Hd_w"

OPINIONS, IDEAS, & PRACTICE

Improving the Food Environment in
Washington State–Run Correctional
Facilities: The Healthy Commissary
Project
Alyssa Auvinen, MPH, Jessica Marcinkevage, PhD, MSPH, Chris Mornick, RD, MPH, Susmitha Nambuthiri, PhD, MSc,
Mary Daniel, BS, Brent Carney, RDN, CD, Charles Prather, and Jamie Dolan, MA, BPS

Improvements to correctional facilities’ food environment can provide healthier food and beverage options
for incarcerated individuals, a population disproportionately affected by chronic disease. This article
describes efforts to increase healthy options in the commissary program at Washington State correctional
facilities from 2017 to 2019, and the role of a multidisciplinary collaboration between the state’s
Department of Corrections, Department of Health, and Statewide Family Council. Through the

August 2021, Vol 111, No. 8

Council (SFC), consisting of incarcerated

settings can affect incarcerated

commissaries; and the Statewide Family

ood environments in correctional

individuals’ family members. The SFC

individuals’ diet and potentially mitigate

The HCP improved the nutritional

AJPH

development, implementation, and promotion of nutrition standards, the nutritional quality of foods and
beverages in the commissary program improved. (Am J Public Health. 2021;111(8):1439–1442. https://
doi.org/10.2105/AJPH.2021.306292)

F

advises with the DOC to improve the

or exacerbate chronic disease.

quality of life of those incarcerated.1

INTERVENTION

nutrition standards and could be
sourced through distributors. CI formally adopted commissary nutrition
standards in June 2017; products meeting nutrition standards were added to
the commissary program in all 12

facilities had access to healthier commis-

Washington State correctional facilities’

uals in Washington State correctional

commissary.

foods and beverages for sale in 12

ensure their sustainability in the

of improving the nutritional quality of

and (4) monitoring product sales to

Commissary Project (HCP), with the goal

about healthier commissary offerings;

implement, and evaluate the Healthy

material for incarcerated individuals

(DOH) facilitated a work group to plan,

standards; (3) disseminating educational

Washington State Department of Health

offering products that met nutrition

including foods and beverages. The

missaries; (2) identifying, procuring, and

individuals to purchase products,

for products available for sale in com-

functions as a store for incarcerated

facilities the same month. No products

ages by (1) creating nutrition standards

The commissary at correctional facilities

Washington State–run correctional

quality of commissary foods and bever-

commissaries. The work group included

PLACE AND TIME

representatives from the Washington

were removed as a result of the HCP.
Meetings held in August 2017 and February 2018 helped monitor and evaluate
the HCP’s progress.

PERSON
On average, 16 950 incarcerated individ-

sary products on any given day during the
HCP (June 2017–May 2019). State data

The majority of incarcerated individuals

ning, and CI identified products that met

arm of the DOC that operates

on average 39 years old during this time.

February to May 2017 for project plan-

Correctional Industries (CI), the business

show that incarcerated individuals were

The work group convened monthly from

State Department of Corrections (DOC);

Notes From the Field

Auvinen et al.

1439

OPINIONS, IDEAS, & PRACTICE

were male (92%); 70% identified as White,

reviewed products offered in the com-

made identifying and categorizing

18% as Black, 14% as being of Hispanic

missary and CI’s operating procedure

products easier for CI.

origin, 5% as American Indian/Alaska

used to evaluate product healthfulness;

Native, and 4% as Asian/Pacific Islander.

and agreed to a timeline for imple-

categorized commissary foods, bever-

menting changes. At subsequent meet-

ages, and condiments into one of three

ings, members discussed security and

categories: “best choice,” “better choice,”

PURPOSE

logistic considerations (e.g., foods pack-

and “limited” (Table 1). Limited products

Because food service in correctional

aged in tin cans present a security haz-

contained high amounts of fats, sugars,

facilities is primarily a closed system,

ard) and opportunities to increase

or salt (e.g., candy, chips, and soda).

incorporating healthier options has the

communication to incarcerated individ-

Better choice products were lower in

potential to positively affect the health of

uals about healthier products (e.g., flyers

sodium, sugar, and fat than limited

incarcerated individuals,2 a population

detailing healthier products available).

products, but they did not meet best

AJPH

August 2021, Vol 111, No. 8

shown to have a higher burden of

Outside of work group meetings, the

choice guidelines. Better choice was

chronic medical conditions than the

DOH, DOC, and CI updated CI’s operat-

included as a category because CI’s old

general population.3,4 Foods and bever-

ing procedure for determining which

operating procedure had three catego-

ages available in commissaries are gen-

products were healthy. The work group

ries, and CI wanted to keep an interme-

erally of poor nutritional quality.5 The

decided that because of limitations in

diate category to demonstrate that it

purpose of the HCP was to increase the

commissary offerings (e.g., products

was offering products that met at least

availability of healthier products in

must be nonperishable, which excludes

some nutrient guidelines.

