Incarceration Is Associated With Increased Cardiovascular Disease Risk Factors

 

In US studies, current and former inmates have higher rates of hypertension (Wang et al. 2009), smoking (Cropsey et al. 2008), and left ventricular hypertrophy (Wang et al. 2009) than the general population. Analyses comparing diabetes in patients with and without a history of incarceration have yielded conflicting results (Leddy et al. 2009). Other studies have shown higher rates of cardiovascular disease risk factors among current and former inmates, but are based on extrapolations from noninstitutionalized Americans (2002), data from single institutions (Baillargeon et al. 2000), or limited to self-reported health outcomes, (Wilper et al. 2009) which may be subject to detection bias given that health care is constitutionally guaranteed in prison. In spite of these limitations, current and former inmates appear to have increased rates of cardiovascular risk factors, including hypertension, diabetes, and smoking.
Mechanisms For Increased Cardiovascular Disease Risk
Despite the evidence supporting the association between incarceration and cardiovascular risk factors and disease, it is not known why this association might exist. There are several plausible biological, behavioral, and psychosocial factors through which incarceration may lead to increased cardiovascular disease morbidity and mortality. No study has determined which or what combination of these potential mechanisms leads to poor health outcomes (Fig. 1).



Incarceration May Be Associated With Dysregulated Stress Responses
As early as 1971, psychiatrist George Engel published a paper reconstructing the events in the hours before 170 people died and described the sudden death of a gentleman just released from prison as evidence that major stressful life events can lead to sudden cardiac death (Engel 1971). While researchers speculate that current and former inmates may have dysregulated stress mechanisms leading to increased risk for poor health outcomes (Massoglia 2008), no studies have examined the association between incarceration and various markers of stress – dysfunction of the hypothalamus-pituitary-adrenal axis, increased catecholamines, blood pressure reactivity, or physiological responses to chronic stresses, as measured by allostatic load. Alterations in these pathways may lead to cardiovascular disease, as elevated catecholamines have direct effects on the heart, blood vessels, and platelets. Catecholamines and cortisol have been implicated in the development of heart failure and cardiac ischemia. Blood pressure reactivity is associated with hypertension (Matthews et al. 2006). And allostatic load, a measure of cumulative stress burden, has been found to be a mediator for social disparities in cardiovascular disease (Sabbah et al. 2008). However, while life post release is stressful and may lead to dysregulated stress responses, this has not been studied.