INTRODUCTION

The diseases with the greatest incidence amongst the prison population in the last century were those related to the respiratory tract and malnutrition, and unhealthy conditions were a contributory or aggravating factor in such pathologies¹. The Spanish Prison Regulations (Reglamento Penitenciario)² in fact gave great importance to the inmates’ diet. In article 226 of the Regulations it states that “the inmates in all prisons shall be provided with a suitably prepared diet, which should respond to the dietary requirements of the prison population and the specific needs of age, health, work, climate, costumes and, whenever possible, personal and religious convictions”. It also establishes that:

The situation in Catalonia regarding concern for nutrition of the prison population is very similar. The Autonomous Community has had powers since 1983 over the management of prisons after transfer under Royal Decree 3482/83 of 28 December, and the concern over diet can be seen in article 89 of Decree 329/2006, of 5 September³, which specifies:

There are few previous studies about the analysis of diet in Spanish prisons. A study⁴ carried out at the old Barcelona Modelo prison showed after a detailed analysis of quality, quantity, temperature, variety, taste, noise and lighting, that the worst opinion about the food dispensed was reserved for the taste, followed by the variety. What was even more important was that the analysis of the diet, according to the Spanish Healthy Diet Index (IASE)⁵, gave a rating of “acceptable” without being “healthy”.

In Catalonia the collective prison kitchens are managed by a public company of the Regional Government of Catalonia: the Centre of Initiatives for Reinsertion (Centre d’Iniciatives per a la Reinserció (CIRE)). In February 2017, the nutrition department of this company started to redesign the menus and unified many of the diets that had coexisted up till then. This study describes and analyses these new menus using a random gathering of the daily spreadsheets, the new diets offered are checked to see if they are healthy for the prison population and perceptions about the diets taken from a sample of inmates are described. Finally, and analysis is run to see if the new menus match the dietary recommendations for the chronic and metabolic pathologies that are most prevalent amongst the inmates.

MATERIALS AND METHODS

A cross-sectional descriptive study was carried out of the new diets offered by the kitchen service, managed by the public company CIRE, regarding the number of medically prescribed diets and in particular, the description of the diet called the “special diet”. The study was carried out at the Quatre Camins Prison (Barcelona), where approximately 1,400 adult males are interned. Table 1 describes the changes that the supply company began to implement in the first quarter of 2017 to the collective nutrition of Catalonian prisons and in particular, to the Quatre Camins Prison. A template was prepared to give a schematic view of the different meals offered on a given day and the respective dishes (Table 2).

A cross-section dated 26/4/2017 was carried out on the Prison IT System of Catalonia (Sistema Informático Penitenciario de Cataluña (SIPC))⁶ to obtain the diets prescribed by doctors. The analysis by groups of the food in these menus (Table 2), according to the IASE, is described in Table 3. Scores were given of the groups of foods of the daily menus randomly selected from the Department of Nursing/Psychiatry via the IASE. The distribution sheets of meals per module were obtained from the prison kitchen service. The IASE consists of ten variables by groups of foods: cereals-derivatives, vegetables-root vegetables, fruit, milk and derivatives, meat, legumes, sausage-cold meats, sweets, soft drinks-sugar and variety-diet. The categories of the IASE5 have a maximum score of 100 and are classified as: “healthy nutrition”, at more than 80 points; “needs changes”, at between 50 and 80 points; “not healthy”, at 50 points. This scales was drawn up from the Consumption Frequency Questionnaire (Cuestionario de Frecuencia de Consumo (CFC)) and from the recommendations of the Dietary Guides of the Spanish Society for Community Nutrition in 2004 (Guías Alimentarias de la Sociedad Española de Nutrición Comunitaria en 2004). The IASE is based on the methodology used for the HEI, or Healthy Eating Index, and this tool was selected for its usefulness in estimating the quality of the diet in a population, in this case the prison population of Quatre Camins.

The data base of the Primary Healthcare IT System of the Catalonian Health Institute (l’Institut Catalá de la Salut) e-Cap: DbsForm (“Health problems”) was used for the diagnostic classification of pathologies. Inmates’ perceptions were assessed qualitatively by means of a brief interview and completing an ad hoc questionnaire, structured one closed question, four with a value from 1 to 10 points, and three open questions, which were answered by a sample of 22 randomly selected inmates during the nursing examination. Participation was voluntary, anonymous and given under informed consent.

RESULTS

The manager and technical director of the food service of the CIRE informed the healthcare services of the prison via a corporate electronic mail message of the changes to be made to the inmates’ diets, describing in detail what could be prescribed for medical reasons. The diet now called “special” replaces the previous diets issued under medical prescription, depending on the different medical pathologies, such as “diabetic”, “high blood pressure “, “dyslipidemia” or “obesity”.

