Cardiovascular risk factors among prisoners
Author(s)/
Country
Fawad et al, 2011
Pakistan
Richmond et al,
(2011)
Australia
Design
Not explicitly stated
Aim/objectives
Assessment of elderly male prisoners in
England and Wales
Randomized controlled trial
Compare cardiovascular risk factors (CVRF) among male smoking prisoners with males of similar age and socioeconomic background in the general population.
Population and
Sample size
-Prisons 100 miles from
Oxford in
England and
Wales
-Sample: n=203
Mean age: 65.5 years
-Prisoners: male, smoking
-Aboriginal: n=64
(15%)
-Non-Aboriginal: n=361 (85%)
Sample: n=425
Data collection and analysis methods
-Semi-structured interview
-Analysis of medical records
-Bartel functional score
Main findings
-Men in prison had high rates of morbidity
-Cardiovascular illness among one of three major illnesses (psychiatric, musculoskeletal and respiratory)
-Angina or ischemic heart disease and hypertension among the most common
CVD
-High smoking prevalence
-Questionnaire: smoking history, socioeconomic status, physical activity, risky alcohol use.
- Biophysical measurements: blood pressure
-Kessler Psychological
Distress Scale to assess anxiety and depression
-Comparative data on
CVD risk factors from
Australian Bureau of
Statistics using a number of data sources.
-39% of prisoners had 3+
CVRF compare to 10% in general population.
-Significantly more Aboriginal prisoners had 3+ CVRF than non-Aboriginal prisoners
(55% vs. 36%, p< 0.01) and;
-Twice as likely to have 4+
CVRF (27% vs. 12%).
-70% smoke more than 20+ cigarettes per day
-Insufficient physical activity
(23%)
-Hypertension (4%)
-Risky drinking (52%)
-Symptoms of depression
(14%)
-Low socio-economic status
(SES) (44%)
Limitations/ Rigor Comments
-Report bias:
Health exclusively assessed by selfreport and reviewing of medical records
-Elderly define as age 60 years and above which is higher compare to studies among elderly prisoners defined as age 50 years and above
-Study not primarily set-up to measure
CVD risk factor
-Measures only a limited number of
CVD risk factors;
-Second blood pressure readings only obtained if first was abnormal.
-Underestimation of prevalence of CVD risk factors because did not include overweight prisoners
-Exclude prisoners with current cardiac disease and medication for mental illness;
Study participants all smoker compare to only a portion of community sample;
Which might bias results among prisoners
-Study demonstrated that health problems of elderly prisoners are significantly worse than those of younger prisoners
-Aboriginal prisoners higher levels of risky alcohol use, symptoms of depression and more likely to be of low
SES;
-Prisoners a high risk group for CVD risk factors
-Highlight the need to focus on specific public health interventions
1

Cardiovascular risk factors among prisoners
Author(s)/
Country
Hafizullah et al.
(2010)
Pakistan
Design
Crosssectional
Survey
Binswange r et al .
