key: cord-1015501-yvxjsqdo
authors: Al Abosy, Jude; Grossman, Anna; Dong, Kimberly R.
title: Determinants and Consequences of Food and Nutrition Insecurity in Justice-Impacted Populations
date: 2022-05-24
journal: Curr Nutr Rep
DOI: 10.1007/s13668-022-00421-4
sha: fa97a48ec3f351b5d040d3aeada10e981d38a737
doc_id: 1015501
cord_uid: yvxjsqdo

PURPOSE OF REVIEW: The purpose of this paper is to provide an overview of the state of the science of food and nutrition security among justice-impacted populations, identify who might be most at-risk and health consequences, and to highlight areas for continued research and policy implications. RECENT FINDINGS: This population is at-risk for experiencing food and nutrition insecurity due to high rates of unemployment, parental history of incarceration, housing instability, depressive symptoms, and social isolation, which result from involvement with the corrections system. Health consequences associated with food insecurity include depressive symptoms, self-reporting lower health status, and engaging in HIV-risk behaviors. SUMMARY: The justice-impacted population has a disproportionately higher risk of chronic and infectious diseases compared to the general population. Compounding this with food and nutrition insecurity can exacerbate these outcomes and further contribute to poor health. Structural issues related to nutrition safety net programs and employment create barriers to healthy food access. More research related to food, employment, and corrections system policies are critical to improve the well-being of this population.

Food and nutrition insecurity are determinants of health that impact people across the globe. Although food insecurity, defined as the "limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways," [1] includes nutritional adequacy in the definition, much of the focus and how it has been measured has been on access to food to alleviate hunger, while negating the nutritional quality and equity aspects. Therefore, the term nutrition security is a term that has been recently gaining attention due to the emphasis on "having consistent access, availability, and affordability of foods and beverages that promote well-being and prevent (and if needed, treat) disease" [2] . The field of food and nutrition insecurity has been expanding over the past two decades; however, this critical issue in the context of justiceimpacted populations is less well understood.

Much research has studied the adverse physical, psychological, and social outcomes associated with food insecurity. Food insecurity can increase the risk of severe health outcomes, including chronic diseases, such as diabetes, cardiovascular disease, hypertension, asthma, chronic obstructive pulmonary disease (COPD), and kidney disease [3, 4] ; infectious diseases, such as HIV and HIV-hepatitis C (HCV) co-infection [5] [6] [7] ; and mental health conditions, such as depression and anxiety [8, 9] . Food insecurity has also been associated with lower medication adherence in people with diabetes [10, 11] and HIV [5, 12] due to tradeoffs with limited resources.

The prevalence of food insecurity in the USA has remained relatively stable over the past few decades, with the exception of the recession in the mid-2000s [1] . The National Commission on Hunger identified several root This article is part of Topical Collection on Public Health Nutrition causes of food insecurity and hunger, such as underemployment, unstable family environments, low education levels, exposure to violence, a history of racial or ethnic discrimination, and combination of these factors [13] . Americans most at risk of being food insecure are households with children (both single and dual-headed households); Black, non-Hispanic households; and households in the South [1] . In 2015, the National Commission on Hunger also identified seven populations at high risk for experiencing food insecurity: older adults, single parent families with young children, veterans and active duty military, people with disabilities, Native Americans, people who immigrated to the USA, and people impacted by high incarceration rates [13] . The purpose of this paper is to provide an overview of the state of the science of food and nutrition security among justice-impacted populations, identify who might be most at-risk and health consequences, and to highlight areas for continued research and policy implications.

The US corrections system is comprised of the carceral system and community corrections. Of adults under corrections supervision, approximately one-third are in the carceral system and two-thirds are in community corrections [14] .

The US carceral system is inclusive of jails and prisons and houses 25% of the people imprisoned globally. Jails house people who are pre-trial or pre-plea deal, awaiting sentencing, or people sentenced to be incarcerated for a short period, usually for 1 year or less. Prisons house people who are sentenced for a longer term, generally over 1 year. As of 2019 one in every 123 American adults were incarcerated [14] . At midyear 2020, 549,100 people were incarcerated in local jails while 1,215,821 people were incarcerated in state or federal prisons [14, 15] . More than 650,000 adults are released from prison back into the community each year.

