Higher rates of alcohol abuse and illicit drug use in patients with a history of incarceration are well documented and could contribute to increased cardiovascular risk. Injection drug use is associated with contracting HIV and hepatitis C, both of which are independently associated with developing cardiovascular disease. Whether substance abuse and its medical comorbidities contribute to the observed increased cardiovascular disease in this population is unknown. Epidemiologic studies looking at the association between incarceration and cardiovascular disease risk factors, either include measures of a single substance of abuse (Binswanger et al. 2009), do not explore it at all (Wilper et al. 2009), or find that it does not contribute (Wang et al. 2009).
Similarly understudied are the selfmanagement strategies of current and former inmates – their physical activity, diet, pharmacologic adherence behaviors, and how the correctional system environment and its health care system might affect this. The average prison inmate spends an average of 2 years incarcerated, during which time there are limited opportunities for exercise, choice of diet, and self-management of medications. Limited studies have demonstrated that prison diet can either positively or negatively influence cardiovascular risk (Eves and Gesch 2003). Prison diets (inclusive of inconsistent timing and poor availability of sugar-free or fat-free alternatives) have been identified as a source of cardiovascular disease-related complications in some prisons. Even fewer studies examine the association between physical activity and cardiovascular disease risk factors among incarcerated patients. These studies have found that being in prison is associated with a decrease in physical activity among women (Young et al. 2005) but an increase among men (Leddy et al. 2009). Studies examining body mass index during incarceration have found that inmates who serve shorter sentences had a nonsignificant trend for a reduction in body mass index while those who serve longer sentences have significant increases (Leddy et al. 2009). A study of older inmates reveals that being incarcerated can facilitate developing skills in managing one’s cardiovascular risk factors; however, these skills may not be translatable to managing one’s disease in the community (Loeb et al. 2007). In most correctional settings, patients do not manage their own medications. They do not pick up their medications at a pharmacy, dispense their own medications (for example, inject insulin or learn which medications to take at mealtime), nor develop the skills to manage complications of chronic medical conditions, including using a glucometer or sleep apnea machine. These are all skills that are essential to managing chronic conditions upon release to the community. No studies detail how best to provide chronic disease self-management support in correctional settings around hypertension, diabetes, and dyslipidemia, which is a cornerstone of cardiovascular disease risk factor management (Wagner et al. 2001).