(2009)
US
Crosssectional
Survey
(secondary analysis)
Aim/objectives
-to determine the frequency of risk factors for CVD in prisoners
Population and
Sample size
Sample n=166
Male: n=146
(86%)
Female:
20(12%)
Data collection and analysis methods
-Interview
--Biophysical and anthropometric measurements
-Blood samples and test (finger prick)
-To quantified differences in prevalence of major medical conditions, including cardiovascular risk factors and disease, pulmonary disease, arthritis, cancer and hepatitis among inmates within the noninstitutionalised US adult population;
- to determine whether age, sex, race, education, employment, US as birthplace and alcohol consumption accounted for differences in medical conditions across jail inmates, prison inmates and noninstitutionalised adults
Jail (n=6582)
Prison
(n=14,373)
Noninstitutionalised adults
(n=76,597)
-2002 Survey of
Inmates in Local Jails
(SILJ): structured, inperson interviews;
-2004 Survey of
Inmates in State and
Federal Correctional
Facilities (SISFCF): interviews;
-200-2004 National
Health Interview
Survey-Sample Adult
File (NHIS-SAF): inperson interviews
Main findings Limitations/ Rigor Comments
-Risk factors for CVD like lack of exercise, smoking, obesity and hypertension was high
-Mean BMI: 26.52 (+4.49)
-Mean SBP: 136.8(+22.91)
-Mean DBP: 87.77(+11.93)
-Mean bChol: 178.91(+29.12 mg/dL)
-MBS: 135 (+4.93 mg/dL)
Smoking: 21.7%(36)
Not exercise: 71.7%(119)
Jail and prison inmates had higher odds of hypertension
-but no increased odds of diabetes, angina or myocardial infarction;
-Jail inmates had lower odds of obesity
-Being incarcerated was associated with a greater prevalence of each condition among non-Hispanic whites and non-Hispanic blacks or
Hispanics compared with non-institutionalised adults;
-non-Hispanic whites and
Hispanics had a lower adjusted prevalence of hypertension than non-
Hispanic blacks
-Blood sample tested by finger prick method
-Measurement validity
-Relatively small sample
Conclusion: We found that risk factors for cardiovascular diseases like lack of exercise, smoking, obesity and hypertension is quite frequent in this group.
Report bias: some data (weight, height, BMI; hypertension) were based on selfreports and has not been validated with confirmatory testing;
-Self-awareness of risk factors among some inmates could have contributed to under-reporting
-Highlights the high prevalence of CVD risk factors, particularly in younger prisoners
-Jail and prison inmates had a higher burden of most chronic medical conditions than the general population even with adjustment for important sociodemographic differences and alcohol consumption
-Highlighted a higher odds of hypertension among jail and prison inmates;
-Demonstrates the association between incarceration and a greater prevalence of hypertension and other chronic medical conditions;
-Need for more longitudinal research to investigate hypotheses of whether individuals in worse health were more likely to commit crimes and be incarcerated; or whether incarceration led to worse health by exposing inmates to adverse lifestyles, increased risk for infection, or psychosocial stress and stigma
2

Cardiovascular risk factors among prisoners
Author(s)/
Country
Plugge et al . (2009)
UK
Sioen al et
. (2009)
Belgian
Design
Prospective longitudinal
Single blind field trial with pre- and postmeasurement
Aim/objectives
To examine the prevalence of five modifiable CVD risk factors (smoking, physical activity, diet,
BMI and hypertension) in women on entry to prison and to document short-term changes in these risk factors 1 month after imprisonment
Population and
Sample size n=505 (82.4%) women only
Mean age 31.5
(SD 9.2), range
18-72
1 month later: n=220 (86%)
To investigate the effect of an ALA enrichment food supply on cardiovascular risk factors in healthy males (volunteer prisoners)
Initial n=70
(68.8% response), 11 dropped out
-final: n=59
-Men only
Data collection and analysis methods
-Postal survey
-Questionnaire (Oxford
Healthy Lifestyle
Survey)
-Response rate: 82% and completion rates: only indicated as high
-Biophysical measures: height, eight, BP
-descriptive statistics
-CI, ttest’s, binary variables (McNemar’s test)
-Dietary intervention (n-
3 fortified foods)
-Dietary questionnaire: habits and behaviour(calculate diet-scores (1 st score) and fish-score (2 nd score))
-Biophysical measurements:
-Blood samples and tests fasting blood function samples fatty acids, phospholipids, plasma lipids, Apo B and A1, glucose, CRP, hepatic
-General linear model
Main findings
-85% smoked cigarettes
-87% insufficiently active to benefit their health
-86% did not eat at least five portions of fruit and vegetables each day
-30% were overweight or obese.
