February 22, 2022: 10:00 – 4:30 p.m. EST
February 23, 2022: 10:00 – 12:30 p.m. EST
Description
The NIH’s National Heart, Lung, and Blood Institute (NHLBI) and the American Heart Association (AHA) convened a one-and-a-half day workshop on “Promoting Cardiovascular Health of Youth in the Juvenile Justice System and Their Transitions Outside of the System” on February 22-23, 2022. The workshop was opened to the public and over 200 participants registered for the workshop.
The objectives were to:
- Evaluate the current state of knowledge of the epidemiology of obesity and obesogenic behaviors (e.g., nutrition, physical activity/sedentary behavior) in youth who are in the juvenile justice system (JJS).
- Discuss the influence of structural racism and health inequity and other factors related to the health of youth in the JJS.
- Understand the policies and programs on health and nutrition among various types of JJS facilities across geographic regions of the country (statewide, rural, urban, etc.).
- Identify research gaps and opportunities for promoting the cardiovascular health of youth in JJS and their transitions outside of the system.
Key findings of the workshop:
- Currently and formerly incarcerated people, including youth, are more likely to have certain nutrition-related chronic disease and risk factors such as obesity and hypertension compared with the general population.
- There is substantial variation in the robustness of food and nutrition policies for correctional settings, as well as inconsistent accountability related to putting policy into practice.
- Incarcerated persons, including youth, consistently reported low-quality and unappetizing food, limited access to fresh fruits and vegetables, rushed and hostile eating environments, and staff neglect of food safety and quality control measures.
- Limited resources, security concerns, and lack of political will are consistent barriers to improving food quality and nutrition in correctional facilities. Progress requires patience, buy-in from JJS leadership, and robust accountability measures.
Opening remarks were provided by Rear Admiral Dr. Paul Reed, U.S. Public Health Service Deputy Assistant Secretary for Health, Department of Health and Human Services (HHS), who asserted that health equity “will have been achieved when every person has the opportunity to attain their full potential for health and no one is disadvantaged from achieving this potential because of their social position or other socially determined circumstance.” He noted that Social Determinants of Health (SDoH) factors influence the health of youth before they enter the JJS. Exposure to healthy eating and physical activity while in custody has the potential to improve their cardiovascular health for a lifetime and can help society overcome health disparities. Given the high percentage of youth from underrepresented racial and ethnic groups who are confined in juvenile justice facilities and the overall higher risk for cardiovascular disease among non-Hispanic Black people, every effort must be made to adopt the Food Service Guidelines for Federal Facilities to support healthy eating for youth in custody.
The workshop focused on the following discussion topics:
A. Background on Juvenile Justice Systems, Including Health and Nutrition: Race, Trauma, and Adolescent Well-being: An Overview of the Juvenile Legal System
Participants noted that while youth arrests have declined over the past 30 years, racial disparities in youth arrests are increasing each year. Youth in underrepresented racial and ethnic groups are arrested at 2 to 2.5 times the rate of White youth. Black youth accounted for 15 percent of the population in the juvenile court system in 2018. However, they represented 35 percent of juvenile arrests, 39 percent of cases formally processed in juvenile court, 40 percent of cases in which youth were sent to detention to await trial or sentencing, and 51 percent of youth transferred to adult court that year.
Among both law enforcement and the general public, participants across multiple studies perceived Black felony suspects as significantly older and more culpable than they perceived White felony suspects and Latino felony suspects of similar ages. Youth of color are disproportionately sent to residential out-of-home placement after they are adjudicated or plead guilty in the JJS. Black youth are at highest risk of out-of-home placement.
Health Impacts of Detention.
Obesity: Once placed in detention, youth are at serious risk of weight gain and obesity. For example, in one study, the number of youths categorized as overweight or obese increased during the first three months of admission to a juvenile justice facility. Upon admission, 26 percent were overweight, and 12 percent were obese. After three months of incarceration, those rates increased to 66 percent and 26 percent, respectively. Among those taking psychotropic drugs (23 percent), the percentage who were overweight or obese increased from 59% to 78%. The researchers attributed weight gain in penal institutions to psychotropic medications, constrained by poor-quality food choices, and lack of exercise.
Mental Health: Shackling, for example, can worsen preexisting mental health disorders. Detention is associated with interrupted schooling, which may lead to dropping out; increased recidivism and criminal conduct; and exacerbated risk of physical and sexual abuse. Increased length of incarceration is associated with worsened mental health, including depression; significant weight gain that increases with the length of stay; and poor physical health in adulthood, including higher rates of hypertension, and diabetes later in life.
