Improving the Food Environment in Washington State-Run Correctional Facilities, 2021
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Hd_w" OPINIONS, IDEAS, & PRACTICE Improving the Food Environment in Washington State–Run Correctional Facilities: The Healthy Commissary Project Alyssa Auvinen, MPH, Jessica Marcinkevage, PhD, MSPH, Chris Mornick, RD, MPH, Susmitha Nambuthiri, PhD, MSc, Mary Daniel, BS, Brent Carney, RDN, CD, Charles Prather, and Jamie Dolan, MA, BPS Improvements to correctional facilities’ food environment can provide healthier food and beverage options for incarcerated individuals, a population disproportionately affected by chronic disease. This article describes efforts to increase healthy options in the commissary program at Washington State correctional facilities from 2017 to 2019, and the role of a multidisciplinary collaboration between the state’s Department of Corrections, Department of Health, and Statewide Family Council. Through the August 2021, Vol 111, No. 8 Council (SFC), consisting of incarcerated settings can affect incarcerated commissaries; and the Statewide Family ood environments in correctional individuals’ family members. The SFC individuals’ diet and potentially mitigate The HCP improved the nutritional AJPH development, implementation, and promotion of nutrition standards, the nutritional quality of foods and beverages in the commissary program improved. (Am J Public Health. 2021;111(8):1439–1442. https:// doi.org/10.2105/AJPH.2021.306292) F advises with the DOC to improve the or exacerbate chronic disease. quality of life of those incarcerated.1 INTERVENTION nutrition standards and could be sourced through distributors. CI formally adopted commissary nutrition standards in June 2017; products meeting nutrition standards were added to the commissary program in all 12 facilities had access to healthier commis- Washington State correctional facilities’ uals in Washington State correctional commissary. foods and beverages for sale in 12 ensure their sustainability in the of improving the nutritional quality of and (4) monitoring product sales to Commissary Project (HCP), with the goal about healthier commissary offerings; implement, and evaluate the Healthy material for incarcerated individuals (DOH) facilitated a work group to plan, standards; (3) disseminating educational Washington State Department of Health offering products that met nutrition including foods and beverages. The missaries; (2) identifying, procuring, and individuals to purchase products, for products available for sale in com- functions as a store for incarcerated facilities the same month. No products ages by (1) creating nutrition standards The commissary at correctional facilities Washington State–run correctional quality of commissary foods and bever- commissaries. The work group included PLACE AND TIME representatives from the Washington were removed as a result of the HCP. Meetings held in August 2017 and February 2018 helped monitor and evaluate the HCP’s progress. PERSON On average, 16 950 incarcerated individ- sary products on any given day during the HCP (June 2017–May 2019). State data The majority of incarcerated individuals ning, and CI identiﬁed products that met arm of the DOC that operates on average 39 years old during this time. February to May 2017 for project plan- Correctional Industries (CI), the business show that incarcerated individuals were The work group convened monthly from State Department of Corrections (DOC); Notes From the Field Auvinen et al. 1439 OPINIONS, IDEAS, & PRACTICE were male (92%); 70% identiﬁed as White, reviewed products offered in the com- made identifying and categorizing 18% as Black, 14% as being of Hispanic missary and CI’s operating procedure products easier for CI. origin, 5% as American Indian/Alaska used to evaluate product healthfulness; Native, and 4% as Asian/Paciﬁc Islander. and agreed to a timeline for imple- categorized commissary foods, bever- menting changes. At subsequent meet- ages, and condiments into one of three ings, members discussed security and categories: “best choice,” “better choice,” PURPOSE logistic considerations (e.g., foods pack- and “limited” (Table 1). Limited products Because food service in correctional aged in tin cans present a security haz- contained high amounts of fats, sugars, facilities is primarily a closed system, ard) and opportunities to increase or salt (e.g., candy, chips, and soda). incorporating healthier options has the communication to incarcerated individ- Better choice products were lower in potential to positively affect the health of uals about healthier products (e.g., ﬂyers sodium, sugar, and fat than limited incarcerated individuals,2 a population detailing healthier products available). products, but they did not meet best AJPH August 2021, Vol 111, No. 8 shown to have a higher burden of Outside of work group meetings, the choice guidelines. Better choice was chronic medical conditions than the DOH, DOC, and CI updated CI’s operat- included as a category because CI’s old general population.3,4 Foods and bever- ing procedure for determining which operating procedure had three catego- ages available in commissaries are gen- products were healthy. The work group ries, and CI wanted to keep an interme- erally of poor nutritional quality.5 The decided that because of limitations in diate category to demonstrate that it purpose of