[16].

The prison system disproportionately houses people of color with Black adults 5.6 times more likely and Hispanic adults 3 times more likely to be incarcerated compared to White adults [17] . For males ages 18 to 19 years of age, Black males were 12.7 times as likely to be incarcerated and Hispanic males 3.3 times as likely compared to White males in 2018 [17] . Females comprise 7.6% of the people incarcerated in US prisons. For those 18 to 19 years, Black females were 3.6 times as likely and Hispanic females 1.7 times as likely compared to White females to be incarcerated in 2018 [17] . Black adults are convicted of drug felonies at a higher rate compared to White adults even though drug use is comparable between both groups [18] , indicating racial disparities with arrests and prosecutions.

Sixty-five percent of incarcerated US adults have alcohol or substance use disorder [19] . Because the carceral system incarcerates individuals with high rates of drug misuse, predominantly injection drug use, the system houses a substantial number of individuals with higher rates of HCV [20] and HIV. The HIV prevalence is five times higher among the US prison population compared to the general population [21] .

Community corrections include both probation and parole. Probation is serving a sentence while living in the community [22] , while parole refers to the early release of individuals who spend the remainder of their sentence under community supervision [22, 23] . Under both probation and parole supervision, if the conditions imposed by a judge are not met, the result is possible incarceration. Most forms of probation and parole require the person under supervision to regularly meet with a probation or parole officer. About 1 in 59 US adults are under some sort of community supervision [24] . As of 2019, 1 in every 73 US adults were on probation and 1 in every 291 were on parole [24] .

Although data are limited, food insecurity among correctional populations seems to be among the highest of any population, at an estimated 70-91% [25, 26] . Prior research on people impacted by the correctional system have highlighted the social inequities related to securing employment [27] [28] [29] and housing instability [30, 31] that can impact risk for food and nutrition insecurity. Challenges in finding stable employment [32] , federal bans for accessing the Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF) program [30, 31] , as well as residing in communities in which the built environment makes accessing healthy food difficult [33] , create disparities that impact formerly incarcerated people. Table 1 summarizes some identified risk factors for experiencing food insecurity among justice-impacted populations.

Criminal justice-impacted individuals are at particular risk for experiencing food insecurity, though few studies have directly examined the links between incarceration and risk for future food insecurity [34] . Incarceration acts as a stressor contributing to food insecurity in a number of ways following release from jails or prisons, due to economic instability, adverse effects on physical and mental health, and isolating people from social communities [35] . Formerly incarcerated individuals are less likely to be employed in positions that provide sufficient economic stability or social Table 1 Studies demonstrating impact of incarceration on level of food insecurity or who is most at-risk of experiencing food insecurity among justice-involved populations

Cox [40] (3) both personal and family involvement support to prevent future criminal justice contact [32, 36] . Social stigma surrounding incarceration can contribute to food insecurity by damaging social networks for incarcerated people, alienating them from potential support systems . Incarceration has long-term impacts on income and wages, which are considered the main predictors for food insecurity [37] . Applicants with criminal records experience callbacks for jobs at a lower rate than those without criminal records. There is evidence of racial discrimination influencing loss of adult wages following incarceration [37] . While White and Latino respondents see no significant changes in adult wages with criminal justice contact, formerly incarcerated Black respondents earn significantly lower wages [35, 37] , and having a criminal record has been estimated to have a 40% greater impact on job applications for Black applicants compared to White applicants [27] . Additionally, young Black men with a history of incarceration attain lower levels of education and have more difficulty securing stable employment and established households compared to White peers [38] .

Parental incarceration is defined as a disruptive life event for both the incarcerated adult as well as the family they leave at home. A parental history of criminal justice involvement significantly increases odds of persistent household food insecurity by 2.28 times, as well as other factors, such as parental history of school suspension or expulsion (2.46 times odds), parental history of job termination (1.89 times odds), and parental history of institutionalization for mental health (3.49 times odds) [39] . In households with one or both parents who experienced all of these adverse life events, the odds of persistent household food insecurity increase by a factor 13.52 compared to households with parents who experience none of these events [39] .

