Abstract

A descriptive, cross-sectional, and quantitative study was conducted in 2019 with 202 participants randomly selected from a male penitentiary, with the application of a questionnaire, clinical care, and laboratory tests to estimate the prevalence of risk factors and noncommunicable chronic diseases in people deprived of their liberty. Data analysis verified associations using Fisher’s Exact Test and Chi-square Test. The predominant sociodemographic profile of the participants consisted of less-educated single, black, over 30 males with high prison recidivism. Most were sedentary smokers with high alcohol and drug consumption before incarceration. We identified prevalence levels of hypertension (24.8%), dyslipidemia (54.5%), overweight (49.9%), metabolic syndrome (16.8%), and diabetes (2.5%). The difficulty in accessing health services associated with long sentences and the unhealthy environment favors the development and deterioration of chronic diseases and their risk factors, a challenge for the organization of prison health care. This setting reiterates the need to apply resources and efforts to implement comprehensive, longitudinal, and equitable care for people deprived of liberty.

Key words:
Prisons; Noncommunicable diseases; Health profile; Health vulnerability

Introduction

The world’s prison population increased by 24% in the early 21^st century, with 175% in South America alone, totaling more than 10.7 million people deprived of liberty (PDL) globally¹1 Walmsley R. World Prison Population List. London: Institute for Criminal Policy Research; 2018.. The number of PDLs has grown by 576% in Brazil since the 1990s, reaching more than 700,000 people, of which 40% are still unconvicted²2 Soares Filho MM, Bueno PMMG. Demografia, vulnerabilidades e direito à saúde da população prisional brasileira. Cien Saude Colet 2016; 21(7):1999-2010.. The state of São Paulo has more than 202,000 male prisoners, a third of the PDLs in Brazil³3 São Paulo. Governo do estado de São Paulo. Secretaria de Administração Penitenciária. [acessado 2021 nov 24]. Disponível em: http://www.sap.sp.gov.br
http://www.sap.sp.gov.br... , distributed in 179 Prison Units (PU), whose most common causes of incarceration are drug trafficking (28%), robbery (26%), theft (12%), and homicides (11%)³3 São Paulo. Governo do estado de São Paulo. Secretaria de Administração Penitenciária. [acessado 2021 nov 24]. Disponível em: http://www.sap.sp.gov.br
http://www.sap.sp.gov.br...

4 Brasil. Ministério da Justiça e Segurança Pública. Levantamento nacional de informações penitenciárias. Brasília: Departamento Penitenciário Nacional; 2019.^-55 Gois SM, Santos Junior HPO, Silveira MFA, Gaudêncio MP. Para além das grades e punições: uma revisão sistemática sobre a saúde penitenciária. Cien Saude Colet 2012; 17(5):1235-1246..

PDLs have fundamental rights similar to all citizens, regardless of the nature of the offense. They are deprived of liberty but not of human rights. Prison should assume a resocializing nature and not revenge or punishment. Extreme conditions such as overcrowding, insalubrity, drug use, violence risk, and poor diet and hygiene affect the health of PDLs and trigger the so-called “the condemned dual penalty”⁶6 Assis RD. A realidade atual do sistema penitenciário brasileiro. Rev CEJ 2007; 11(39):74-78..

Since 1955, the United Nations⁷7 United Nations (UN). Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules). General Assembly; 2015. [cited 2021 abr 22]. Available from: https://undocs.org/A/RES/70/175
https://undocs.org/A/RES/70/175... recommends that every penitentiary establishment has at least one doctor with knowledge of mental health and close links to the general administration of the PU and other points in the Health Care Network (RAS)⁸8 Enggist S, Møller L, Galea G, Udesen C. Prisons and Health. WHO Regional Office for Europe. Copenhagen: WHO; 2014. [cited 2021 nov 21]. Available from: https://www.euro.who.int/__data/assets/pdf_file/0005/249188/Prisons-and-Health.pdf. In 2014, the publication of the National Comprehensive Health Care Policy for People Deprived of Liberty in the Prison System (PNAISP)⁹9 Brasil. Ministério da Saúde (MS). Portaria Interministerial nº 1, de 2 de janeiro de 2014. Institui a Política Nacional de Atenção Integral à Saúde das Pessoas Privadas de Liberdade no Sistema Prisional (PNAISP) no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2014; 3 jan. reiterated the State’s responsibility to provide comprehensive care to PDLs and normalized the promotion, protection, prevention, care, recovery, and surveillance measures.

Even so, few Brazilian units have implemented health teams, hindering access to health services²2 Soares Filho MM, Bueno PMMG. Demografia, vulnerabilidades e direito à saúde da população prisional brasileira. Cien Saude Colet 2016; 21(7):1999-2010.. Notably, the PUs are primarily found in small municipalities, which often do not have a RAS articulated with other complexity levels. Besides the responsibility for comprehensive care at the PU, the municipality receives the migration of the convicts’ relatives, increasing the number of residents, which can influence the general population’s health indicators. Thus, the organization of adequate prison health reduces disease burdens for society as well²2 Soares Filho MM, Bueno PMMG. Demografia, vulnerabilidades e direito à saúde da população prisional brasileira. Cien Saude Colet 2016; 21(7):1999-2010.^,1010 Fernandes LH, Alvarenga CW, Santos LL, Pazin Filho A. Necessidade de aprimoramento do atendimento à saúde no sistema carcerário. Rev Saude Publica 2014; 48(2):275-283.^,1111 Wildeman C, Wang EA. Mass incarceration, public health, and widening inequality in the USA. Lancet 2017; 389(10077):1464-1474..

