grade levels. This allows approximately 150-200 minutes of instruction time per week to be used at the discretion of the teacher. It should be noted that in both the daily and weekly schedule that reading and language arts activities should be incorporated into other instructional areas, and rich content should be incorporated into reading and language arts.

References: ADE Sample Recommended Instructional Time: The Arizona Department of Education gratefully acknowledges the work of the Missouri Department of Education in providing a sample of recommended elementary school instructional minutes. Slide @07/18/2017 Over-Dosing on Seat-Time slashing PE & recess time has harmed students & did not improve test scores Total change, 1992*-2015/2050 43 1000% 800% 600% 400% 200% 0% -200% Sitting is the new smoking. -59% 6.69 172% - Mayo Clinic & other studies 274% 2050 2015 Notes/References: Research evidence shows that instruction time reallocation from physical education has not improved academic achievement e.g., Trudeau & Shephard, 2008: Given competent providers, [up to 60 minutes] PA can be added to the school curriculum by taking time from other subjects without risk of hindering student academic achievement. On the other hand, adding time to academic or curricular subjects by taking time from physical education programs does not enhance grades in these subjects and may be detrimental to health. Lees & Hopkins, 2013: systematic review of RCTs: There was no documentation of APA [aerobic physical activity) having any negative impact on childrens cognition and psychosocial health, even in cases where school curriculum time was reassigned from classroom teaching to aerobic physical activity. Dills, Morgan & Rotthoff, 2011: changing time spent in recess and PE is unlikely to affect student test scores. See other slides, edunuity.org for detailed references. NAEP 2017 The Condition of Education, US reading and math scale scores, 1992 2015: average student achievement increased only 3.6%, but research shows that this increase was not due to reductions in PE & recess time. *Estimated typical reduction in PE, health ed instruction minutes & recess time ~40

minutes/day, last 25+ years, at many schools. Using ADE Recommended Instruction Minutes (=assumed baseline) for PE & health ed, ADE 2010 PE & Recess Survey, and Edunuity estimates for recess time based on traditional recess breaks. Child obesity & adult diabetes: historical data1992-2015, projected 2050 diabetessee other slides for details. Dr. James Levine, Mayo Clinic, 2014-17. Slide @08/25/2017 Serious Warning Signs an undeclared 20+ year public health emergency 44 $3.2 trillion/year USA health costs $10,000/person Unaffordable/unsustainable: median household income = $22,200/person US costs 2-3x other major developed countries, yet worse health 50+% of US adults = chronic conditions Chronic conditions = 86% US health costs, mainly preventable US adults: 36+% obese, 11+% heart disease/25+% hypertension, 14+% diabetic/35+% pre-diab. 4-5% teens severely obese (>100 lbs.); 23% teens pre-diabetic Latinos, Native-Americans, African-Americans, lower-income: much higher prevalence rates, mortality AZ approaching USA levels AZ: 20% ave. (20-30% lower-income) child obesity/25-30+% adult obesity; ~83% lower-income kids unfit 1/3 of adults diabetic by 2050 (@3x healthy person cost) Health costs: serious social, business/economic & philanthropic Notes/References: Google images; NHE, 2015: US health costs; US Census, 2016: median HH income: $57,600 @2.6 people; OECD Health Indicators, 2015; JAMA, 2014; risks CDC, 2015: http://www.cdc.gov/chronicdisease/: treating people with chronic diseases accounts for 86% of our nations health care costsHalf of all American adults have at least one chronic condition, and almost one of three have multiple chronic conditions.; Mensah G., May 23, 2006: Global and Domestic Health Priorities: Spotlight on Chronic Disease, National Business Group on Health webinar: 80% of heart disease & stroke & type-2 diabetes and 40% of cancer is preventable; NHIS, 2014: diagnosed levelstrue levels higher+; also see ADA & AHA, 2011-15; Pediatrics, 2012 in US News, 5/21/2012 (youth prediabetes); Skinner et al, 2016: Prevalence of obesity and severe obesity in US children, 1999-2014; Milken, 2007; ADHS AZ CVD State Plan, 2005?; ADHS State Health Assessment, 2014; ~83%: EYH FitnessGram baseline data, 2012J. Reeves, UofA, Principal Investigator; Diabetes% (adults): Boyle et al, 2010; Schneiderman et al, 2014; No chronic conditions=$4,342/year; Diabetes=$13,313/year: Kaiser Family Fdn., 2012 (Medicaid); Edunuity ests. Slide @06/01/2017 Warren Buffett, May 2017: Its the Health Care Costs, Stupid! 45 "If you go back to 1960, or thereabouts, corporate taxes were about 4% of GDP, now theyre about 2% of GDP." By contrast, in 1960, "healthcare was 5% of GDP, and now its about 17%