Families and children of incarcerated people experience financial difficulties and disadvantages leaving them more likely to utilize government aid programs [28] . Using data from the Fragile Families and Child Wellbeing Study, fathers with a history of incarceration were found to provide less cash child support to their families compared to fathers with no history of incarceration while also owing $2130 more in child support debts on average [28] . Child support laws rely on incarceration as a penalty for nonpayment and can lead to vulnerable noncustodial fathers working more hours at lower wages, compared to custodial fathers [29] .

The era of mass incarceration resulted in a 79% increase in incarcerated parents between 1991 and 2007, leaving 1.7 million children with a parent in a state or federal correctional facility [40, 41] . Black individuals born in 1990 were 6.8 times more likely to have an incarcerated parent compared to White individuals [42] . Policies that penalize those at risk of incarceration, such as minimum sentencing, prison without parole, and three-strike laws, disproportionately impact Black families [29, 43] .

There is a dearth of information about the dietary intake and nutrition security of people formerly incarcerated or under community supervision. In our previous research of adults on probation in Rhode Island, we found that most had dietary intakes that did not meet the current Dietary Guidelines for Americans [44] . Foods that were consumed were often processed and high in added sugars, saturated fat, and sodium, indicating nutrition insecurity. Our study also found that most adults on probation purchased foods from grocery stores and prepared meals at home and additionally relied upon government assistance with the SNAP and the Special Supplemental Nutrition Program for Women, Infants, and Children. Even with participation in these government food assistance programs, a majority of our participants on probation experienced food insecurity. Many reported practicing strategies to make food last longer such as reducing consumption and grocery shopping on a budget, which included buying items in bulk, comparison shopping, and going to multiple stores to purchase foods on sale.

Although dietary intakes were suboptimal for health, people on probation reported liking the tastes of healthy foods and understood the connection between dietary intake and health. The constraints of the probation system led to challenges with food affordability and the types of foods available for purchase and consumption.

Justice-impacted populations have increased risks for medical conditions with reports showing that half of adults in the carceral system have at least one chronic disease and almost one-fifth have an infectious disease [45] . Weight gain leading to obesity has been documented among adults while incarcerated in prisons [46, 47] and findings also suggest that people who have been recently released from incarceration have a higher risk of being hospitalized and dying from cardiovascular disease [48] . Correctional supervision involvement and food insecurity can increase perceived stress and may contribute to a higher BMI and obesity [49] . Stress can increase overall consumption of food, but also increases consumption of higher calories via foods rich in sugar and fat, which can displace consumption of healthier foods [50] . As a majority of incarcerated individuals will be released from the carceral system, they will need care for their medical conditions in the community. Improving food and nutrition security among this population is critical to help treat and prevent exacerbation of these medical conditions.

Limited studies demonstrate that adults on probation have a high prevalence of chronic diseases, including hypertension, high blood glucose, and low HDL cholesterol [51] , and mortality [52] . Our study about providing wellness screenings at a probation office identified individuals on probation that had elevated blood pressure and blood pressures categorized as stage 1 and stage 2 hypertension that reported no history of high blood pressure [53] . Additionally, in this study, we found that many people on probation with a history of hypertension had elevated blood pressure during the wellness screening indicating that their blood pressure was not well controlled. These findings indicate that this population may not access healthcare regularly and that many risk factors for cardiometabolic disease may go unnoticed. In another qualitative study we conducted among adults on probation, individuals ranked healthcare as their last priority due to the competing importance of other priorities, such as recovery from substance use disorder, obtaining gainful employment, securing safe housing, and accessing food [54] . This highlights an inability to engage in healthcare due to inequities with social determinants of heath. Among this probation population, we found that being food insecure was associated with an increased odds of experiencing symptoms of depression and self-reporting of a lower health status [51] . Table 2 lists studies that found associated health outcomes related to experiencing food insecurity among justice-impacted individuals.