The World Health Organization (WHO) estimates that chronic noncommunicable diseases (NCDs) are responsible for 60% of annual deaths worldwide and up to 75% of public health expenditures¹²12 García-Guerrero J, Vera-Remartínez EJ, Planelles-Ramos MV. Cambios en el uso de recursos hospitalarios desde la prisión: un estudio de 16 años. Rev Esp Sanid Penit 2012; 14(2):41-49., a profile also expected in PDLs. A Spanish study estimated that 50% of PDLs had some type of chronic disease, the most common being dyslipidemia (DLP) (34.8%), hypertension (17.8%), and diabetes mellitus (DM) (5.3%), and a third of these diagnoses were found during the research¹³13 Vera-Remartínez EJ, Borraz-Fernández JR, Domínguez-Zamorano JÁ, Mora-Parra LM, Casado-Hoces SV, González-Gómez JÁ, Blanco-Quiroga A, Armenteros-López B, Garcés-Pina E, GESESP (Grupo de Enfermería Sociedad Española de Sanidad Penitenciaria). Prevalencia de patologías crónicas y factores de riesgo en población penitenciaria española. Rev Española Sanid Penit 2014; 16(2):38-47.. Data from a paper on PDL mortality obtained a mean age of 34.9 years, whose leading cause (45.8%) was “non-HIV” diseases, such as cardiovascular, tumor, liver, respiratory, circulatory, and infectious diseases (except HIV). Such causes were higher than deaths from HIV/AIDS, which reached 39%¹⁴14 García-Guerrero J, Vera-Remartínez EJ, Planelles-Ramos MV. Causas y tendencia de la mortalidad en una Prisión Española (1994-2009). Rev Española Sanid Penit 2011; 85(3):245-255..

There is a gap in the literature on chronic diseases and their risk factors in PDLs. Settings of increased prison mass, aging of the PDL profile of some prisons, and difficult access to health services warn about the hypothesis that NCDs are still underdiagnosed and, thus, not satisfactorily managed in the prison environment¹³13 Vera-Remartínez EJ, Borraz-Fernández JR, Domínguez-Zamorano JÁ, Mora-Parra LM, Casado-Hoces SV, González-Gómez JÁ, Blanco-Quiroga A, Armenteros-López B, Garcés-Pina E, GESESP (Grupo de Enfermería Sociedad Española de Sanidad Penitenciaria). Prevalencia de patologías crónicas y factores de riesgo en población penitenciaria española. Rev Española Sanid Penit 2014; 16(2):38-47.. Thus, this manuscript aims to estimate the prevalence of NCDs and their risk factors in a PU for general crimes in the state of São Paulo.

Methods

This descriptive, cross-sectional, and quantitative study surveyed the prevalence of the main risk factors for NCDs in a male PU in inland São Paulo, where convicts are serving time for general crimes. The PU has an installed capacity of 853 inmates and had 1,943 inmates at the onset of the study³3 São Paulo. Governo do estado de São Paulo. Secretaria de Administração Penitenciária. [acessado 2021 nov 24]. Disponível em: http://www.sap.sp.gov.br
http://www.sap.sp.gov.br... , with an occupancy rate of 227.8%.

The research followed the WHO recommendations, using the three steps to investigate risk factors for NCDs, consisting of the application of questionnaires, physical examination, and laboratory analysis¹⁵15 Bonita R, de Courten M, Dwyer T, Jamrozik K, Winkelmann R. Surveillance of risk factors for noncommunicable diseases: the WHO STEPwise approach. Summary. Geneva: WHO; 2001., with the VIGITEL¹⁶16 Brasil. Ministério da Saúde (MS). VIGITEL Brasil 2018. Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: MS; 2019. [acessado 2020 abr 23]. Disponível em: https://portalarquivos2.saude.gov.br/images/pdf/2019/julho/25/vigitel-brasil-2018.pdf questionnaire as a theoretical framework given the lack of specific tools for this setting. It was adapted after a pre-test conducted in 2018 with 39 PDLs, where it was possible to adapt the tool and improve planning and data collection due to the field’s uniqueness. The final, non-self-administered questionnaire, with 71 variables, comprised socioeconomic data, lifestyle habits, and current and past information about the health of the participants and their families. Trained researchers applied the tool, following the consent and security criteria established by the PU’s direction and ethical precepts, to ensure the confidentiality of the collected data and voluntary participation. The project was submitted to and approved by the National Research Ethics Committee under Opinion N° 3.095.953 and by the Research Ethics Committee of the São Paulo State Penitentiary Secretariat under Opinion n°3.277.832.

We adopted the formula for finite populations to calculate the sample¹⁷17 Franco LJ, Passos ADC. Fundamentos de epidemiologia. Barueri: Manole; 2011., based on a prevalence of 17% of hypertension and a population of 1,943 individuals, with an acceptable error of 5% and a 95% confidence interval (CI), reaching an “N” of 196 people. The participants were randomly selected, with three prisoners drawn per cell and about 25 participants per sector (eight sectors in total).

After the draw, the participants were invited to present the project and read the Informed Consent Form (ICF). Those who agreed to participate signed the ICF, which was filed in their medical records. The PDLs who did not accept to be part of the study were taken to the pavilion of origin, and the convict from the same cell with the immediately higher registration was invited.

Data were collected from June to December 2019, during school holidays at the PU, where classrooms in the school pavilion were used to facilitate the organization of data collection, ensuring individuality and a reserved and protected space for the application of the questionnaires and clinical care. The research was divided into three stages: in the first stage, the questionnaire was applied, obtaining data from the physical examination and clinical care; laboratory tests were collected in the second stage; in the third stage, a new clinical visit was scheduled for the assessment of tests results and the management of the diagnosed diseases.

The physical examination included the measurement of blood pressure (BP) in both arms of each participant with an automatic device, and weight, height, and waist circumference (WC). Laboratory tests of fasting glucose (FG), glycated hemoglobin, total cholesterol (TC), high-density lipoprotein (HDL), and triglycerides (TGC) were performed under a 12-hour fast. All equipment used was calibrated and recommended by Brazilian scientific societies, as was the measurement, gauging, and diagnosis technique¹⁸18 Sociedade Brasileira de Cardiologia (SBC). 7ª Diretriz brasileira de hipertensão arterial. Arq Bras Cardiol 2016; 107(3, supl. 3):1-103.