of GDP." "If you talk about world competitiveness of American industry, health care is the single biggest variable where we keep getting more and more out of whack with the rest of the world. "Medical costs are the tapeworm of American economic competitiveness. Notes/References: Warren Buffett comments at Berkshire Hathaway 2017 annual meeting, Forbes.com, May 10, 2017. Slide @ 10/16/2017 Health Care Costs since 1970+ reforming health care for decades without preventing the root causes Per Capita Health Expenditure, 1970-2008 46 Medicaid capitation, more Medicare reforms will keep costs down! HMOs will save us! Yet more Medicaid/ Medicare reforms, HSAs, more private insurance co-pays & higher employee % of premiums, surely now Ever higher deductibles &

premiums Uhhh HELP!!! Obamacare will tame costs!.. No wait! Repeal & replace ACA !? References: Organisation for Economic Co-operation and Development (2010), OECD Health Data, OECD Health Statistics (database). doi: 10.1787/data-00350en (Accessed on 14 February 2011). Downloaded 11/20/2014: http://kff.org/health-costs/issue-brief/snapshots-health-care-spending-in-the-united-states-selected-oecd-countries/ Research America 2012: Truth and Consequences: Health R&D Spending in US. Notes: Australia & Japan 2007 data. Figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates. Break in series: CAN(1995); SWE(1993, 2001); SWI(1995); UK (1997). Numbers are PPP adjusted. Estimates for Canada and Switzerland in 2008. Slide Americans Health: Not Better yet >2x More Costly US--better: smoking, breast cancer; worse: diabetes, obesity, heart disease, life expectancy, costs 47 Health Indicator USA OECD Life Expectancy 78.8 80.5 at birth, in years Mortality from Heart Disease 128 117 ischemic, deaths per 100K population

Cancer Mortality 198* 202* Breast Cancer Survival 93%* 87%* 5-year relative survival Daily Smoking 14% 20% % for whole population 8.4%* 8.5% liters per capita (15 years +) 47%/78%* 60%/65%* Diabetes Prevalence 13%* 9%* ages 40-59, 2011 data Obesity (adults)

35% 19% UK 25%, Mexico 32% Obesity & Overweight (children) 34%* 23%* % of children at various ages Health Expenditure per Capita $8,713 $3,453 US$ at purchasing power parity (PPP) Health Expenditure % GDP 16.4% 8.9% Alcohol Consumption Fruit & Vegetable Consumption Notes % of population aged 15+ eating fruit/ vegetables daily as share of GDP, 2013 Notes: *Approximate value based on OECD charts. Based on OECD definitions for comparison, may not match other data in slide deck. OECD includes virtually all major Western developed countries + some others. References: OECD Health Indicators, 2015: downloaded 1/28/2016 from http://

www.oecd- ilibrary.org/docserver/download/8115071e.pdf?expires=1454025553&id=id&accname=guest&checksum=49DCF9B5D580BC095DCAB1065E58B255 Diabetes prevalence: OECD, 2015: Cardiovascular Disease and Diabetes: Policies for Better Health and Quality of Care, 2011 data, page 47, downloaded 1/29/2016 from: http://www.keepeek.com/Digital-Asset-Management/oecd/social-issues-migration-health/cardiovascular-disease-and-diabetes-policies-for-better-health-and-quality-ofcare_9789264233010-en#page3 (source: IDF, 2013, IDF Diabetes Atlas, 6th Edition) Slide @10/23/2017 Lost GDP/Tax Revenue from Chronic Conditions bad health is very bad for tax revenuesOr betterto health & productivity potential in new school funding--without Potential increase AZ GDP $2B+ from$200M+/yr 10+% less absenteeism & presenteeism.new taxes Also, $1B in new GDP generates state tax revenue of approx. $100M; so $200M/year. US$ billions in lost productivity, 2003 48 20 18 16 14 12 10 8 17 13 6 4 7 8