Diet Quality and Nutrition: Food in youth detention facilities often does not comply with federal nutritional standards and tends to be low-quality, processed items that are high in fat, salt, and sugar. Food available in commissaries is less likely to be regulated and often has little nutritional value. Further, because food with a higher nutritional value often costs more, implementing nutrition standards can impact prison budgets and lead to cuts in other health-related resources. The regular meals of youth in solitary confinement may be replaced with “a baked nutritional loaf” or “beans and processed food,” and the youth are not able to supplement meals with snacks from the commissary. Many of these youth experience hair loss and weight loss of up to 20 pounds in a month. Girls in solitary confinement may also experience loss of menstruation because of the changes in diet and increased stress associated with solitary confinement.
Several studies have found that poor nutrition in childhood can lead to the externalization of aggressive, antisocial, and hyperactive behaviors in adolescence. In one study involving youth in detention, one group of participants was given a nutritional supplement as an analogue for a better diet and the other group a placebo. Participants who received extra nutrients ended up committing 26 percent fewer offenses in detention and 37 percent fewer serious or violent offenses. Additional studies have found that sugary drinks and food additives can produce hyperactivity, mental distress, and conduct problems among adolescents.
Physical health: Every year, thousands of youths are placed in solitary confinement while they are in the JJS. Preexisting physical health issues can be exacerbated by altered food intake and a lack of exercise during solitary confinement. The nutritional quality of food for youth in solitary confinement is sometimes lower than for youth in the general JJS population.
In summary, the fundamental drivers of health inequity include structural racism and discrimination, income inequality and poverty, and disparities in opportunity, political power, and governance that limit meaningful participation in changing the system. Black people, Indigenous people, and other people of color (BIPOC) are disproportionately affected by both incarceration and diet-related disease.
Research Opportunities
- Develop studies to understand the health-related harms, including cardiovascular health, of the JJS to youth and address harm reduction in order to promote protective measures and document the effectiveness of alternative approaches to public safety.
- Study innovative approaches to reducing the harm to youth caused by poor nutrition in detention facilities by regulating meals and nutrition within facilities, such as reducing reliance on low-quality, processed food, and tracking weight among youth in facilities.
B. Policy and Food Guidelines in the Juvenile Justice System
Discussions focused on “Eating While Incarcerated: The Experience of Food in the Juvenile Justice System,” “Leveraging Juvenile Justice Food Environments to Advance Health Equity and Strategies to Improve the Food Environment in Juvenile Justice Facilities,” and “Synthesizing Diverse Stakeholder Perspectives.”
A summary of a 2020 report “Eating Behind Bars: Ending the Hidden Punishment of Food in Prison,” Indicated that portion sizes in prison are insufficient and that the quality of the food is poor. Many (>90%) respondents to interviews mentioned “starving” in prison because the quantity of food served was too low and the food quality was too poor to eat. In addition to the poor food quality, noisy and hostile food environments contribute to inadequate food consumption.
Eating environments are important. A growing body of research indicates that eating under poor conditions can impact metabolic health and lead to weight gain. Youth in custody may eat in cafeterias or other spaces that can be too loud or too quiet, as well as too hot or too cold. They generally do not eat with adults in the facility. Meals may be rushed and/or served at inconvenient times, and armed guards may be yelling at the youth. The overall message of eating while incarcerated is that the individual is not worthy of care or dignity. Such questions about worthiness can impact youth long after they have been released from custody.
Food and Trauma. Detention diets are likely to have deleterious impact on youth behavior. Those who are at highest risk of food insecurity at the outset (youth of color and low-income youth) are more likely to be thrust into detention systems in which poor food habits are reinforced. After leaving the JJS, they may have a difficult time maintaining a healthy diet because of work/school reentry issues.
Menu Planning/Reviews. Most menus in facilities are approved by a dietitian. Even so, meals may meet dietary guidelines or the National School Lunch Program requirements, but what is listed on the menu may not match what gets served. Poor nutrition and poor hygiene are common.
Opportunities for Improvement. Areas of opportunity for improving nutrition in juvenile justice facilities include food procurement, menu planning, meal preparation, eating environment, nutrition education, commissary/canteen, visitation, programming, reentry, and oversight. Suggestions from young people have included offering salads, obtaining feedback from youth in custody, allowing participation in food preparation and cooking, eliminating strict time limits for meals, and allowing social interaction while eating.
C. Leveraging Juvenile Justice Food Environments to Advance Health Equity
At the national level, there has been a 40 percent drop in youth incarceration, but members of underrepresented racial and ethnic groups are more likely to be incarcerated and to experience higher rates of disease. Worse health outcomes are associated with length of detention. There has been very little research on the food environments within the JJS across the nation.