19 Sociedade Brasileira de Cardiologia (SBC). Atualização da diretriz brasileira de dislipidemias e prevenção da aterosclerose. Arq Bras Cardiol 2017; 109(2, supl. 1):1-92.

20 Sociedade Brasileira de Diabetes (SBD). Diretrizes da Sociedade Brasileira de Diabetes 2019-2020. São Paulo: Clannad Editora Científica; 2019.

21 Associação Brasileira para o Estudo da Obesidade e da Síndrome Metabólica (ABESO). Diretrizes brasileiras de obesidade. São Paulo: ABESO; 2016.^-2222 Sociedade Brasileira de Cardiologia (SBC). I Diretriz brasileira de diagnóstico e tratamento da síndrome metabólica. Arq Bras Cardiol 2005; 84(supl. 1):1-27..

The test results were reported individually to the participants during the second clinical visit in the third phase. The diagnostic criterion for hypertension was two measurements of systolic blood pressure with values ≥140 mmHg or diastolic blood pressure ≥ 90 mmHg¹⁸18 Sociedade Brasileira de Cardiologia (SBC). 7ª Diretriz brasileira de hipertensão arterial. Arq Bras Cardiol 2016; 107(3, supl. 3):1-103.. A DLP result was considered to change the reference values for TC > 200mg/dL; HDL < 40mg/dL; TGL > 200mg/dL or LDL > 160mg/dL¹⁹19 Sociedade Brasileira de Cardiologia (SBC). Atualização da diretriz brasileira de dislipidemias e prevenção da aterosclerose. Arq Bras Cardiol 2017; 109(2, supl. 1):1-92.. Those with FG results ≥ 126 mg/dL or HbA1C ≥ 6.5% were considered for the diagnosis of DM in at least two collection results on different days²⁰20 Sociedade Brasileira de Diabetes (SBD). Diretrizes da Sociedade Brasileira de Diabetes 2019-2020. São Paulo: Clannad Editora Científica; 2019., and the criterion used for nutritional assessment, according to body mass index (BMI), considered eutrophic individuals those with values lower than 24.9 kg/m², overweight those with values between 25 kg/m² and 29.9 kg/m², and obese those above 30 kg/m^{2 21}. WC was measured at half the distance between the lower surface of the last rib and the upper portion of the iliac crest. Those with WC ≥ 94 cm were considered to have increased cardiovascular risk. However, those with values ≥ 102 cm had an extremely high cardiovascular risk²¹21 Associação Brasileira para o Estudo da Obesidade e da Síndrome Metabólica (ABESO). Diretrizes brasileiras de obesidade. São Paulo: ABESO; 2016.. Metabolic Syndrome (MS) was characterized by three or more of the following criteria: WC > 102cm; TGL > 150mgdL; HDL < 40mg/dL; BP > 130mmHg or 85mmHg and FG > 110mg/dL²²22 Sociedade Brasileira de Cardiologia (SBC). I Diretriz brasileira de diagnóstico e tratamento da síndrome metabólica. Arq Bras Cardiol 2005; 84(supl. 1):1-27..

Due to the restricted entry of electronic equipment in the PU, for security reasons, the data were collected in printed instruments, double-entered, and validated in Microsoft Excel^R. We performed quantitative data analysis through absolute frequencies, percentages, contingency tables, and measures of central tendency (qualitative variables) and measures such as mean, standard deviation, minimum, median, and maximum (quantitative variables)¹⁷17 Franco LJ, Passos ADC. Fundamentos de epidemiologia. Barueri: Manole; 2011.. Fisher’s exact test and chi-square test were used for variable correlations. The analyses presented were performed using the R software, version 3.4.1, and the JASP program, version 0.12.1, adopting a significance level of 5% for all comparisons²³23 Gomes F. Correlações em R. 2017. [acessado 2020 abr 23]. Disponível em: http://rstudio-pubs-static.s3.amazonaws.com/333174_2dd6bca1e4cc43159f088229 bb76633e.html
http://rstudio-pubs-static.s3.amazonaws.... .

Results

A total of 228 people were drawn, with 26 losses related to refusals (13), dropouts (4), transfers (7), and serving a sentence (2), with a mean age of 36.5 years, a median of 35.4 years (minimum 21 and a maximum of 64 years), with more than 75% in the age group over 30 years. Most (53%) were single, mixed-race, or black (64.4%), with incomplete elementary school (57%) and 12.4% of illiteracy (Table 1).

The rate of penitentiary recidivism was 84.1%, with a tendency for singles to be more recidivists (p < 0.001) (OR = 4.579; 95%CI 2.788-7.522). About 60% of respondents reported having been arrested two to four times. The total sentence ranged from 1 to 79 years, with a mean of 15 years and a median of 11 years. On average, 44.3% of respondents served 50% of the sentence. At least on one occasion, PU health service clinical care was declared by 58.4% of respondents.

Most respondents were classified as sedentary (70.3%), and the main exercises cited were soccer, running, and weight training. Being active suggested a protective association with tobacco use in prison (OR = 0.399; 95%CI 0.212-0.749). Regarding eating habits, only 11.9% (n = 24) (95%CI 7.8%-17.2%) reported daily consumption of vegetables or fruits.

As for tobacco use habits before incarceration and in the PU, there was a slight reduction from 54% to 49%, respectively (p < 0.001) (95%CI 1.14-2.36). The mean consumption of tobacco in the PU was 11.7 cigarettes/day, mainly straw cigarettes (67%). About 25% of PDLs smoked a pack or more/day, with smokers in all cells and sectors ranging from 29.1% to 68% of inmates per cell. Most (86.2%) started smoking before age 18, with a third reporting frequent tobacco use at age 12 or younger. The younger population (18-33 years) had a higher risk for tobacco use (OR = 1.8; 95%CI 1.036-3.197).