UT NV 2 0 AZ CO Note: Annual cost in $billions, in 2003, in lost productivity/GDP from chronic health conditions. $1+ trillion in lost productivity/GDP for USA. Productivity loss from: ill employees (and their caregivers, if any) forced either to miss work days (absenteeism) or to show up but not perform well (presenteeism). Reference: DeVol, Ross, and Armen Bedroussian, An Unhealthy America: The Economic Burden of Chronic Disease, Milken Institute, October 2007 www.milkeninstitute.org. Tax estimates based on 2013 AZ GDP & tax data from census.gov. Preventing Middle-Income Family Financial Crisis 2020s shock: more & more families will cut non-medical spending to pay for health costs; from 50M+ struggling to pay medical bills now a Great Health Care Recession ? 49 % After-tax Income, Middle Household Income Quintile 14% 12% 10% 8% 6% 4% & what happens to support for education funding, donations to charities, & other non-health spending then!? Health cost % of after-tax income Net disposable

income % of after-tax income 2% 0% -2% Notes: Assumes continued real inflation-adjusted wage stagnation of middle quintile [40%-60%] household income over long-term, based on last 15+ years trends; continued cost-shifting from employer to employee: premiums, out-of-pocket, etc.; 2% real annual average health care inflation until 2025 per CMS federal projections, then 1% real annual health care inflation until 2035; long-term average non-health costs rise at same rate as middle-income wages (Edunuity assumptions based on past trends). References: NerdWallet, 2014: including up to 650K households/year bankrupt from medical bills; BLS Consumer Expenditure Survey, 2013; National Health Expenditures Table 1, CMS, 2015; Health Cost Trend: Behind the Numbers 2016, PWC HRI, June 2015; The Precarious State of Family Balance Sheet, Pew Trusts, Jan. 2015; Turner, 2015-17. [email protected]/05/2017 Win 5 50 Health Govt. Finances K-12 Funding Family Disposable Income Business Profits Notes: Google images: OTC Wholesale. School Book. Slide @10/18/2017 1/3 Students (your Child?) will become Diabetic !?! 23% Teens Pre-diabetic already from Inactivity & Unhealthy Nutrition (We ignored

child obesity early warning signs: CO:person 4%18%; seechronic each column Diabetes cost $15,000+/adult/year [3x nonelderly with no disease] below) 35 Prevalence% (% total US adult population) 51 1/3 30 25 20 CO:18% CO:16% 15 CO:11% 10 5 0 CO:4% 1960 1/30 CO:4%

CO:7% 1970E 1/3 adults = >1M diabetics in AHCCCS (AZ) = Potential $10-15 billion/year just for diabetes in AZ = an existential threat to quality health care, future tax cuts & K-12 funding MexicanAmericans 1980 1990 2000 2010 2050 Notes: 1 out of 3 children are projected to become diabetic as adults. 23% teens, 35% of adults are already pre-diabetic: 86M/243M US adults. Already approaching 500,000 w/diabetes in AZ now. Much higher-than-average diabetes rates among Mexican-American, Native-American, & lower-income populations. Diagnosed + undiagnosed diabetes, prevalence% of US population calculated using same diag./undiag. ratio as in 2010. $245B = USA diabetes costs 2012, 41% increase in 5 years (=trend of doubling every decade), & still growing fast. Annual medical expenditures per nonelderly (ages 18-64) adult enrollee in Medicaid, 2009: No chronic conditions=$4,342/year; CVD (cardiovascular disease) =$9,414/yr; Diabetes=$13,313/year; after out-ofpocket costs; per Kaiser FF. References: Pediatrics, 2012 in USNews, 5/21/2012 (youth prediabetes); Diabetes. org (adults; USA); Boyle et al, 2010 (middle-ground projections); CDC, 2014: Longterm Trends in Diabetes; Schneiderman et al, 2014; child obesity, 1960-2010: CDC, 2010/NHANES & Kit & Flegal, 2012-14, ages 6-11; other estimates & details @edunuity.org. Google images: OTC Wholesale [email protected]/23/2017 Health Costs Up with Obesity/Unfitness 4-5% of teens & 15.5M+ US adults morbidly obese--& increasing fast 52 Relative health care costs by BMI/condition 90%