the HCP was to increase the commissary offerings (e.g., products was offering products that met at least availability of healthier products in must be nonperishable, which excludes some nutrient guidelines. Washington State’s correctional facilities’ many healthy foods like fresh produce), commissaries and assess the uptake of a more accurate descriptor than healthier products through sales “healthy” would be “best choice” for analyses. products that meet speciﬁc food com- The main analysis compared sales of ponent and nutrient guidelines. The best choice foods and beverages versus DOH and CI agreed to align the “best all other foods and beverages (i.e., better choice” products with the US Depart- choice and limited), to allow for better ment of Agriculture’s Smart Snacks in comparability to other studies, and IMPLEMENTATION During the ﬁrst work group convening, EVALUATION 6 the DOC, CI, DOH, and SFC identiﬁed School (“Smart Snacks”). An online tool because these products met estab- shared goals for improving the nutri- was available for determining if products lished nutrition standards. Condiments tional quality of commissary products; met Smart Snacks guidelines, which were not included in the analysis I TABLE 1— Nutrition Standards Developed Through the Healthy Commissary Project Used to Categorize Foods and Beverages in Washington State’s Correctional Facilities’ Commissary Program: June 2017–May 2019 Category 1440 The updated operating procedure Foods Beverages Best choice Meet Smart Snack food component guidelines (i.e., contain whole grains, fruits, vegetables, dairy products, or protein foods) and nutrient guidelines for calories, sodium, total fat, saturated fat, trans fat, and sugar (with the exception that these nutrient guidelines are per serving vs per package, unlike the Smart Snacks guidelines, which calculate nutrient guidelines by package). See Smart Snack guidelines for speciﬁc food component and nutrient requirements and exemptions. Meet Smart Snack guidelines, and include plain or carbonated water; ﬂavored or unﬂavored nonfat and 1% milk and milk alternatives; and 100% fruit juice with no added sugars. Although condiments are not a stand-alone product listed in Smart Snack guidelines, they are products offered in the commissary. Better choice Meet Smart Snacks food component guidelines and all but one of the nutrient guidelines (e.g., the product can be high in sodium and still meet this categorization). Low- and no-calorie (under 60 calories), which includes diet soda. Limited Meet none of the guidelines outlined in the best choice and better choice categories. Meet none of the guidelines outlined in the best choice and better choice categories. Notes From the Field 6 Auvinen et al. OPINIONS, IDEAS, & PRACTICE because of their small contribution to respectively; Figure 1). Overall, data increasing trend in sales of best choice sales and calories. Sales data were plot- showed a 7.5% increase (95% conﬁ- products, from 12% sold in July 2015 to ted over time from approximately two dence interval 5 7.2%, 7.9%; P , .001) in 14% sold in May 2019. years prior to the HCP (the pre-HCP sales of best choice beverages in the ﬁrst period, beginning July 2015) to two years month of HCP implementation (June following initial implementation of the 2017), indicating that individuals were HCP (the post-HCP period, ending May replacing better and limited choice bev- The HCP targeted commissary products, 2019), and an interrupted time series erages with best choice beverages. Sales not meals or other foods and beverages analysis was conducted to account for of best choice beverages showed an available in correctional facilities. Not all seasonal variations and other factors overall 2.6% increase in the post-HCP incarcerated individuals can access the that might affect purchases. Total calo- period, corresponding to 7.2 million commissary, because of lack of money ries sold, by product type (i.e., food, fewer calories from beverages sold or security concerns; therefore, the HCP beverage) and category, was calculated after the HCP compared with before only affected those who used the by multiplying the calories per serving the HCP. There was no signiﬁcant or commissary. times the total servings sold before and meaningful change in best choice food after the HCP. Best choice beverages sales after the HCP compared with made up a greater proportion of bever- before the HCP. Among all foods and age sales after the HCP compared with beverages (combined), there was a Overall, the proportion of foods and before the HCP (63% vs 58%, slight (though not signiﬁcant) beverages for sale that met best choice 7 ADVERSE EFFECTS SUSTAINABILITY AJPH 0 Pre-Best Post-Best 6 Pre-Better+Limited Post-Better+Limited HCP intervention 0 % of Total Beverage Sales • • oo ·o~o~ 60 • • 65 --◊- 0 0 •• • 6 0 55 • • 0 ----.9 0 August 2021, Vol 111, No. 8 70 7.5% jump in sales of “Best Choice” right after intervention 0 o··--~o Pre-HCP Post-HCP 50 0 45 7.5% fall in sales of “Better” + “Limited Choice” right after intervention a ..