Most reported habitual consumption of alcohol (62.4%) and drugs (90.1%) before imprisonment, mainly marijuana (93.9%), cocaine (72%), and crack (24.2%). Young people (18-33 years) had a higher risk of drug use before arrest (OR = 3.35; 95%CI 1.08-10.42), unlike those aged over 50, whose tendency was protective (OR = 0.042; 95%CI 0.01-0.16).

Approximately 47.5% of the interviewed reported having a first-degree family history of hypertension, and 11.4% reported being hypertensive. After the BP measurements, a total prevalence of 24.8% was obtained for hypertension (13.4% of new diagnoses), with a predominance of stage 1 (55.6%), followed by stages 2 and 3, 29.6% and 14.8%, respectively (Table 2). The family history of first-degree relatives doubled the risk of developing hypertension (OR = 2.150; 95%CI 1.127-4.10).

The assessment of nutritional status per BMI identified that 50% were eutrophic, 35.6% overweight, and 13.4% obese. The assessment of waist circumference showed that 144 participants had values below 94 cm and 58 had increased cardiovascular risk (> 94 cm), of which 31 had a huge WC (> 102 cm) and, consequently, a higher cardiovascular risk.

Regarding dyslipidemia, 27.7% of the participants had altered values for TC and 28.2% for HDL concerning the adopted parameters. TGL and LDL levels showed values within the desired parameters, 66.8% and 74.6%, respectively (Table 2). Considering the value of lipids, 54.5% of respondents showed changes in any of the parameters analyzed, of which 98 were newly diagnosed cases.

Only four participants reported having a DM diagnosis, of which two were using insulin. Another DM diagnosis was performed after the laboratory investigation (Table 2). The investigation for MS revealed a prevalence of 16.8% of individuals with three or more of the five criteria necessary for the diagnosis.

Discussion

The participants’ profile is over-represented by less-educated black people, and a growing age of PDLs was observed. NCDs are a reality in the PU, impacting the health of PDLs and the organization of care by health professionals. DLP and hypertension were the significant diseases diagnosed, along with the associated risk factors (overweight, obesity, increased WC, physical inactivity, tobacco use, and previous drug use).

Participants had a low schooling level, with an illiteracy rate almost double that of the Brazilian population²⁴24 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional por Amostra de Domicílios Contínua 2012-2018. 2018. [acessado 2020 abr 24]. Disponível em: https://www.ibge.gov.br/estatisticas/sociais/educacao/9173-pesquisa-nacional-por-amostra-de-domicilios-continua-trimestral.html?=&t=downloads
https://www.ibge.gov.br/estatisticas/soc... . Offering literacy in the PU may not change this reality since the occupation of vacancies in the prison school is not subject to the schooling level criterion but good behavior, personal interest, and available vacancies. The impact of low schooling allegedly perpetuates on the professional career, hindering reintegration into the labor market and less financial stability in post-prison life, which may reduce the opportunities for the social reintegration of those leaving the prison system and reflect on the recidivism rate. In this sense, we observed that the data found on penitentiary recidivism in the PU are more significant than the national literature (46.03%)²⁵25 Adorno S, Bordini EBT. Reincidência e reincidentes penitenciários em São Paulo, 1974-1985. Rev Bras Cien Sociais 1989; 9(3):70-94.. The tendency for single people to be more prone to recidivism highlights the importance of family as a protective and receptive factor, also found in Australia²⁶26 Australian Institute of Health and Welfare (AIHW). The health of Australia's prisoners. Cat. no. PHE 246. Canberra: AIHW; 2018..

Concerning self-declared skin color, more than two-thirds were blacks or browns, as the reality observed in the U.S., where incarceration has a more significant impact on the poor and ethnic minorities, where blacks are more likely to be incarcerated, have imprisoned relatives and neighbors, and greater risk of parental incarceration¹¹11 Wildeman C, Wang EA. Mass incarceration, public health, and widening inequality in the USA. Lancet 2017; 389(10077):1464-1474..

This study presented a population with an older age group than other national prevalence surveys. More than 70% of PDLs were over 30, while data from Rio de Janeiro show that 55% of PDLs were up to 29 years old, a percentage that did not reach 23% in the results of this study²⁷27 Minayo MCS, Constantino P, organizadores. Deserdados sociais. Condições de vida e saúde dos presos do Estado do Rio de Janeiro. Rio de Janeiro: Fiocruz; 2015.. National data reveal an increase in those over 30 from 44.93% in 2014 to 77% in 2020⁴4 Brasil. Ministério da Justiça e Segurança Pública. Levantamento nacional de informações penitenciárias. Brasília: Departamento Penitenciário Nacional; 2019.. These data align with international studies that observe aging in prison²⁸28 Wang EA, Aminawung JA, Ferguson W, Trestman R, Wagner EH, Bova C. A tool for tracking and assessing chronic illness care in prison (ACIC-P). J Correct Health Care 2014; 20(4):313-333.. Moreover, the participants’ mean length of sentence was similar to the national mean, in which 74.4% of prisoners serve a sentence of up to 15 years⁴4 Brasil. Ministério da Justiça e Segurança Pública. Levantamento nacional de informações penitenciárias. Brasília: Departamento Penitenciário Nacional; 2019., showing a long period of stay in an unhealthy environment with difficult access to health services and conducive to the development and aggravation of diseases.