-Women prisoners at high risk of CVD in future
At 1 month:
-Few improvements in risk factors
-Amount of tobacco smoked daily decrease, but proportion of smoking did not decline
-no significant improvement in fruit and vegetable consumption (p=0.13)
-ALA enriched food had no impact on waist circumference, weight and
BMI or systolic BP
-Significant decrease in diastolic BP (from 76.6 +- 8.2 to 71.2 +- 10.1 mmHg; p<0.02);
-Increase HDL level (from
0.97 +- 0.25 to 1.06 +- 0.23 mmol/L; p<0.03) in nonsmoking participants
No significant effect on cholesterol, triglycerides,
LDL, Apo B & A1, glucose,
CRP, hepatic function.
Limitations/ Rigor
-Self-report data;
-Modifiable risk factors only;
-Mainly Caucasian participants
-Control of food consumption;
-compliance to provided diet measured was assess on the basis of questionnaires which did not reflect precise amount of food ingested
Comments
-Need for behaviour modification interventionist research to address CVD risk factors in women prisoners on smoking, physical activity and a healthier diet.
-Highlight the importance for collaboration across different sectors or a “Whole prison approach” in managing chronic diseases in prisons;
-Need for further research in other context to evaluate which approaches to chronic risk factor reduction are most effective
Provision of ALA enriched enables to considerably increase the n-6/n-3 ratio in diet without changing subject’s dietary habits;
- Beneficial effects of an increase n-3 supply in a group of middle-aged men on lowering diastolic BP and increasing HDL in nonsmokers.
3

Cardiovascular risk factors among prisoners
Author(s)/
Country
Wang et al . (2009)
US
Sazhin &
Reznik
(2008)
Australia
Design
Prospective
Longitudinal
Retrospective population survey
Aim/objectives
To examine whether a history of incarceration is associated with the development of CVD risk factors, to explore possible mechanisms and outcomes of this association, and to examine access to health care among those with prior incarceration
Do certain specialised populations, for example patients who were incarcerated and received psychiatric care in prison, also have higher prevalence rates of cardiovascular risk factors?
Population and
Sample size
4350 (288)
Young adults
-Age (45% 18-24 yrs.; 55% 25-30 yrs.)
-Sex: (55% male, 45% female)
Race: 52% black, 48 white
-44 patients
-Mean age: 35.5
± 9.9 years
Diagnosis of major mental illnesses
Data collection and analysis methods
Interview:
Questionnaire
-CARDIA study
-Dietary questionnaire
Incarceration history assess through a questions “During the past year did any of the following happen to you” and “went to jail”
-CVD risk factors measured at 5year exam (BP, total cholesterol, diabetes, hypertension)
Potential confounder:
BMI and smoking
Echo measures
-Healthcare access: three questions asked
-Multivariable logistic regression and explored covariates of association using staged models
Secondary analysis:
Fischer exact, t- and chi-square tests
-Data collection method not specified
-antipsychotic medication
-incomplete data: BSL,
BP, lipid profile
-Data analysis method: not specified
Main findings
-Incident hypertension in young adults more common among former inmates than in those without incarceration history even with adjustment for smoking, alcohol and illicit drug use, and family income;
-Incarceration was significantly associated with incident hypertension in groups with higher prevalence of prior incarceration: black men and less-educated participants and was independent of alcohol and illicit drug use;
-Former inmates were more likely to have left ventricular hypertrophy;
-Cholesterol levels and diabetes rates did not differ by history of incarceration
-84% has a history of smoking
-20% with serum cholesterol of >5.1 mmol/L
-18% with triglycerides, >1.7 mmol/L
-Prevalence rate for hypercholesterolemia in this sample (53%) similar to date form a community sample of participants
Limitations/ Rigor Comments
-History of incarceration was only measured in first 2 CARDIA study examinations;
Lack of accurate information about duration, frequency, or nature of incarceration exposure;
Social desirability and recall bias in regard to reporting of illicit drugs;
Possibility of type 1 error as only 3 types of CVD risk factors were chosen but found an association of only incarceration with hypertension
-incomplete data for blood sugar levels, blood pressure and lipid profiles
-Sample include only male patients
-Small sample
-Highlight the impact of prison environment on incidence of CVD risk factors;
-Need for further research to establish whether incarceration is an independent risk factors for the development of hypertension and LVH;
-Or whether incarceration cause hypertension and
CVD
Need for a more thorough review and treatment of cardiovascular risk factors among psychiatric patients in custody.