80% 70% 60% 50% 40% 30% 20% 10% 0% t t t e e se h h s s h e g g e e g b b b ei ei ei O O O w w w rly ly

al er e s d i v d u rm n O rb 18.5-24.9; 25-29.9; io BMI (kg/m2): o<18.5; o r Notes: Per capita U health care expenditures, 2009. Chart: from Underweight on left to Morbidly Obese on right: N Se 2013-14. 15.5M USMadults severely/morbidly 30-34.9; 35-39.9; >=40 (typically >100 lbs. overweight as adult). 4.3% of teens severely/morbidly obese, obese in 2010. References: Arterburn et al, 2005: Impact of morbid obesity on medical expenditures in adults; Skinner et al, 2016: Prevalence of obesity and severe obesity in US children, 1999-2014; Sturm & Hattori, 2013; Google images losttogain.blogspot.com Slide @5/26/2017 Teen Fitness 1/2 - 2/3 less Diabetes as Adult >100x lifetime payback/ROI for Empower Youth Health Program preventive ed-vaccination Hazard ratio: increased risk for diabetes in adulthood

53 3.0 2.0 1.0 0.0 helps achieve this lowerfuturediabetes fitness level Notes: Type 2 diabetes. Hazard ratio (HR) (95% CI), P value <0.001: 1.00, 1.58, 3.07 respectively (controlled for SES, education level, BMI, family history of diabetes, etc.; national cohort study population of 1.53M 18-year-old males without prior diabetes). Aerobic capacity had biggest associated impact, but muscle strength was also important. Overall, the combination of low aerobic capacity and muscle strength was associated with a 3-fold risk for type 2 DMOverall, these findings suggest that physical fitness has important health benefits for all, even for persons who are not overweight or obeseThese findings suggest that interventions to improve aerobic and muscle fitness levels early in life could help reduce risk for type 2 diabetes mellitus in adulthood. Empower Youth Health (EYH) is an evidence-based program that helps K-12 schools improve physical & nutrition education, including both aerobic/cardiovascular fitness and muscular strength, as verified by FitnessGram. Reference: Crump, Sundquist, et al, 2016: Physical fitness among Swedish military conscripts and long-term risk for type 2 diabetes mellitus. Reeves, Teen Fitness 35% less Heart Attacks as Adult 54 >100x lifetime payback/ROI for Empower Youth Health Program preventive ed-vaccination $160,000,000,000 $120,000,000,000 $80,000,000,000 $40,000,000,000 $- potential $50 billion/year Medicaid savings? helps achieve this less-futureheart-attacks fitness level Notes/References: CVD=cardiovascular disease. Results from long-term study of population of 743K 18-year-old men in Sweden followed into middle-age; controlled for BMI, diseases, education level, blood pressure, SES, etc. Thus, our results indicate that regular cardiovascular training in late adolescence is