The high profile of a sedentary lifestyle (70.30%) contrasted with the national mean of men engaging in moderate physical activity (45.4%), which tends to decrease with age and increase with education level¹⁶16 Brasil. Ministério da Saúde (MS). VIGITEL Brasil 2018. Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: MS; 2019. [acessado 2020 abr 23]. Disponível em: https://portalarquivos2.saude.gov.br/images/pdf/2019/julho/25/vigitel-brasil-2018.pdf. A study in Australia²⁹29 Hannan-Jones M, Capraa S. Prevalence of diet-related risk factors for chronic disease in male prisoners in a high secure prison. Eur J Clin Nutr 2016; 70(2):212-216. evaluated risk factors for NCDs and found a high proportion of actives (84%). Possible factors for the sedentary lifestyle findings of this study are sector crowding, restricted shared space during sunbathing, lack of institutional projects that promote physical activities, or perpetuation of a little habit of exercise acquired before prison. Research on the impact of physical activity on PDLs concluded that ten of the 11 studies reported significant changes in self-reported mental and physical health³⁰30 Sanchez-Lastra MA, Álvarez VD, Pérez CA. Effectiveness of prison-based exercise training programs: a systematic review. J Phys Act Health 2019; 16(12):1196-1209.. Besides its leisure nature, physical activity can reduce the risk of diseases, promote health, provide general well-being, and contribute as a rehabilitating and resocializing tool. However, the main challenges in implementing these projects were the lack of resources and difficulty recruiting qualified personnel³¹31 Conselho Federal de educação Física (CONFEF). Atividade física e ressocialização. Rev Educ Fis 2017; 66:8-10..

The respondents believe that the low daily consumption of vegetables (11.9%) was justified by the unavailability of meals, especially vegetables. In the Brazilian population, 33.9% consume fruits and vegetables, which is lower among men (27.7%)¹⁶16 Brasil. Ministério da Saúde (MS). VIGITEL Brasil 2018. Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: MS; 2019. [acessado 2020 abr 23]. Disponível em: https://portalarquivos2.saude.gov.br/images/pdf/2019/julho/25/vigitel-brasil-2018.pdf, but more than double the documented in the PU. The WHO recommends a daily intake of at least 400 grams of this food group, equivalent to five daily servings¹⁶16 Brasil. Ministério da Saúde (MS). VIGITEL Brasil 2018. Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: MS; 2019. [acessado 2020 abr 23]. Disponível em: https://portalarquivos2.saude.gov.br/images/pdf/2019/julho/25/vigitel-brasil-2018.pdf. Studies point to inmates’ dissatisfaction regarding access, food variability, frequency of meals, and quality of preparation²⁷27 Minayo MCS, Constantino P, organizadores. Deserdados sociais. Condições de vida e saúde dos presos do Estado do Rio de Janeiro. Rio de Janeiro: Fiocruz; 2015.. A strategy to improve the availability of vegetables already implemented in some PUs involves organic garden projects to offer new jobs within the prison and the local production of some fresh supplies³²32 Jucá K. Horta da Penitenciária II de Pontim emprega reeducandos. Secretaria de Administração Penitenciária. 2020 fev 18. [acessado 2020 abr 23]. Disponível em: http://www.sap.sp.gov.br/noticias/not1626.html
http://www.sap.sp.gov.br/noticias/not162... .

PUs remain one of the few closed environments where tobacco use is still allowed²⁷27 Minayo MCS, Constantino P, organizadores. Deserdados sociais. Condições de vida e saúde dos presos do Estado do Rio de Janeiro. Rio de Janeiro: Fiocruz; 2015.^,3333 Rochadel S, Moura RJ. População Prisional. In: Gusso G, Lopes JMC, Dias LC, organizadores. Tratado de medicina de família e comunidade: princípios, formação e prática. Porto Alegre: Artmed; 2019. p. 508-513.. The general Brazilian population trends towards a decrease in smoking over the years. About 20 million smokers, or 15.6% of the population, were identified from 2006 to 2012. In 2018, these values were even lower, 9.3% for the general population and 12.1% for males¹⁶16 Brasil. Ministério da Saúde (MS). VIGITEL Brasil 2018. Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: MS; 2019. [acessado 2020 abr 23]. Disponível em: https://portalarquivos2.saude.gov.br/images/pdf/2019/julho/25/vigitel-brasil-2018.pdf^,3434 Instituto Nacional de Ciência e Tecnologia para Políticas Públicas do Álcool e Outras Drogas (INPAD). O consumo de tabaco no Brasil (2006/2012). In: INPAD. Segundo levantamento nacional de álcool e drogas. São Paulo: INPAD/UNIAD/UNIFESP; 2014. p. 44-53.. This smoking cessation aspect is not reflected in PUs. A lower number of cigarettes/day after incarceration is observed, possibly influenced by the difficult access, but with habit preservation. In Rio de Janeiro, lifetime tobacco use was reported by 65.5% of respondents, in line with Spanish data, where 71% of male habitual smokers were found¹³13 Vera-Remartínez EJ, Borraz-Fernández JR, Domínguez-Zamorano JÁ, Mora-Parra LM, Casado-Hoces SV, González-Gómez JÁ, Blanco-Quiroga A, Armenteros-López B, Garcés-Pina E, GESESP (Grupo de Enfermería Sociedad Española de Sanidad Penitenciaria). Prevalencia de patologías crónicas y factores de riesgo en población penitenciaria española. Rev Española Sanid Penit 2014; 16(2):38-47.^,2727 Minayo MCS, Constantino P, organizadores. Deserdados sociais. Condições de vida e saúde dos presos do Estado do Rio de Janeiro. Rio de Janeiro: Fiocruz; 2015.. Australian data show a tobacco use prevalence of close to 80% in prisons, a value four times higher than in the general population, and the preferential use of hand-rolled cigarettes (96%)³³33 Rochadel S, Moura RJ. População Prisional. In: Gusso G, Lopes JMC, Dias LC, organizadores. Tratado de medicina de família e comunidade: princípios, formação e prática. Porto Alegre: Artmed; 2019. p. 508-513..