4

Cardiovascular risk factors among prisoners
Author(s)/
Country
Khavjou et al . (2007)
US
Design Aim/objectives
Not specified To assess the baseline heart disease risk profile of
WISEWOMEN participants screened in a South Dakota state prison and compare it with that of the general
WISEWOMEN population of lowincome, unsecured women in South
Dakota
Population and
Sample size
Incarcerated: n=261
Nonincarcerated: n=1427
Data collection and analysis methods
Survey instrument and interview
-Biophysical and anthropometric measurements
-Blood samples and tests
-Regression analysis and adjusting for demographics
Main findings
-Incarcerated participants had significantly lower (p<0.01) total cholesterol (183 mg/dL) than non-incarcerated participants (199mg/dL)
-Higher percentage of incarcerated women (85%) than non-incarcerated women
(54%) with high cholesterol were unaware of their condition
-Despite a smoke-free status of the prison, 24% of incarcerated participants reported smoking
-Significantly (p<0.01)higher attendance at lifestyle intervention session among incarcerated participants
(53%) than non-incarcerated
(23%) participants;
-Intervention completion rates significantly higher among incarcerated (43%) than nonincarcerated participants
(4%)
Limitations/ Rigor
-Unable to assess changes in baseline heart disease risk factors over a 1-year period;
-Lack of information on duration of incarceration;
-Hence, cannot state with certainty whether observed differences are associated with incarceration or not;
-Comparison of characteristics among incarcerated women is relative to other low-income and underinsured/ uninsured women
Comments
-Highlights the need for screening and education programs in prisons
-Screening help identify cases of abnormal blood pressure and cholesterol that otherwise would go undiagnosed;
-Heart disease screening an intervention is a promising strategy for prison-based settings
-Did not assess differences between incarcerated women who participate in the WISEWOMEN program and those who do not.
-Need for research to test the hypothesis that programs like
WISEWOMEN does improve discharge planning and linkages between released women and community service providers
5

Cardiovascular risk factors among prisoners
Author(s)/
Country
Denney-
Wilson et al . (2007)
Australia
Design
Survey
D’Souza et al . (2005)
Australia
Crosssectional survey design
Aim/objectives
To identify the prevalence of overweight, obesity and associated cardiovascular and fatty liver risk markers in a population of community-supervised young offenders in new
South Wales, Australia.
To compare prevalence estimates of diabetes and CVD risk factors in
Indigenous and non-
Indigenous prisoner population in 1996 and
2001
To compare 2001 prevalence estimates with Australian population data
Population and
Sample size n=518 (n=445 boys and n=73 girls)
Data collection and analysis methods
-Comprehensive interview
-Battery of psychological, cognitive and educational assessments
-Biophysical and anthropometric measurements *(BMI)
-Blood samples and tests (LDL, HDL, ALT, cholesterol and triglycerides)
SPSS: Bivariate analyses, OR and CI
Stratified random sample
1996: n=789
(657 males &
132 females, including 235
Indigenous)
2001: n=916
(748 males &
168 females, including 254 indigenous);
-Mean age:
Indigenous vs. non-Indigenous
(27 vs. 33) for
1996; and in
2001 (27 vs. 32)
-90% response rate (1996) and
85% (2001) survey
-Face-to-face interviews
-Questionnaire: physical and mental health issues
-Biophysical/ and anthropometric measurements: weight, height and BP
-Blood serum tests: non-random blood glucose; cholesterol panel
-Chi square stats,
Fisher’s Exact test
(0.05 level)
-multivariate logistical analysis, Odds ratios and CI (95%)
Main findings Limitations/ Rigor Comments
Cardiovascular risk factor prevalence extremely high compare with other published studies;
-40% boys and over 20% of girls having low levels of
HDL’s
-over 10% of boys and girls having elevated LDL’s
-15% of boys and 30% of girls having raised ALT’s
Suggesting hepatic cell injury;
Cardiovascular and fatty liver disease risk factors were significantly associated with overweight and obesity among boys, but not girls;
-Young people of Aboriginal or Torres Strait Islander decent were at no greater risk than the rest of the population.
