Journal of Correctional Health Care - April 2023 - 131

OBESITY IN PRISON: A META-ANALYSIS
131
recreation (Harner & Riley, 2013; Smoyer & Blankenship,
2014). In some cases, this may be due to legitimate
security concerns. For instance, federal statutes limit the
presence of weightlifting and exercise equipment (Houle,
2014).
As in the general U.S. population, dietary changes are
likely a major driver of increasing OB in people who are
incarcerated. Due to the division of prisons into federal,
state, local, and private facilities, it is difficult to systematically
assess the quality of diets. In federal facilities,
diets are supposed to adhere to Institute of Medicine
(IOM) recommended dietary intakes (Spark, 2007). In
state facilities, diet compositions and energy allowance
are determined by each state's legislature and thus vary
(Spark, 2007). Jail diets are governed by local regulations
(MacReady, 2009). Facilities often have commissaries
where people may purchase additional snack foods, which
are often highly processed and energy dense (Clarke &
Waring, 2012; Houle, 2011).
After reports that South Carolina Department of
Corrections (SCDC) prisons were spending only $1.15
per person per day on meals, an independent study was
completed on the nutritional content of SCDC meals
(Collins & Thompson, 2012). The authors were required
to file a Freedom of Information Act motion with the
SCDC to obtain institutional meal plans. The authors
noted that compliance with the menu was not enforced,
leading to significant dietary variation. A dietary analysis
of the meals being served found ''higher levels of
cholesterol, sodium, carbohydrates, and sugar and lower
levels of fiber, magnesium, potassium, vitamin D and
vitamin E than recommended'' (p. 210).
Narratives provided by incarcerated people have further
expanded on the poor quality of prison diets (Harner
& Riley, 2013; Smoyer & Blankenship, 2014).
Additional publications have noted that incarcerated
females are often provided a relative excess of calories
compared to their daily needs (Cook et al., 2015; Herbert
et al., 2012; Leddy et al., 2009). Stress, which many people
report as a consequence of incarceration, may also
factor into their food choices. Weight increases associated
with chronic stress can be partially explained by a
shift in an individuals' food preferences toward items
with higher levels of carbohydrates and saturated fat
(Boggiano et al., 2017; Roberts et al., 2014).
It is possible for correctional facilities to improve the
physical health of people. Incarcerated men in Japan
with type 2 diabetes mellitus demonstrated dramatic
improvements in their hemoglobin A1C measurements
during the course of their sentence (Hinata et al.,
2007). The men were fed a high-fiber diet and had no
access to sweetened beverages, ''junk food,'' or snacks.
People incarcerated in Japan completed 8 hours of
light labor daily and could exercise for 30 minutes two
to three times a week (Hinata et al., 2007).
Similar results have been obtained in Europe. A smallscale
Italian trial of supervised physical activity for 120
minutes per week improved BMI, blood pressure, and
cholesterol profiles in incarcerated males compared to
sedentary controls (Battaglia et al., 2013). A less drastic
approach to improving the health of incarcerated people
could include facility implementation of NCCHC's
Healthy Lifestyle Promotion standard (Titus & Alvarez,
2018).
This literature review and meta-analysis have several
important limitations. The reviewed studies contain
data that were collected over the last 23 years. In that
time frame, the background rates of OW/OB increased
(Flegal et al., 1998, 2012) among the general U.S. population.
There were few available studies that measured
actual weight gain during incarceration, and those studies
oversampled females. In nearly 50% of the studies, BMIs
were self-reported, which, as previously noted, may lead
to underestimation of the prevalence of OW/OB in the
study population.
Studies that demonstrated weight gain predominantly
used women, despite the fact that females make up only
8% of the U.S. corrections population (Carson, 2015).
Two studies used subjects from a unified correctional system,
which may have introduced a small number of people
detained pretrial into the data set (Baldwin et al.,
2016; Clarke & Waring, 2012). Additionally, there are
not enough data to ascertain whether there are racial or
ethnic variations in OB among incarcerated people, and
whether there is regional variance in OB.
Furthermore, prevalence ofOW in incarcerated people
was not determined in this meta-analysis, and research is
needed to determine the percentage of OW incarcerated
people who then become OB while incarcerated.
This review illustrates the paucity of nongovernmental
data available on OB among incarcerated people in the
United States. Due to the heterogeneity of the results,
no firm conclusions can be made with the exception
that in a very small sample of females (n = 341), the
majority gained weight during incarceration (Clarke &
Waring, 2012; Drach et al., 2016; Massie, 2000).
There are several explanations for the lack of available
data on incarcerated people. The most important is the
onerous nature of the research. Due to past human rights
abuses, the use of U.S. prison populations in research is
highly regulated (Cislo & Trestman, 2013). The challenges
of conducting studies and developing a research
infrastructure in U.S. correctional settings has been
well documented (Cislo & Trestman, 2013).
Although caution is warranted in dealing with any vulnerable
population, even the IOM has acknowledged the
generally poor health profile of prison populations and
the potential health benefits of future research (Gostin
et al., 2007). Unfortunately, the IOM also proposed additional
regulation of research in prison populations
Journal of Correctional Health Care - April 2023

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