In this research, about half of the respondents were smokers, mainly of straw cigarettes, which are more toxic than the standard filter cigarette. Straw cigarettes have higher nicotine and tar content, and more smoke is inhaled with each puff, increasing the risk of tobacco-related diseases³⁵35 Muakad IB. Tabagismo: maior causa evitável de morte do mundo. Rev Fac Dir Univ São Paulo 2014; 109:527-558..

Considering smokers in all sectors and overcrowding, the number of cigarettes per day, lack of ventilation, and the probable consumption inside the cells, we can estimate that all of them could be passive smokers while serving their sentence in a closed regime. It is further condemnation of deprivation of liberty, as cited by the U.S. Supreme Court as “cruel and unusual punishment”³³33 Rochadel S, Moura RJ. População Prisional. In: Gusso G, Lopes JMC, Dias LC, organizadores. Tratado de medicina de família e comunidade: princípios, formação e prática. Porto Alegre: Artmed; 2019. p. 508-513.. Given this setting, partial or total bans have been implemented in U.S. prisons for disease prevention and fear of lawsuits by non-smokers³³33 Rochadel S, Moura RJ. População Prisional. In: Gusso G, Lopes JMC, Dias LC, organizadores. Tratado de medicina de família e comunidade: princípios, formação e prática. Porto Alegre: Artmed; 2019. p. 508-513..

The prevalence of alcohol-related problems is high among PDLs, considered the most significant public health issue in Europe⁸8 Enggist S, Møller L, Galea G, Udesen C. Prisons and Health. WHO Regional Office for Europe. Copenhagen: WHO; 2014. [cited 2021 nov 21]. Available from: https://www.euro.who.int/__data/assets/pdf_file/0005/249188/Prisons-and-Health.pdf. Data showed high consumption of alcohol before arrest by most respondents, above the mean consumption of alcoholic beverages (five or more drinks per occasion) by Brazilians in the community (17.9%)¹⁶16 Brasil. Ministério da Saúde (MS). VIGITEL Brasil 2018. Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: MS; 2019. [acessado 2020 abr 23]. Disponível em: https://portalarquivos2.saude.gov.br/images/pdf/2019/julho/25/vigitel-brasil-2018.pdf. Evidence points to the association between alcohol use and criminal activity, family violence, mental disorder, risky sexual behavior, and unemployment, where the prison environment is an opportunity for detecting and treating those with alcohol abuse⁵5 Gois SM, Santos Junior HPO, Silveira MFA, Gaudêncio MP. Para além das grades e punições: uma revisão sistemática sobre a saúde penitenciária. Cien Saude Colet 2012; 17(5):1235-1246.^,88 Enggist S, Møller L, Galea G, Udesen C. Prisons and Health. WHO Regional Office for Europe. Copenhagen: WHO; 2014. [cited 2021 nov 21]. Available from: https://www.euro.who.int/__data/assets/pdf_file/0005/249188/Prisons-and-Health.pdf^,2626 Australian Institute of Health and Welfare (AIHW). The health of Australia's prisoners. Cat. no. PHE 246. Canberra: AIHW; 2018..

Most respondents reported using illicit drugs before prison, and marijuana and cocaine were the most cited by users, data similar to those found in national and European studies⁵5 Gois SM, Santos Junior HPO, Silveira MFA, Gaudêncio MP. Para além das grades e punições: uma revisão sistemática sobre a saúde penitenciária. Cien Saude Colet 2012; 17(5):1235-1246.^,88 Enggist S, Møller L, Galea G, Udesen C. Prisons and Health. WHO Regional Office for Europe. Copenhagen: WHO; 2014. [cited 2021 nov 21]. Available from: https://www.euro.who.int/__data/assets/pdf_file/0005/249188/Prisons-and-Health.pdf. Drug use was more common among younger people, and aging was a protective factor in the PU. This reality was also observed in Australia, among 74% of the youngest and 42% of those over 45 years of age²⁶26 Australian Institute of Health and Welfare (AIHW). The health of Australia's prisoners. Cat. no. PHE 246. Canberra: AIHW; 2018.. The use of illicit drugs by men deprived of their liberty is reported three times more often than people in the community, with clinical and social repercussions²⁶26 Australian Institute of Health and Welfare (AIHW). The health of Australia's prisoners. Cat. no. PHE 246. Canberra: AIHW; 2018..

The identified diagnoses of hypertension are close to the self-reported prevalence for people over 18 years of age (25%)¹⁶16 Brasil. Ministério da Saúde (MS). VIGITEL Brasil 2018. Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: MS; 2019. [acessado 2020 abr 23]. Disponível em: https://portalarquivos2.saude.gov.br/images/pdf/2019/julho/25/vigitel-brasil-2018.pdf and slightly below the diagnosed rate (32.5%)¹⁸18 Sociedade Brasileira de Cardiologia (SBC). 7ª Diretriz brasileira de hipertensão arterial. Arq Bras Cardiol 2016; 107(3, supl. 3):1-103.. However, it is noteworthy that hypertension is more prevalent in patients aged over 60 years (44.4%), a profile different from the prison population studied. The values were higher than those found in a study conducted in Rio de Janeiro, where PDLs aged 20-29 reported having cardiovascular diseases in 17.5%²⁷27 Minayo MCS, Constantino P, organizadores. Deserdados sociais. Condições de vida e saúde dos presos do Estado do Rio de Janeiro. Rio de Janeiro: Fiocruz; 2015.. The increase in the number of hypertension diagnoses suggests the importance of systematically tracking new cases.