independently associated with ~35% reduced risk of myocardial infarction in men.: Hogstrom, Nordstrom, Nordstrom, 2014: High aerobic fitness in late adolescence is associated with a reduced risk of myocardial infarction later in life: a nationwide cohort study in men. 2009 Medicaid annual medical expenditure data for nonelderly adults ages 18-64: in 2009, per Kaiser Family Foundation 2012 Fact Sheets: 28% of Medicaid nonelderly adult enrollees had CVD, costing Medicaid $9,414/year: Kaiser Family Foundation, 2012: The Role of Medicaid for People with Cardiovascular Diseases. $4,342/year per capita cost to Medicaid for nonelderly Medicaid beneficiaries without chronic illness: Kaiser Family Foundation, 2012: The Role of Medicaid for Adults with Chronic Illnesses. 56,274,369 adult Medicaid enrollees, of which 28%=approx. 15.8 million with CVD x $9,414/year = $148B * .35 = $52B in potential savings. Slide @04/12/2017 EYHP: Evidence-based MVPA+ Program 55 % Fit much higher fitness, better health incl. lower diabetes/heart disease risk, from more moderate-to-vigorous physical activity @$10/student/year Notes: $10/child/year cost at-scale of 50K-100K students/year. Empower Youth Health Program (EYHP) results 2012-2015 from lower-income AZ schools with 79-98% FRL (Free & Reduced Lunch) student population; 90% Hispanic, 5% Native-American, 3% White, 2% African-American. By Year 3: 20 schools in EYHP, 16,000 students, Sunnyside USD, Tucson; increased % students with cardio-vascular aerobic fitness 4x from 17% to 78%; >6x increase in % of students with good nutrition: 11% 73% consuming recommended fruit & vegetable servings; % of students at normal weight increased by 12.5% from 48% to 54% among students in the Healthy Fitness Zone (HFZ), even though students would typically be increasing BMI and becoming more obese as they age; 35-40% of students receiving 60+ mins. PA/day. Healthy Fitness Zone is the national FitnessGram/PYFP standard for fitness, as measured by objective aerobic capacity (PACER), BMI, & muscular strength & endurance metrics. Students in HFZ are considered to be at the level of fitness needed for good health (www.cooperinstitute.org/healthyfitnesszone). EYHP costs $10/student/year at scale (produce costs may be additional). References: Reeves, 2016: US Department of Education Grant Performance Report (ED 524B): Jennifer Reeves, UofA, Principal Investigator; fall 2012 - spring 2015. Other notes/references: EYHP costs kept low by: school-wide wellness policy planning; training existing PE & classroom teachers & MS/HS student fitness volunteers (& not adding more staff); and regular assessment with FitnessGram. Moderate-to-vigorous physical activity (MVPA) & healthy nutrition increase brain capacity & academic achievement, per extensive research evidence. Teen aerobic fitness is correlated with 35% less heart attacks in middle-age (Hogstrom, Nordstrom, 2014); reducing % of Medicaid enrollees with CVD by 35% would save $50B/year nationally (Kaiser Family Foundation, 2012). Teen fitness correlated with 1/2 - 2/3 less risk of type 2 diabetes in middle-age (Crump et al, 2016). Potential for EYHP & school-based preventive education to reduce chronic health conditions & costs by 20+% with 100x or more ROI, including postponing disease on-set, reducing disease severity from up to 13 years healthier behavior (Edunuity estimate; see other slides). Rapid payback for health sector within first year of EYHP implementation in schools, due to reduced health costs for ADHD, asthma, obesity, depression, and related preventable child health issues (see Payback slides/references). Rationale: as fitness increases & nutrition improves, chronic health conditions decrease, Medicaid/AHCCCS/health insurance & out-of-pocket health costs decrease, & productivity & GDP increase from less absenteeism/ presenteeism (Milken, 2007); also, as a result, state (& local & federal) tax revenues go up & govt. costs go down. [email protected]/24/2017. Contact: Scott Turner 602-513- Better Nutrition Habits & 12.5% more HFZ students at normal weight 56

Notes: Empower Youth Health Program (EYHP) results 2012-2015 from lower-income Arizona schools with 79-98% FRL (Free & Reduced Lunch); 90% Hispanic, 5% Native-American, 3% White, 2% African-American populations. By Year 3: 20 schools in EYF, 16,000 students; increased % students with cardiovascular aerobic fitness 4x from 17% to 78%; 7x increase in % of students with good nutrition: 11% 73% consuming recommended fruit & vegetable servings; (produce costs may be additional above $10/student/year); % of students at normal weight increased by 12.5% from 48% to 54% among students in Healthy Fitness Zone. HFZ is the nationally validated FitnessGram/PYFP standard for fitness, as measured by objective aerobic capacity (PACER), BMI & muscular strength & endurance metrics. Students in HFZ are considered to be at the level of fitness needed for good health (www.cooperinstitute.org/healthyfitnesszone). References: Reeves, 2016: US Department of Education Grant Performance Report (ED 524B): Jennifer Reeves, UofA, Principal Investigator; fall 2012 - spring 2015 (Reeves, 2016). Slide version MS Students Know: Exercise & Nutrition Help Me Academically 57 How you do in class when have been physically active? Physical Activity I do Worse I do About Same I do Better 4% 49% 47% How you do in class when you eat healthy food? Nutrition I do Worse 2% I do About Same 53%

I do Better 45% References: Turner, 2013 (research in 3 primarily lower-income schools, grades 6-8, in Maricopa County, AZ) Fit Kids: MVPA Prog. #2 investing $1M/year in schools 58 Outcomes: ~50% reduction in likelihood* of child obesity Est. $60-90**/student/yr health cost savings = 1st year payback Win-Win ($60-70/student/year physical activity program cost) If NAHs peers invested comparable amount = $100M+/year new K-12 money for Arizona $1M/yr from Northern AZ Healthcare, since 2012 =~$100/student/yr invested in PA, etc. 20 elementary/middle schools, 5 districts, >9000 students/year in greater Flagstaff+ Mandatory 1 class/week moderate-to-vigorous physical activity (MVPA) & nutrition ed, led by trained Health Aides Optional before/after/lunch activity sessions Supplements existing PE, health education Evaluation = evidence-based: 2350 children, 4x BMI measurements over first 2 years Note: *50% reduction in the incidence of being overweight from what would be expected based upon school district data. Based on 7.5-10% of students not

