ArticlesPrevalence of risk factors for non-communicable diseases in prison populations worldwide: a systematic review
Introduction
Non-communicable diseases (NCDs) are increasingly viewed as a global health crisis, demonstrated by an escalating prevalence of diseases such as heart disease, stroke, diabetes, cancer, and respiratory disease.1 The four key modifiable risk factors identified for NCDs are smoking, alcohol, inadequate physical activity, and unhealthy diet. In 2008, 36 million of 57 million deaths worldwide were attributable to NCDs. Of these, 14 million were attributable to unhealthy diet, 3 million to insufficient physical activity, and 3 million to obesity.2
While NCDs affect people of all nationalities, ages, and classes, unambiguous inequalities exist in the burden of these diseases between and within countries, affecting especially those in vulnerable situations (eg, in prisons or detention).3 Within countries a clear link exists between socioeconomic disadvantage and NCDs. Most of the 9·8 million people imprisoned worldwide4 are from the poorest and most marginalised sections of society5 and are therefore likely be at greater risk for NCDs.6 Contact with the criminal justice system is a public-health opportunity to promote health in this high-risk population.6 In particular, the prison regime and ethos is important in mediating an individual's exposure to risk factors for NCDs. Prisons, therefore, have a responsibility to create a healthy environment as well as engaging in individual health promotion.6
Although prevalence of tobacco7 and alcohol use8 by prisoners has been assessed, no systematic review has been done of the other two key modifiable risk factors in prisoners: diet and physical activity. Our systematic review, therefore, aims to address this gap, focusing on diet (including dietary salt), physical activity, and obesity in prison populations worldwide. The review also highlights areas that require further research to provide an objective picture of the risk-factor profiles of prisoners, so that resources can be better directed to improve health promotion and prevention in this vulnerable population.
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Search strategy and selection criteria
We developed a protocol for the systematic review using PRISMA guidelines.9 We searched PubMed (upto May 11, 2011), EMBASE (1980 to May, 2011), Global Health (1973 to April, 2011), Ovid Medline (1948 to May, 2011), and PsycINFO (1967 to May, 2011) for articles using the following search strategy combining text and MeSH terms: prison* OR inmate* OR jail* OR gaol* OR incarcerat* OR youth offend* AND obes* OR overweight* OR “BMI” OR Body mass index AND nutrition OR diet OR nutrition assessment OR
Results
31 eligible cross-sectional surveys were reported in 29 publications,12, 13, 15, 16, 18, 19, 20, 21, 23, 26, 28, 30, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52 including a total of 60 027 prisoners in at least 884 institutions (figure 1). Of these 60 027 prisoners, 51 452 (86%) were male (western Australian mixed population, included here as male).44 Nine dietary studies had mean values for institution meals with no data on number of prisoners.37, 38, 40, 42, 44, 45, 47
Discussion
Our systematic review suggests that key modifiable risk factors for NCDs are a public health issue for prisoners around the world. We provide the first comprehensive summary of existing research on obesity, physical activity, and diet in this vulnerable population. Furthermore, our findings show persistent health inequalities between the general population and prisoners and thus reinforces the UN's call for action to address key risk factors of NCDs for those living in vulnerable situations.3
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