--------···o •. --··6 ~--6 40 ~~~;-· 66 35 30 Dec 2014 Jul 2015 Jan 2016 Aug 2016 Mar 2017 Sep 2017 Apr 2018 Oct 2018 May 2019 Dec 2019 Date I FIGURE 1— Sales of Best Choice vs Better Choice and Limited Beverages, as Percentage of Total Quantity of Beverages Sold During (July 2015–May 2017) and After (June 2017–May 2019) the Healthy Commissary Project: Washington State Note. HCP 5 Healthy Commissary Project. Dashed line represents linear trend as assessed through an interrupted time series regression analysis7 (model ﬁt R2 5 0.82). Notes From the Field Auvinen et al. 1441 OPINIONS, IDEAS, & PRACTICE criteria increased from 13% before the further increase access to healthy food HCP to 19% after the HCP. Best choice and beverage options. AJPI-I products continue to be offered more than three years after the HCP was ﬁrst implemented, and CI and the DOC continue to promote healthier commissary products through posters and newsletters. The HCP showed how government agencies can collaborate to improve the food environment in correctional facilities. This approach can be replicated in CORRESPONDENCE 4. Maruschak L, Berzofsky M, Unangst J. Medical problems of state and federal prisoners and jail inmates, 2011–12. US Dept of Justice. February 2015 (revised October 4, 2016). NCJ 248491. Available at: https://www.bjs.gov/content/pub/pdf/ mpsfpji1112.pdf. Accessed January 8, 2021. translated to other commissary pro- PUBLICATION INFORMATION grams regardless of size. As a result of Full Citation: Auvinen A, Marcinkevage J, Mornick C, et al. Improving the food environment in Washington State-run correctional facilities: the Healthy Commissary Project. Am J Public Health. 2021;111(8): 1439–1442. 6. US Dept of Agriculture Food and Nutrition Services. A guide to smart snacks in school. 2016. Available at: https://fns-prod.azureedge.net/sites/default/ ﬁles/resource-ﬁles/USDASmartSnacks_508_62019. pdf. Accessed May 17, 2021. grams. CI’s operating procedure can be the HCP’s success, the DOH, DOC, and CI continued collaboration in 2018 to address meals, which affect most incarcerated individuals. PUBLIC HEALTH SIGNIFICANCE Correctional facilities provide an exceptional opportunity for implementing public health nutrition interventions because of the controlled nature of the food environment. Research suggests Acceptance Date: March 16, 2021. DOI: https://doi.org/10.2105/AJPH.2021.306292 CONTRIBUTORS A. Auvinen and J. Marcinkevage conceptualized the study, and A. Auvinen wrote the ﬁrst draft of the article with input and edits from C. Mornick, J. Marcinkevage, M. Daniel, J. Dolan, B. Carney, and C. Prather. S. Nambuthiri performed data analysis, and S. Nambuthiri and J. Marcinkevage interpreted the data for the article. A. Auvinen, J. Marcinkevage, B. Carney, and C. Prather participated in the intervention research on which this article is based. All authors approved the ﬁnal version of the article. that many incarcerated individuals gain excess weight while incarcerated and experience higher rates of chronic medical conditions compared with the general population.3,4 Nutrition interventions are therefore especially important to implement in the correctional setting. ACKNOWLEDGMENTS Funding for this project was provided by the Centers for Disease Control and Prevention (CDC; cooperative agreements NU58DP005531 and NU58DP006504). Note. The contents of this article are solely the responsibility of the authors and do not represent the ofﬁcial views of the CDC. CONFLICTS OF INTEREST The HCP demonstrates the feasibility The authors have no conﬂicts of interest to report. of partnerships between health departments, corrections, and advocacy organizations to implement effective nutrition interventions in correctional HUMAN PARTICIPANT PROTECTION The Washington State institutional review board deemed evaluation activities exempt from review. facility commissaries. This project also serves as a model for implementing nutrition interventions in additional food service venues, such as mealtimes, to 1442 3. Binswanger IA, Krueger PM, Steiner JF. Prevalence of chronic medical conditions among jail and prison inmates in the USA compared with the general population. J Epidemiol Community Health. 2009; 63(11):912–919. https://doi.org/10.1136/jech. 2009.090662 5. Rosenboom LM, Shlafer RJ, Stang JL, Harnack LJ. Evaluation of the nutritional quality of commissary foods offered in American women’s prisons. J Correct Health Care. 2018;24(3):264–275. https://doi. org/10.1177/1078345818782474 country that have commissary pro- August 2021, Vol 111, No. 8 Alyssa Auvinen, Jessica Marcinkevage, Chris Mornick, Susmitha Nambuthiri, and Mary Daniel are with the Prevention and Community Health Division, Washington State Department of Health, Tumwater. Brent Carney is with the Health Services Division, Washington State Department of Corrections, Tumwater. Charles Prather and Jamie Dolan are with Correctional Industries, Washington State Department of Corrections, Tumwater. 2. American Diabetes Association. Diabetes management in correctional institutions. Diabetes Care. 2014;37(suppl 1):S104–S111. https://doi.org/10. 2337/dc14-S104 Correspondence should be sent to Alyssa Auvinen, PO Box 47848, Olympia, WA 98504 (e-mail: alyssa. email@example.com). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. other correctional facilities across the AJPH ABOUT THE AUTHORS gov/family/council.htm#statewide-family-council. Accessed July 2, 2020. Notes From the Field Auvinen et al. REFERENCES 1. Washington State Dept of Corrections. Family Council. 2020. Available at: https://www.doc.wa. 7. Bernal JL, Cummins S, Gasparrini A. Interrupted time series regression for the evaluation of public health interventions: a tutorial. Int J Epidemiol. 2017; 46(1):348–355.