People recently released from prison or jail who experience food insecurity and were unable to eat for an entire day were at higher risk of engaging in HIV-risk behaviors, including using alcohol, heroin, and cocaine before sex, and to exchange sex for money [26] . Food insecurity among people with HIV has also been associated with poor HIV treatment adherence, insufficient viral load suppression, and lower CD4 counts [55] . Justice-impacted individuals are more likely to have HIV compared to the general population [45] so these factors continue to compound in an already vulnerable population [45] . 

The poor health outcomes among justice-impacted populations are of even greater public health importance because of the disparities in access to healthcare with this population. Previously incarcerated men were more likely to be uninsured than those without a history of incarceration [56] . Previously incarcerated men are also less likely to have access to primary care, often due to their lack of health insurance [57] , which contributes to decremental health outcomes.

However, a recent study demonstrated that formerly incarcerated individuals that received enhanced primary care that focused on patients' behavioral health needs, their chronic health conditions, and utilized community health workers had significantly lower odds (AOR: 0.38; 95% CI 0.16 to 0.93) of returning to prison compared to those who did not have access to enhanced primary care [58] . While 26% of men included in the National Survey of Family Growth had been previously incarcerated, of the uninsured in that survey, 38.6% were formerly incarcerated [59] . The Affordable Care Act (ACA) has increased insurance coverage for people on community supervision, leading to a nearly six percent decline of uninsured formerly incarcerated men after the implementation of the ACA [59] . For example, in Hennepin county, MN, 65.9% of people on probation that were enrolled in Medicaid were eligible because of the Medicaid expansion due to the ACA [60] . Medicaid expansion has reduced recidivism and overall arrests. A 2020 study demonstrated that Midwestern counties with Medicaid expansion reduced rearrests by up to 5.8% and Southwestern counties with Medicaid expansion reduced rearrests by up to 13.3% [61] . These studies suggest that better healthcare coverage could both improve health and reduce recidivism.

In 1996 the Personal Responsibility and Work Opportunity Reconciliation Act produced a ban that prevented anyone with felony convictions for certain crimes including evading arrest, violating the terms of probation or parole, committing welfare fraud by applying for benefits in multiple states, and those with drug violations from accessing SNAP and TANF benefits [31, 62] . As of 2020, 22 states as well as Washington DC have opted out of the SNAP ban. An additional 27 states have modified bans, allowing those with drug felony convictions to receive SNAP benefits with completion of regular drug tests, work requirements, and complying with parole. South Carolina is the only state with a full ban in place.

SNAP is designed to support individuals and households who cannot presently afford food, yet evidence shows that many justice-impacted individuals participating in SNAP remain food insecure [25] . SNAP is meant to be supplemental; however, our study found that most people on probation use SNAP benefits to meet all of their food and nutrition needs [44, 54] . Despite massive growth in the number of people who receive SNAP, the number of those who are considered food insecure continues to rise. A study that examined the "resource gap," the additional income and support that a household would require to be considered food secure, found that an additional weekly income of $41.62 would make households food secure [63] . For households which have zero net income and therefore receive the maximum amount of benefits, this would result in an average increase of benefits of 42%, but lead to a 62% decline in food insecurity among SNAP participants-an endeavor that was estimated to cost about $27 billion [63] .