A relevant challenge in this setting involves the longitudinal follow-up of patients with hypertension and the management of the hypertensive crisis, with comprehensive care required but not always available at the PU and, sometimes, with the need for referrals to other points of the RAS. Extramural trips of the PDLs under the custody of the State demand coordination between health services, security, and police escort. It is essential to consider that most PUs are in small municipalities, thus not always with sufficient resources and infrastructure to accommodate the flow of referrals to medium and high complexity²2 Soares Filho MM, Bueno PMMG. Demografia, vulnerabilidades e direito à saúde da população prisional brasileira. Cien Saude Colet 2016; 21(7):1999-2010.^,1010 Fernandes LH, Alvarenga CW, Santos LL, Pazin Filho A. Necessidade de aprimoramento do atendimento à saúde no sistema carcerário. Rev Saude Publica 2014; 48(2):275-283..

Almost half of the participants were overweight (BMI > 25 kg/m²), a value slightly lower than that observed in the Brazilian male population (57.5%)¹⁶16 Brasil. Ministério da Saúde (MS). VIGITEL Brasil 2018. Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: MS; 2019. [acessado 2020 abr 23]. Disponível em: https://portalarquivos2.saude.gov.br/images/pdf/2019/julho/25/vigitel-brasil-2018.pdf. The prevalence of obesity among those overweight was 37.5%, a value higher than that found in national data (30%)³⁶36 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde: 2019, atenção primária à saúde e informações antropométricas Brasil. Rio de Janeiro: IBGE; 2020.. Likewise, international studies carried out with PDLs also found a higher prevalence of overweight in Spain (51.9%), the U.S. (69.4%), and Australia (72.5%)¹³13 Vera-Remartínez EJ, Borraz-Fernández JR, Domínguez-Zamorano JÁ, Mora-Parra LM, Casado-Hoces SV, González-Gómez JÁ, Blanco-Quiroga A, Armenteros-López B, Garcés-Pina E, GESESP (Grupo de Enfermería Sociedad Española de Sanidad Penitenciaria). Prevalencia de patologías crónicas y factores de riesgo en población penitenciaria española. Rev Española Sanid Penit 2014; 16(2):38-47.^,3737 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.^,3838 Bradshaw R, Pordes BA, Trippier H, Kosky N, Pilling S, O'Brien F, Guideline Committee for the NICE guideline on physical health of people in prisons and the NICE guideline on mental health of adults in contact with the criminal justice system . The health of prisoners: summary of NICE guidance. BMJ 2017; 356:j1318.. Obesity appeared as a more severe condition in the U.S., affecting 23.7% of the PDLs studied³⁷37 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.. Considering overweight as an essential risk factor for the development of NCDs, the literature indicates that even minimal altered values in frequency should not be tolerable in the adult population³⁶36 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde: 2019, atenção primária à saúde e informações antropométricas Brasil. Rio de Janeiro: IBGE; 2020..

DLP was diagnosed in more than half of the population studied, consistent with data from the Brazilian population, whose variation is 43-60% in population-based studies¹⁹19 Sociedade Brasileira de Cardiologia (SBC). Atualização da diretriz brasileira de dislipidemias e prevenção da aterosclerose. Arq Bras Cardiol 2017; 109(2, supl. 1):1-92.. These data corroborate the results observed in the prison population of Australia and Spain¹³13 Vera-Remartínez EJ, Borraz-Fernández JR, Domínguez-Zamorano JÁ, Mora-Parra LM, Casado-Hoces SV, González-Gómez JÁ, Blanco-Quiroga A, Armenteros-López B, Garcés-Pina E, GESESP (Grupo de Enfermería Sociedad Española de Sanidad Penitenciaria). Prevalencia de patologías crónicas y factores de riesgo en población penitenciaria española. Rev Española Sanid Penit 2014; 16(2):38-47.^,3838 Bradshaw R, Pordes BA, Trippier H, Kosky N, Pilling S, O'Brien F, Guideline Committee for the NICE guideline on physical health of people in prisons and the NICE guideline on mental health of adults in contact with the criminal justice system . The health of prisoners: summary of NICE guidance. BMJ 2017; 356:j1318.. Lipid alterations are often neglected by users and health professionals, resulting in a lack of screening and, consequently, underdiagnosis, despite being a significant risk factor for developing NCDs²¹21 Associação Brasileira para o Estudo da Obesidade e da Síndrome Metabólica (ABESO). Diretrizes brasileiras de obesidade. São Paulo: ABESO; 2016..

The low prevalence of DM was similar to data from international studies, ranging from 5.0 to 7.3%¹³13 Vera-Remartínez EJ, Borraz-Fernández JR, Domínguez-Zamorano JÁ, Mora-Parra LM, Casado-Hoces SV, González-Gómez JÁ, Blanco-Quiroga A, Armenteros-López B, Garcés-Pina E, GESESP (Grupo de Enfermería Sociedad Española de Sanidad Penitenciaria). Prevalencia de patologías crónicas y factores de riesgo en población penitenciaria española. Rev Española Sanid Penit 2014; 16(2):38-47.^,3737 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.^,3838 Bradshaw R, Pordes BA, Trippier H, Kosky N, Pilling S, O'Brien F, Guideline Committee for the NICE guideline on physical health of people in prisons and the NICE guideline on mental health of adults in contact with the criminal justice system . The health of prisoners: summary of NICE guidance. BMJ 2017; 356:j1318.. It is worth mentioning that the prevalence of this disease is higher in older patients, whose profile is different from PDLs for general crimes. Since almost half of the respondents were overweight and sedentary, it is necessary to carry out health promotion and prevention actions for the early diagnosis and treatment of DM and its risk factors.

The main challenges of DM are related to early diagnosis, drug control, and prevention of complications since some PUs have insufficient numbers of laboratory tests and drugs¹⁰10 Fernandes LH, Alvarenga CW, Santos LL, Pazin Filho A. Necessidade de aprimoramento do atendimento à saúde no sistema carcerário. Rev Saude Publica 2014; 48(2):275-283.. The use of insulin can be a hindrance to DM management since its application is usually performed only in the PU’s health sector, which requires the articulation of security agents for the daily trips of these patients, even during the night and on the weekends. Likewise, glycemic monitoring performed by finger prick also requires the organization of security agents, health workers, and patients. It may be necessary to provide care at other points of the RAS to investigate DM complications, which implies articulation between the stakeholders involved, available escorts, and vacancies in health services.