being obese, who would have otherwise been obese @$600 health cost/obese student/year, NAH is estimated to be saving $45-60/student/year in obesity-related costs alone; ADHD/asthma/depression & other mental health savings could add savings of up to $30-50/student/year. Fit Kids physical activity programs in K-8 schools costs approx. $60-70/student/year, primarily cost of trained health aide to lead physical activity (PA). References: Child obesity health costs: Buescher et al, 2008; Hampl et al, 2007; Kuhle et al, 2011; see MVPA-related annual child health cost savings slides for detailed references. Fit Kids evaluation reports (DeHeer, 2014) & emails with NAU Prof. DeHeer; Fit Kids website: https://nahealth.com/fit-kids; Fit Kids staff. Edunuity total cost savings estimates. [email protected]/03/2017 Comprehensive School Physical Activity Program (CSPAP) 59 Empower Youth Health Program (EYHP) addresses all of these Notes: A Comprehensive School Physical Activity Program (CSPAP) is a multi-component approach by which school districts and schools use all opportunities for students to be physically active, meet the nationally-recommended 60 minutes of physical activity each day, and develop the knowledge, skills, and confidence to be physically active for a lifetime. A CSPAP reflects strong coordination and synergy across all of the components: physical education as the foundation; physical activity before, during, and after school; staff involvement; and family and community engagement. References: CDC, SHAPE America, 2016 Slide @10/16/2017 Whole School, Whole Community, Whole Child Model 60 WSCC=Coordinated School Health 2.0: a collaborative preventive approach to health via schools Empower Youth Health Program (EYHP) addresses many of these References: ASCD, CDC, 2014-16: http://www.cdc.gov/healthyyouth/ wscc Elements of a Healthy Community Empower Youth Health Program (EYHP) addresses many of these 61 Source: http://www.livewellaz.org/ Slide @10/16/2017 Influencers of Childrens Health biggest missing impact: schools with parents 62 Governor

State Legislature: Ed. & Health Parents Employers Insurance/Health/Wellness Plans State Board of Ed State Dept. of Ed State Dept. of Health State Social Services Depts. CDC USDA Parents Health Care Providers Principal School District City/Town Council/ Govt. School Nurse/ Health Aide Pediatrician USHHS: Other American Academy of Pediatrics Parks & Rec. Dept. School Board Food & Beverage Manufacturers

(Unhealthy & Healthy) Agribusiness (Unhealthy & Healthy) POTUS Teachers Aide Mother Father Child Siblings Behavioral Health Prof. Health/Social Non-Profits CMS: Medicaid/ACA PE Teacher Counselor FDA Notes: Major Continual Influencer; Other Key Influencer; Other Influencer Teacher(s) (Classroom)

State Medicaid Director & Plans Relatives Close Friends School Food Services Mgr. County Health Dept. Classmates County Governing Board Team/Club/Church/ Enrichment Adult Social Worker Parent/Volunteer Local Non-Profit at School Personnel Other Urban Employers Planners Fast Food Restaurants Food Retailers (mainstream) US Senate Lower-income Food Retailers (food deserts)

US House of Rep. US Dept. of Education First Lady Health Insurance Cos. (national) County/City Social Services Dept. National/Regional Non-Profits Notes: Illustrative Media & not comprehensive. Advertising Cos. References: Turner, 2013-17 (Bronfenbrenner, 1979; Vygotsky, 1978) @09/06/2016 Healthy Behavior through Lifelong Learning 63 K-12 lays foundation; ages 0-5 & follow-up policies with adults TBD Financial/TBD Medicare: Prev. Incents. Strategy: financial financial (dis)incentives (dis)incentives for for adults adults reinforce reinforce centives+ Strategy: In training of

of parents parents & & education education of of children. children. Medicare Tax: Prevention Financial Incentives training s lt u d A h it w Criteria: measured, measured, evidence-based, evidence-based, behaviorbehaviorCriteria: Employee Wellness: Programs & Prev. Incentives Use Most Most Effective Effective Approaches Approaches throughout throughout Use Life Life changing, changing, low cost, cost, high high effect effect size, size, practical, practical, developmentally developmentally low appropriate, demanding,