Under present SNAP regulations, those seeking benefits who are considered Able Bodied Adults Without Dependents (ABAWDs) must fulfill work requirements to qualify. This requirement may be fulfilled by paid labor, unpaid labor, or volunteering for a minimum of 80 hours a month [64] . Those who do not meet this work requirement only maintain their SNAP benefits for 3 months and are not eligible to re-apply for SNAP benefits for another 3 years. These work requirements may pose a challenge for justice-impacted individuals given the difficulties with securing gainful employment. In a sample of adults on probation in Rhode Island, we found that 86% of unemployed individuals without dependents were participating in SNAP and among this group, 52% had gone at least one day in the past month without eating any food [65] , highlighting the difficulties with securing food even with SNAP benefits for the justice-impacted ABAWD population. At the time of this study, the work requirement was not enforced but if it were instituted, these individuals would have a worsening of food security. Additionally, many reported seeking employment but had challenges due to limited opportunities and stigma associated with their involvement with the corrections system. Present SNAP policies ban people with certain felony convictions from accessing food benefits, but this does not prevent these individuals from being counted as household members. This becomes problematic for families and applicants seeking SNAP benefits [66] . Under 21 US Code 862a,"Denial of Assistance and Benefits for Certain Drug-Related Convictions," members of households with felony drug convictions on their records are excluded from the "household" used to define eligibility and allocation of funds [66] . Despite this, the income and resources that these individuals contribute to the household are still counted as part of the household [66] . This in essence means that households will receive fewer funds, for more people, forcing recipients to stretch their monthly benefits to purchase sufficient amounts of food. Such discriminatory policies disproportionately impact Black, low-income men and their families, contributing to intergenerational instability and food insecurity [39, 40] . These policies which restrict access to aid have no real basis other than to be punitive, presenting another barrier to reintegration into communities and contributing to the high rates of recidivism.

Current SNAP and employment policies create significant barriers to food and nutrition security for justice-impacted individuals and continue collateral consequences of punishment. We summarize some future areas for discussion and research to improve the access to healthy, high quality, and affordable foods among this population.

End the SNAP Ban Existing SNAP policies do not adequately support the food security needs of justice-impacted communities. Bans on accessing nutrition aid and benefits that go beyond income-based criteria harm justice-impacted people as well as their families. Additionally, programming to assist this population with applying for SNAP benefits is needed.

End the Work Requirement for SNAP Economic challenges, including difficulties in finding a stable job with livable wages, have ripple effects on the food security of families. With federal law including work requirements for SNAP benefits, many justice-impacted people are put at a severe disadvantage because of the difficulty finding employment.

Increasing the monthly benefit amount would alleviate justice-impacted individuals from experiencing food insecurity [63] . More research is warranted to study whether this increase in benefits would lead to increased purchasing power for healthier food options.

Pandemic Electronic Benefit Transfer (P-EBT) has had profound impacts on reducing food insecurity during the pandemic and poses a unique opportunity for policy makers to improve the accessibility and efficiency of SNAP programs. The prevalence of food insecurity did not increase after 2019, even with the presence of COVID-19, likely due to the Emergency Supplemental Nutrition Assistance Program, although some disenfranchised populations did experience higher rates of food insecurity during this period [1, 67] . Changes to funding in response to increased needs from emergencies are made possible by the entitlement grant model, which is the type of funding SNAP currently functions under. The impending threat of moving to block-granting for SNAP would restrict the ability of officials to adapt programming in real time to respond to economic shocks, such as the COVID-19 pandemic, and force states to rely on a fixed annual budget which would threaten eligibility and decrease benefits, leaving more families unable to access food. Block grants are a set amount of federal funding to states, that are usually based upon an annual expenditure, where states can divert money to other programs. Even in non-pandemic times, lack of resources could challenge money budgeted for SNAP and shift to other programs.

Activist campaigns such as the ban-the-box movement advocate for policies barring employers from asking about conviction histories, reforms which have been implemented in nine states and more than 50 local governments.

Offer More Training Programs for Justice-Impacted Populations A majority of people released from prison or jail will be arrested again in the following 10 years (82%) [68] . The limited resources to aid in the integration back into the community contributes to high recidivism rates in the USA [69] . Reincarceration disrupts income and housing for those working to rebuild a life [27] .

Criminal Justice Reform Efforts to decriminalize drug use and promote decarceration for individuals with minor offenses should be considered to improve outcomes for this population.

This paper summarizes current research that indicates how imperative it is to improve food and nutrition security among justice-impacted individuals. Studies show that the prevalence of food insecurity is extremely high in this sector of the population. Being food and nutrition insecure has been associated with increased risk for depression symptoms, self-reporting a lower health status, and engaging in HIVrisk behaviors following release from prison or during community supervision. The justice-impacted population also experiences health and racial disparities which adversely affects their ability to access healthy and nutritious foods. Policy recommendations to revise nutrition safety net programs and improve employment opportunities for justiceimpacted individuals are provided.

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