Food is also characterized as an aggravating factor for metabolic control. Despite the offer of three daily meals, breakfast (7:00 am), lunch (11:00 am), and dinner (4:00 pm), with food supplementation at night for people with diabetes, PDLs complained about the quality, volume, and variety of food served, mainly in terms of the smaller amount of fruits and vegetables and greater availability of refined foods. It is noteworthy that there is a lack of nutritionists among the PU⁴4 Brasil. Ministério da Justiça e Segurança Pública. Levantamento nacional de informações penitenciárias. Brasília: Departamento Penitenciário Nacional; 2019. servants, which can compromise the development of more balanced menus.

One in four U.S. adults has Metabolic Syndrome. However, few data on its prevalence in Brazil²²22 Sociedade Brasileira de Cardiologia (SBC). I Diretriz brasileira de diagnóstico e tratamento da síndrome metabólica. Arq Bras Cardiol 2005; 84(supl. 1):1-27. are available in the literature. The data found align with national data²²22 Sociedade Brasileira de Cardiologia (SBC). I Diretriz brasileira de diagnóstico e tratamento da síndrome metabólica. Arq Bras Cardiol 2005; 84(supl. 1):1-27. but are lower than the Australian PDL data³⁸38 Bradshaw R, Pordes BA, Trippier H, Kosky N, Pilling S, O'Brien F, Guideline Committee for the NICE guideline on physical health of people in prisons and the NICE guideline on mental health of adults in contact with the criminal justice system . The health of prisoners: summary of NICE guidance. BMJ 2017; 356:j1318.. MS is related to increased cardiovascular risk and general and cardiovascular mortality. In this sense, the findings are alarming and may represent the tip of the iceberg since its development is associated with aging and risk factors such as obesity, increased WC, dyslipidemia, and sedentary lifestyle, found in most PDLs in this study²²22 Sociedade Brasileira de Cardiologia (SBC). I Diretriz brasileira de diagnóstico e tratamento da síndrome metabólica. Arq Bras Cardiol 2005; 84(supl. 1):1-27.. As a result, it is imperative to invest in proposing health promotion and disease prevention actions to change lifestyles and reduce these factors and the establishment of NCDs, which could overload prison health services, burden the State, and attach a more significant burden of suffering and death to this population.

Respondents reported difficulty in accessing the health service since 40% reported never having received clinical care at this unit. In the PHC context, it is estimated that 21.7% of a community would need health care per month, which correlated with the PU studied (1,943 people). It would represent 422 monthly visits, about 14 visits/day, without considering the vulnerability of this population³⁹39 Conselho Nacional de Secretários de Saúde (CONASS). Planificação da atenção à saúde. Oficina 3 - atenção primária à saúde. Rio Grande do Sul: CONASS; 2019.. Possible causes of this lack of care involve the lack of doctors in the team and the care model that historically performs specific walk-in demand actions, without situational diagnosis and planning of health actions²2 Soares Filho MM, Bueno PMMG. Demografia, vulnerabilidades e direito à saúde da população prisional brasileira. Cien Saude Colet 2016; 21(7):1999-2010.^,1010 Fernandes LH, Alvarenga CW, Santos LL, Pazin Filho A. Necessidade de aprimoramento do atendimento à saúde no sistema carcerário. Rev Saude Publica 2014; 48(2):275-283.^,2828 Wang EA, Aminawung JA, Ferguson W, Trestman R, Wagner EH, Bova C. A tool for tracking and assessing chronic illness care in prison (ACIC-P). J Correct Health Care 2014; 20(4):313-333..

NCDs were the leading cause of mortality in 2011, following the global trend of epidemiological transition¹⁴14 García-Guerrero J, Vera-Remartínez EJ, Planelles-Ramos MV. Causas y tendencia de la mortalidad en una Prisión Española (1994-2009). Rev Española Sanid Penit 2011; 85(3):245-255.. International studies have shown that this reality is also found in prisons, as transmissible infectious diseases such as hepatitis and HIV/AIDS, which can now be controlled, do not currently represent the leading cause of mortality in this population¹⁴14 García-Guerrero J, Vera-Remartínez EJ, Planelles-Ramos MV. Causas y tendencia de la mortalidad en una Prisión Española (1994-2009). Rev Española Sanid Penit 2011; 85(3):245-255.^,2828 Wang EA, Aminawung JA, Ferguson W, Trestman R, Wagner EH, Bova C. A tool for tracking and assessing chronic illness care in prison (ACIC-P). J Correct Health Care 2014; 20(4):313-333..

Thus, care models focused on longitudinal care for patients with NCDs and comprehensive actions to prevent diseases and promote health are indicated for citizens and reiterated by the PNAISP for PDLs.

This study’s data are the profile and prevalence of NCDs and their risk factors in a male penitentiary in the state of São Paulo and cannot be extrapolated to those who have not yet been convicted, serving time for sexual crimes, to female PDLs or those under 18 years of age. However, they explain the reality of PDLs for general PU crimes that do not have organized health care as recommended by the PNAISP.

The encounter of ethnic low income and schooling minorities points to the profile of marginalized populations over-represented in prison, with difficult access to education, health, and work services, translated by high illiteracy and penitentiary recidivism rates. The long sentences associated with the unhealthy environment with difficult access to health services favor the development and deterioration of chronic diseases and their risk factors, portrayed by the high prevalence rates of arterial hypertension, dyslipidemia, overweight, tobacco use, and sedentary lifestyle. From the perspective of ensuring the right to health in the prison environment, transforming the curative care model into a comprehensive care modality, emphasizing universal, humanized, and longitudinal care integrated into a resolute, equitable, and efficient care network, is a public health challenge.

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