Elsevier

The Lancet

Volume 379, Issue 9830, 26 May–1 June 2012, Pages 1975-1982
The Lancet

Articles
Prevalence of risk factors for non-communicable diseases in prison populations worldwide: a systematic review

https://doi.org/10.1016/S0140-6736(12)60319-5Get rights and content

Summary

Background

The burden of non-communicable diseases (NCDs) is disproportionately carried by low-income and middle-income countries and disadvantaged sectors of society such as prisoners. No systematic analysis has been done to assess the prevalence of poor diet, inadequate physical activity, and overweight and obesity in prisoners. We aim to synthesise current evidence and to highlight areas for action and further research.

Methods

We systematically searched online databases for reports published between 1948 and May, 2011. Studies were screened against eligibility criteria; two authors then independently extracted data with previously agreed proformas. The risk of bias was assessed for each study with a domain-based assessment. Data on body-mass index and physical activity were presented in forest plots; no overall estimates were calculated on account of data heterogeneity. Available data from the population subgroup most similar in terms of age and sex were used to calculate age-adjusted and sex-adjusted prevalence ratios, which estimate the likelihood of insufficient activity and obesity prevalence in prisoners compared with the national population.

Findings

31 eligible studies were reported in 29 publications, including more than 60 000 prisoners in 884 institutions in 15 countries. Male prisoners were less likely to be obese than males in the general population (prevalence ratios ranged from 0·33 to 0·87) in all but one study (1·02, 0·92–1·07), whereas female prisoners were more likely to be obese than non-imprisoned women in the USA (1·18, 1·08–1·30) and Australia (prevalence ratios ranged from 1·15 to 1·20). Australian prisoners were more likely to achieve sufficient activity levels than the general population compared with prisoners in the UK (prevalence ratio 1·19, 95% CI 1·04–1·37, for women in Australia in 2009 vs 0·32, 0·21–0·47, for women in the UK; prevalence ratios ranged from 1·37 to 1·59 for men in Australia vs 0·71, 0·34–0·78, for men in the UK). Female mean energy intake exceeded recommended levels and sodium intake was about two to three times the recommended intake for all prisoners.

Interpretation

Contact with the criminal justice system is a public-health opportunity to promote health in this vulnerable population; the costs to the individual and to society of failing to do so are likely to be substantial. Improved monitoring and further research is essential to inform appropriate targeting of public health interventions.

Funding

Oxford University Department of Public Health, Oxford University Hospitals NHS Trust.

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.

Section snippets

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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