demanding, systemic systemic & & systematic, systematic, appropriate, well-implemented, & & politically politically achievable, achievable, with with well-implemented, net tax tax reduction reduction from from ROI ROI savings. savings. aa net / w ls o o h c S dren il h C Health Insurance: Prevention Financial Incentives Medicaid/ACA: Prevention Financial Incentives Sales Tax: Stop Subsidizing Unhealthy Foods/Bevs. Other: Public info/warnings, Limit misleading Collegeadvert. w/Student: TBD & Prevention Financial Incentives High School: Health Ed & PE/aerobic alternatives w/Teen & Peers

Middle School: Healthy Behavior Ed & rigorous PE w/Child, Peers, Parent(s) l+ a ic nts Elementary School: Behavior-changing Health Ed & rigorous PE with Child & Parent(s) d e M Pare Preschool: with Child & Parent(s) w/ Primary Care (Pediatric+WIC+): with Mother & Child OB/GYN: with Mother-to-be 0 -0.75 (Preg- (Birth) nancy) 3 6 9 12 15 18 Working Parent/Family Senior Age Note: Rigorous PE includes high # MVPA (moderate-to-vigorous physical activity) minutes. Reference: Turner, 2013-17. Slide @11/01/2017 Top 10 Benefits for Health Orgs Unique Upside of Whole-Student-Population Preventive Education 64

Bad newsGood news for health organizations: Universal: Health orgs dont knowwhich child will be a customer/patient in future - So need to preventively ed-vaccinate all children Early: Too difficult & costly to change adults behaviorneed to work w/children - Need to improve habits in childhood to have a stronger chance for healthy adulthood; K-12 learning also lays a foundation for better following health recommendations in adulthood Indispensable: Given lack of prevention alternativeswhat choice do we have? - Child obesity epidemic started in 1980s, diabetes epidemic in 1990s; no other solutions, no end in sight Payback: Child health costs so high alreadythat payback is rapid - Capitated, Managed Care, Value-based, HMO/many PPOsbenefit now from child health savings ROI: Adult chronic health costs so highearly investments provide very high ROI - A single major health organization can cost-justify whole-population preventive ed-vaccination; Top 10 Benefits for Health Orgs (contd) 65 Additional Unique Upside of Whole-Student-Population Preventive Education perspectives: Benefits for health organizations Viability-Reinsurance: Preventive education-vaccination protects balance sheets Invest 0.TBD% of chronic health costs as self-reinsurance pool Health care providers/plans invest in K-12 from surplus/reserves and/or add to chronic condition reimbursements/plan premiums; e.g., shared TBD% symbiotic investment PR: Whole-Population PR is extremely compelling public communications Nothing as powerful as investing in major breakthroughs for everyone in the community -- not just your own customers + some incremental-change-but-not-move-the-needle charitable grants Control without Responsibility: HFAZ gives health orgs. control w/t oper. responsibility

Invest in & work through Healthy Future Arizona; health orgs./funders do not work directly in schools Pay-for-Performance: Health organizations pay for what works & reduces costs Start in targeted populations, ensure results; health organizations choose whether to keep scaling Shared Costs: Co-investment accelerates payback/increases ROI from reduced child costs Everyone is Paying (More & More) for everyone elses preventable bad health 66 Taxpayers Medicaid/AHCCCS, Medicare, ACA/Obamacare, Veterans, Federal/military/state/county/muni. Individuals/ Employees Employers/ Small Biz Higher health insurance premiums/co-pays/ deductibles/out-of-pocket, other non-covered health care $$, lower salaries, lost work days Health insurance premiums, lost work days, presenteeism & lower productivity, disability Hospitals/HC reimbursements, Providers ER/other uncompensated care, low quality of care challenges, financial stress Health Plans/Insurers Unsustainable premium increases, disappearing Slide @06/01/2017 Coalition for Healthy Behavior 67