-Limitations in terms of interpreting these findings
-No statistical findings is provided to support conclusions that
Aboriginal young offenders were at no greater risk for
CVD
-Study not design to specifically assess obesityassociated morbidity
-Conclusion about
Aboriginal subjects beyond study objective
-Prevalence of hypertension, hypercholesterolemia and smoking lower in 2001 prison sample compare with 1996 survey.
-smoking extremely high in both prison surveys
-No differences in age and sex-adjusted prevalence estimates for any condition;
-Except, prison sample had a higher standardised morbidity ratio for angina than Ausdiab population
- use non-fasting blood sugar levels
- No confirmation of elevated BSL with formal OGTT
-Use vagaries of self-report
-relatively young population
-Highlight the prevalence of
CVD and fatty liver disease risk factors among young offenders;
-Highlights young offenders as among most disadvantage groups vulnerable to a range of health problems;
-Need for more timely intervention to address the complex health needs of this under-served population;
-Need for programmes that address physical, social and mental health needs are required to treat existing risk factors and improve longterm outcomes among young inmates
-Need for more research to identify novel strategies and interventions to improve the health of young offenders.
-Highlights the high prevalence of CVD risk factors, particularly in younger prisoners compare with Australian non-prison population
-Advocate programs for routinely screen for chronic disease conditions
-Highlight the importance of education of prisoners on
CVD and diabetes risk factors and their long-term management;
-Need for further research to investigate CVD risk factors among similar ethnic groups in different countries and evaluate the effect of novel strategies and interventions to improve CVD
6

Cardiovascular risk factors among prisoners
Author(s)/
Country
Nara &
Igarashi
(1998)
Japan
Design
Prospective
Aim/objectives
To test whether physical activity under a prison labour lifestyle with restricted nutrition, abstinence from smoking and drinking alcohol, would enhance change in serum lipids and obesity in bot pre- and postmenopausal female prisoners
Population and
Sample size
Female prisoners n=400
Pre-menopausal: n=312
Postmenopausal
: n=88
Data collection and analysis methods
-Standard medical questionnaire
-Biophysical and anthropometric measurements
-Blood samples and tests
Main findings Limitations/ Rigor Comments
-Both pre- and postmenopausal female prisoners showed decreased in systolic (5.3%) and diastolic pressure (14%), total cholesterol (5.3%), triglycerides (5.8%), LDL’s
(12%) and BMI (13%)
-Both show increase in HDL cholesterol (3.1%)
Postmenopausal groups showed significantly greater percent changes in systolic pressure, diastolic pressure, total cholesterol, HDL cholesterol, triglyceride, LDL cholesterol and BMI’s
-Activity levels prior to incarceration not reported
-Study conducted in a special labour environment hence findings not generalizable to other labour populations of women
-Observed difference between pre- and postmenopausal women in blood pressure and serum lipids cannot not directly be attributed to the menopausal or hormonal status
-Factors such as exercise or psychological effect not accurately calculated
- Appears that BP, the serum lipid concentration and obesity can be altered effectively by strict labour lifestyle interventions such as life in prison;
-It remains more difficult to achieve such changes in postmenopausal than in premenopausal women;
7