The following fundamental drivers of health inequity were identified: structural discrimination, income inequality and poverty, disparities in opportunity, disparities in political power, and governance that limits meaningful participation. The United States incarcerates more youth than any other country and mass incarceration can influence the long-term health outcomes for youth and communities of color. Income inequality makes it difficult for people to access healthful foods prior to incarceration and upon reentry to society.
In summary, presenters noted there is a need to focus on current gaps in meal service regulations. For example, food served at dinner, over the weekend, or during the holidays is required to be served but not addressed by the National School Lunch Program requirements. Commissaries and other food sale points within the JJS also have potential for policy change.
Research Opportunities
- Study the food environment and the type and quality of foods served in the juvenile justice facilities.
- Understand the perspectives of people who have been incarcerated
- Study health equity and advocacy efforts related to the JJS.
Presenters provided their perspectives and strategies to improve the food environment in juvenile justice facilities. These strategies include:
Implementing the HHS Food Service Guidelines for Federal Facilities: Advocating for food-related reforms can reduce harm, facilitate healthy reentry, and leverage institutional purchasing power to foster more equitable shifts in the food system. A project—funded by an innovation, equity, and exploration workgroup grant from AHA’s Voices for Healthy Kids initiative and the Robert Wood Johnson Foundation (RWJF)— convened an ad hoc expert workgroup with the purpose of filling a knowledge gap needed to advance equity through Food Service Guidelines policies.
D. Structural or Systems-based Research Around Implementation of Nutrition Guidelines
The science supporting the Dietary Guidelines for Americans is extensively documented in the Scientific Report of the 2020 Dietary Guidelines Advisory Committee. The committee conducted evidence reviews to examine the relationship between nutrition and health. For children and adolescents, these nutrition-related health benefits include lower adiposity and lower total and low-density lipoprotein (LDL) cholesterol.
Physical Activity. Like the Dietary Guidelines for Americans, the Physical Activity Guidelines for Americans (updated in 2018) makes recommendations by age group. For children and adolescents, it recommends that youth need 60 minutes or more a day of moderate to vigorous physical activity. They should also do activities that are muscle-strengthening and bone-strengthening on three or more days a week. Such physical activity confers benefits to bone health, heart health, weight management, fitness, and cognition, and it reduces the risk of depression. Studies demonstrate that sports and recreational activities provide a positive impact in justice settings, including psychosocial benefits; personal development; increases in self-esteem; development of social skills; reduced anxiety, depression, hopelessness, insomnia, anger, and aggression; and promotion of rehabilitation. These studies also found that sports interventions are not common in justice settings and that younger participants engage more readily.
E. Inherently Unhealthy: The Limits of Justice Intervention for Youth Development and Community Well-being
Impacts of the JJS. Detention is supposed to mean short-term confinement in jail, not prison, prior to processing in court. It is not a synonym for out-of-home placement. In some cities, however, detention is used for long-term confinement (e.g., 3–4 months) because it is inconvenient to transfer the youth elsewhere. Confinement in the JJS serves to advance unacknowledged goals, e.g., detaining youth with problems that could be ameliorated with treatment rather than incarceration.
Research Opportunities
- Examine the landscape of nutrition in JJS facilities across the nation, including those that are privately owned.
- Examine the impact of JJS nutrition-related activities on youth’s future health outcomes.
Steering Committee Members:
Erin Iturriaga, DNP, MSN, RN (NHLBI/DCVS)
Charlotte Pratt, PhD (NHLBI/DCVS)
Funke Ajenikoko, MPH (AHA)
Alison Brown, PhD, MS, RDN (NHLBI/DCVS)
Nicole Redmond, MD, PhD, MPH (NHLBI/DCVS)
Tanya Agurs-Collins, PhD, RD (NCI)
Sung Sug (Sarah) Yoon, PhD, RN (NINR)
Workshop Speakers:
David Goff, MD, PhD
Paul Reed, MD
Kristin Henning, JD
James Demry
Elle Neal, BA
Mikayla Hill, MS, BS
Leslie Soble, MA
Nessia Berner Wong, MPH
Jessi Silverman, MSPH, RD
Janet M. de Jesus, MS, RD
Jeffrey Butts, PhD
Kristen Giombi, PhD
Workshop Material
Workshop Videos:
Day 1:
Day 2:
Contact
For programmatic questions, contact Dr. Iturriaga at erin.iturriaga@nih.gov. For logistical questions, contact Myesha Macdonald at NHLBIWorkshopSupport@nih.gov.