Conservatives/ Libertarians Lower government spending; No new taxes; Tax cuts; Personal responsibility; Not pay for others unhealthy behavior; Choice/avoid single-payer fed. system Democrats Improve health of lower-income families and affordability of & access to health care for all Businesses Reduce costs, boost productivity & profits Health Advocates Educators Improve publics health as much/broadly as possible Healthier kids; Higher student achievement, engagement; Lower district health costs HC Providers/Plans Better patient health; Lower costs; Long-term financial viability National Security Fit, eligible recruits; More $$ available for Defense Voters/Taxpayers/ USA Deficit/Debt Sustainably affordable health care & lower family, private, Medicaid, Medicare, ACA costs References: dcsdk12.org & medscape.com & azcentral.com & commons.wikimedia.com & thenation.com at Google images. Slide 11/01/2017 FitnessGram: Balanced Fitness Assessment

(replaced Presidential Physical Fitness Test) 68 Key criterion-referenced metric: % students in Healthy Fitness Zone (HFZ) = evaluates if student at level of fitness for good health Aerobic capacity - 15-20 meter sprints (PACER/beep test), 1 mile run/walk Muscular strength & endurance, flexibility - curl-ups (crunches), arm hang/pull-ups, push-ups, trunk lift [Body composition] - [BMI] Notes: Healthy Fitness Zone standards represent the minimal levels of fitness needed for good health based on the students age and gender, per Presidential Youth Fitness Program (PYFP). BMI = Body Mass Index: comparing height vs. weight. [BMI]: Not recommending including BMI at present. References: PACER photo: blogs.birmingham.k12.mi.us from Google images; cooperinstitute.org; PACER test overview: https://www.youtube.com/watch?v=lroAhVO83iI Slide @02/14/2017 Fitness Assessments esp. FitnessGram 69 multi-state precedents--yet FitnessGram rare in AZ & only part of solution States that recommend or require a fitness test have significantly more recess and PE time, most likely to help students prepare for these evaluations. - Dills et al, 2011 - PE assessments mandated in 21+ states: AL, AR, CA (grades 5,7,9), CT, DC, DL, GA, LA (focused on high-poverty districts), MO, MN (local assessments), MS (grade 5), NC, NY (local assessments), RI, SC (grades 2,5, 8-12), TN, TX (grades 3-12), VA (grades 412), VT (grades 5-12), WV (grades 4-8 & HSx1), WI - Mandated public reporting of results in 10+ states: AL, CA, CT (in Strategic School Profile), DC, DL (results to parents), MO (% meeting min.), SC (to parents + school effectiveness score), TX (summarized results to TEA) VA, WV Note: State assessments appear to be FitnessGram or equivalent in vast majority of cases. References: co.chalkbeat.org in Google images. Quote: Dills et al, 2011: Recess, physical education, and elementary school student outcomes. Preliminary state analysis by Edunuity: NASBE., 2011: http://www.nasbe.org/healthy_schools/hs/bytopics.php?topicid=1110; Shape of the Nation 2016: Status of Physical Education in the USA, 2016; E CS personal communications, 2015-16. PYFP, 2014. Plowman et al, 2013. Slide @06/06/2017.

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    holoparasite = parasite obligatoire. Selon leur niveau de fixation sur l'hôte. Plantes parasites . épiphytes implantées sur les parties aériennes. Plantes parasites . épirhizes fixées sur le système racinaire. II.
  • Game Making with Alice - cs.utexas.edu

    Game Making with Alice - cs.utexas.edu

    Game Making with AliceEat the Hay Game. What is Alice? Alice is a visual programming language. ... Download Alice for free: www.alice.org. Games In Alice. Alternate Game - Eat The Hay. Create a Game with a cow. The arrow keys...
  • Programming Languages &amp; Software Engineering

    Programming Languages & Software Engineering

    Environment passed as argument to interpreter helper function. A variable expression looks up the variable in the environment. ... Lack of magic: The interpreter uses a closure data structure (with two parts) to keep the environment it will need to...
  • What can &quot;Economics of Information Security&quot; offer for SMEs

    What can "Economics of Information Security" offer for SMEs

    [email protected] Presentation for BCS 8th October 2015 Background Grew up in Lincoln Modest, but not poor… father owned a small business but his real interest was Science & Maths exceled in Maths at school also excellent in Latin & Greek!...
  • Bamboo : as a construction material Anatomy of

    Bamboo : as a construction material Anatomy of

    Similar to grass, bamboo is characterized by a jointed stem called a culm. Typically the culms are hollow but some species of bamboo have solid culms. Each culm segment begins and ends with a solid joint called a node. Nodes...