The Special diet consists of a balanced diet, low in salt (1,500-2,000 mg/day of sodium) and with a heart-healthy lipid profile. It is a diet indicated for any pathology that requires restrictions on salt, that is in a compensated stage, in other words, without severe oedemas or abdominal fluid retention (ascites). In the opinion of the CIRE it is recommended for inmates with high blood pressure, excess weight, obesity or dyslipidemia. The diet can also be used for diabetic inmates as it distributes as part of its composition throughout the day a carbohydrate content of 50-55% of the total energy value (TEV) and is low in fast absorption sugars. Therefore, and according to the nutrition service of the CIRE, this diet excludes pork and uses less fatty, leaner meats such as veal, chicken or turkey. Fried dishes, stews and casseroles are systematically excluded, and so the cooking processes used are without salt, grilled, roast or steamed, boiled in stew form using a dietary approach. The bread and crackers that accompany the dishes are salt free.

Breakfast for inmates with diabetes mellitus type 1 or 2 consists of a sandwich with turkey sausage meat or fat and salt free cheese. They are also given a hot drink. An additional supplement to the breakfast is two crackers with diet jam, and a piece of fruit for elevenses. When lunch is served, they receive four crackers with light cheese slices for an afternoon snack, and with the dinner, they are given a piece of fruit or skimmed milk yoghurt as a night time dietary supplement.

Other medically prescribed diets are not described since they are not associated with metabolic diseases, such as the “soft diet”, “diet without fish”, “astringent diet”, “diet specific celiac diet” and “dairy free diet”.

DISCUSSION

Following the ethnographic lines of the article by Fornons⁷, after the changes established in the diet of the CIRE, it could be seen that pork and pork products were removed from all the diets, regardless of the beliefs professed by the inmate, to make it “healthier”. Only roast pork cheeks are served twice a month as a special dish in the general diet. The fact that this type of meat has been removed from all the diets is a measure that solves the problems of cooking processes crossed with oils or surfaces in contact with different raw materials.

In the study by Sáiz-Izquierdo et al.⁴, negative assessments were given by inmates of the quality, taste, temperature and hardness of the meat, although they did not appear to object to the quantity, since they explained that they could have second helpings. Despite the changes made by the Dietetics and Nutrition Service of the CIRE in 2017, the diet offered only obtains 60.5 points and therefore the evaluation is one of “needs changes”. The outcome obtained by Sáiz-Izquierdo et al.⁴ was 58.4 points, a very similar result, and the researchers suggested changes to improve the scores, which included reducing the consumption of meat and increasing legumes as a main course. This measure could be a good choice, as one of the main complaints from inmates is in fact the hardness or undercooking of the meat. The proposed measure could therefore be an effective one since legumes are tasty, healthy and economical, and the prison would benefit by having a cost-sustainable menu.

It is also interesting to comment on the culinary and cooking techniques, since it is suggested that frying and fats should be avoided and this measure was adopted by almost exclusively using oven cooking, grills or boiling, which possibly makes for a considerable improvement in terms of cardiac health, but which is hardly accepted or even rejected by the inmates. It is one reason why many inmates ask to be taken off the special diet.

There is therefore a major difference between the prescribed “special” diets and the number of diagnoses of metabolic diseases that require this type of diet, which shows that there is a problem of dietary under-prescription.

On the other hand, there are studies^4,9 that affirm that increasing the variety of fresh fruit available at lunch, breakfast or afternoon snack can be a good option in preventing consumption of products from the prison shops, which takes place in over 95% of the surveyed inmates. In some Latin American countries, such as Colombia⁸, families are permitted to bring food into prison for the visits, and are generally typical meals; although in Spain the prison regulations prohibit this practice², probably to ensure control and hygiene of foodstuffs and maintain equality of nutrition amongst the prison population.

The conclusion is that the analysis by groups of foods of the meals offered by the CIRE shows that the diet needs changes, according to the IASE, since the score compared to the previous study in 2014 has hardly changed, despite recent changes in planning of planned menus and new cooking techniques mentioned in this article. It would therefore be advisable for the Dietetics and Nutrition Service of the CIRE to revise the menus, so as to correct the small deviations that were detected. These include reducing cured meats and pastries served on a daily basis, offering more variety in fruit and vegetables, increasing legumes as an option for the main course, and revising the thawing and cooking techniques of foods such as fish, eggs and meat to make them more palatable.

Another aspect requiring improvement is the food offered at the prison shops. It is suggested that products that are recommended for healthy eating should be included, such as sugar-free drinks, different types of fruit, fresh vegetables that can be eaten raw, brown bread and cereals, fresh cheese, etc.

As regards inmates’ perceptions, the improvements made in the first quarter of 2017 have not been noted, either in terms of taste or quality of the meals.

Most of the medically prescribed diets drawn up before 2017 have been simplified by the CIRE in the form of one single diet, the “special diet”, which covers all types of infectious and metabolic diseases. This means that any inmate who has one of these pathologies has to be fed with the same diet.

To sum up, the diet in prison needs to be improved. It is recommended that the food service of the CIRE and prison healthcare teams work together on this area. Implementing programmes to promote healthy habits, as suggested by other authors⁹, may also be beneficial.