EDITORIAL

 

New times for Prison Health: The constraints of age and metabolic syndrome

Nuevos tiempos para la Sanidad Penitenciaria: los condicionantes de la edad y del síndrome metabólico

 

 

E.J. Vera-Remartínez

Healthcare department of the Correctional Facility of Castellón-I

 

 

Prison health is facing new or at least different times, since the time of control and management of infectious pathology has given way to an increase of non-communicable chronic conditions^1-2, leading to necessary structural and functional readjustment of our organizational system. On one hand, these changes are a direct consequence of an ageing population: life expectancy has grown between 12 and 13 years on average throughout the last 50 years³ from 67 to 79 years in males and from 72 to 85 in females. On the other hand, they are a consequence of unhealthy lifestyles: inappropriate diets, sedentary habits, obesity, smoking, etc. Thus "age" and "metabolic syndrome" have become issues of paramount importance.

Ageing is not synonymus to disease, but the addition of epidemiological risk factors to age entails an increased prevalence of chronic pathology and thus, an increased morbimortality. The average age of Spanish convicts is currently 39 years old, although it should be noted that the number of inmates over 60 years old has increased four-fold so far this century: from 584 to 2071. In fact, the 41 to 60 age group includes 22862 inmates; this is 1 in every 3 Spanish inmates⁴. Therefore, those who are imprisoned, as well as those who have been for a while need more healthcare resources and more frequently need treatment for the control of chronic conditions such as hypertension, dyslipidemia, diabetes, hyperuricemia, COPD or cardiovascular and ischemic pathologies, as it has been already stated in some studies carried out in Spanish prisons⁵.

Metabolic syndrome was first described in 1923 by Swedish MD. Eskil Kylin, who described it as an association between hypertension, increased levels of blood glucose and the presence of gout⁶. Until the 1980s different definitions were used for the same concept, such as Raven's "syndrome X"⁷ which included "several metabolic alterations based on insulin resistance". Currently, according to the International Diabetes Federation (IDF) metabolic syndrome is "a cluster of metabolic alterations including central obesity, reduced HDL cholesterol, raised triglycerides, raised blood pressure and raised fasting plasma glucose"⁸. This syndrome is one of the main public health issues of this century. Studies carried out in our country based on data from different autonomous communities, such as the ENRICA⁹ or the DARIOS¹⁰ study, conclude a prevalence of metabolic syndrome of around 22.7-32.0% in the Spanish population. This is even higher when the same IDF criteria are applied to patients suffering from schizophrenia or bipolar disorder, as the CRESSOB¹¹ study has already pointed out, with a prevalence of 71.1% in males and 65.8% in females. Among predictive factors, the following have been pointed out: genetic risk, sedentary lifestyle, inactivity, diet and the use of second-generation antipsychotics (clozapine, olanzapine, risperidone, quetiapine, ziprasidone or aipiprazole) which minimize extrapyramidal side effects in comparison with first-generation drugs but which increase body weight and the risk of dyslipidemia and/or hyperglycemia, therefore promoting the appearance of metabolic syndrome^12-13. This is especially crucial in prison, where the prevalence of severe mental disorders is four times higher than in the general population¹⁴ and where approximately 44% of patients pursuing psychiatric consultation suffer from psychotic disorders and other conditions treated with neuroleptic drugs.

As we can infer from the aforementioned, the provision of healthcare in prison has to adapt to its ageing population and the increased risk of alterations included in the metabolic syndrome.

To that end, it is not enough simply to remind and discuss it, the implementation of preventive and assistance activities and programs both inside and outside prison is needed, to provide much more that epidemiological data. It is necessary to design and implement preventive strategies (to quit smoking, to promote aerobic exercise, no avoid overweight and obesity, etc.) which should be aimed at reducing the causes of premature death which had been pushed into the background due to the importance of the HIV/AIDS epidemics in prison². Moreover, this will probably need of intensive efforts in the penitentiary context, where some risk habits, such as smoking are especially widespread — some studies estimate that the prevalence of smoking among inmates is around 70-80%^5,16, and thus are difficult to eliminate. Anyhow, it seems evident that the approach for a comprehensive future plan should be based on prevention aimed at modifying lifestyles, especially regarding improved diets, promoting physical activity and quitting smoking. To that end, probably profound social transformation is needed, initiated in children as to promote and integrate health improving activities.

With regard to diet, interventions should be aimed at promoting a Mediterranean diet, which has proved to reduce the incidence of diabetes and therefore reduce the risk of premature death, without disregarding other low-carbohydrate diets and low glycemic load meal plans, nor hypocaloric diets with low saturated fat, trans fat, cholesterol and sugar load¹⁷. In this respect, there has been some field experience in some correctional facilities by means of nutrition specialists helping design meal plans for preventive purposes¹⁸ or by means of workshops and even self-help groups¹⁹, according to Hyppocrate's principle: Let food be your medicine and medicine be your food²⁰.

With reference to physical activity, this has been used to different ends in prison²¹. It has been used to reduce criminality, as a basis for social rehabilitation, as an instrument to reduce drug abuse or to promote personal self-control, among others. If we further consider that physical activity is effective in preventing and treating overweight and obesity, improving insulin resistance (mainly aerobic and strength exercises) and fasting plasma glucose levels in type 2 diabetes, as a therapeutic complement in the control of dyslipidemia and hypertension or as an element in the reduction of the incidence of some types of cancer such as breast or colon cancer²², there can be little doubt that physical exercise is convenient and necessary and thus should be promoted.

Last, the prevention of smoking is of paramount importance in prison, since the prevalence of this habit is almost three times higher than in the general population. It is the largest preventable cause of ill health and premature death in Western countries and therefore, intervention strategies should be implemented by means of prevention, withdrawal and treatment programmes, which should systematically be included in all prisons.

Prison population is ageing and its epidemiological profile has undergone profound changes throughout recent years. Therefore, it is necessary to implement modifications in the healthcare system that will meet such changes. It is time to replace the objective of survival, threatened for so many years by the AIDS epidemics, for qualitative improvements aimed at reducing preventable causes of premature death. It is time, in conclusion, to provide years with more life and not life with more years. To reach maturity and an old age is an extraordinary objective. To further have a good health condition is an essential complement which we cannot renounce.

 

References

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