Washington State’s correctional facilities’

many healthy foods like fresh produce),

commissaries and assess the uptake of

a more accurate descriptor than

healthier products through sales

“healthy” would be “best choice” for

analyses.

products that meet specific food com-

The main analysis compared sales of

ponent and nutrient guidelines. The

best choice foods and beverages versus

DOH and CI agreed to align the “best

all other foods and beverages (i.e., better

choice” products with the US Depart-

choice and limited), to allow for better

ment of Agriculture’s Smart Snacks in

comparability to other studies, and

IMPLEMENTATION
During the first work group convening,

EVALUATION

6

the DOC, CI, DOH, and SFC identified

School (“Smart Snacks”). An online tool

because these products met estab-

shared goals for improving the nutri-

was available for determining if products

lished nutrition standards. Condiments

tional quality of commissary products;

met Smart Snacks guidelines, which

were not included in the analysis

I

TABLE 1—

Nutrition Standards Developed Through the Healthy Commissary Project Used to Categorize
Foods and Beverages in Washington State’s Correctional Facilities’ Commissary Program: June 2017–May
2019

Category

1440

The updated operating procedure

Foods

Beverages

Best choice

Meet Smart Snack food component guidelines (i.e., contain whole
grains, fruits, vegetables, dairy products, or protein foods) and
nutrient guidelines for calories, sodium, total fat, saturated fat,
trans fat, and sugar (with the exception that these nutrient
guidelines are per serving vs per package, unlike the Smart Snacks
guidelines, which calculate nutrient guidelines by package). See
Smart Snack guidelines for specific food component and nutrient
requirements and exemptions.

Meet Smart Snack guidelines, and include plain or carbonated
water; flavored or unflavored nonfat and 1% milk and milk
alternatives; and 100% fruit juice with no added sugars.
Although condiments are not a stand-alone product listed
in Smart Snack guidelines, they are products offered in the
commissary.

Better choice

Meet Smart Snacks food component guidelines and all but one of the
nutrient guidelines (e.g., the product can be high in sodium and
still meet this categorization).

Low- and no-calorie (under 60 calories), which includes diet
soda.

Limited

Meet none of the guidelines outlined in the best choice and better
choice categories.

Meet none of the guidelines outlined in the best choice and
better choice categories.

Notes From the Field

6

Auvinen et al.

OPINIONS, IDEAS, & PRACTICE

because of their small contribution to

respectively; Figure 1). Overall, data

increasing trend in sales of best choice

sales and calories. Sales data were plot-

showed a 7.5% increase (95% confi-

products, from 12% sold in July 2015 to

ted over time from approximately two

dence interval 5 7.2%, 7.9%; P , .001) in

14% sold in May 2019.

years prior to the HCP (the pre-HCP

sales of best choice beverages in the first

period, beginning July 2015) to two years

month of HCP implementation (June

following initial implementation of the

2017), indicating that individuals were

HCP (the post-HCP period, ending May

replacing better and limited choice bev-

The HCP targeted commissary products,

2019), and an interrupted time series

erages with best choice beverages. Sales

not meals or other foods and beverages

analysis was conducted to account for

of best choice beverages showed an

available in correctional facilities. Not all

seasonal variations and other factors

overall 2.6% increase in the post-HCP

incarcerated individuals can access the

that might affect purchases. Total calo-

period, corresponding to 7.2 million

commissary, because of lack of money

ries sold, by product type (i.e., food,

fewer calories from beverages sold

or security concerns; therefore, the HCP

beverage) and category, was calculated

after the HCP compared with before

only affected those who used the

by multiplying the calories per serving

the HCP. There was no significant or

commissary.

times the total servings sold before and

meaningful change in best choice food

after the HCP. Best choice beverages

sales after the HCP compared with

made up a greater proportion of bever-

before the HCP. Among all foods and

age sales after the HCP compared with

beverages (combined), there was a

Overall, the proportion of foods and

before the HCP (63% vs 58%,

slight (though not significant)

beverages for sale that met best choice

7

ADVERSE EFFECTS

SUSTAINABILITY

AJPH

0

Pre-Best

Post-Best

6

Pre-Better+Limited

Post-Better+Limited

HCP intervention
0

% of Total Beverage Sales

•

•

oo

·o~o~

60

•

•

65

--◊-

0

0

•• •
6

0

55

•

•

0

----.9
0

August 2021, Vol 111, No. 8

70

7.5% jump in sales of “Best Choice” right after intervention

0

o··--~o

Pre-HCP

Post-HCP

50
0

45

7.5% fall in sales of “Better” + “Limited Choice” right after intervention

a ..--------···o
•. --··6
~--6

40
~~~;-·

66

35

30
Dec 2014

Jul 2015

Jan 2016

Aug 2016

Mar 2017

Sep 2017

Apr 2018

Oct 2018

May 2019

Dec 2019

Date

I

FIGURE 1—

Sales of Best Choice vs Better Choice and Limited Beverages, as Percentage of Total Quantity of Beverages
Sold During (July 2015–May 2017) and After (June 2017–May 2019) the Healthy Commissary Project: Washington State

Note. HCP 5 Healthy Commissary Project. Dashed line represents linear trend as assessed through an interrupted time series regression analysis7 (model fit
R2 5 0.82).

Notes From the Field

Auvinen et al.

1441

OPINIONS, IDEAS, & PRACTICE

criteria increased from 13% before the

further increase access to healthy food

HCP to 19% after the HCP. Best choice

and beverage options. AJPI-I

products continue to be offered more
than three years after the HCP was first
implemented, and CI and the DOC continue to promote healthier commissary
products through posters and
newsletters.
The HCP showed how government
agencies can collaborate to improve the
food environment in correctional facilities. This approach can be replicated in

CORRESPONDENCE

4. Maruschak L, Berzofsky M, Unangst J. Medical
problems of state and federal prisoners and jail
inmates, 2011–12. US Dept of Justice. February
2015 (revised October 4, 2016). NCJ 248491. Available at: https://www.bjs.gov/content/pub/pdf/
mpsfpji1112.pdf. Accessed January 8, 2021.

translated to other commissary pro-

PUBLICATION INFORMATION

grams regardless of size. As a result of

Full Citation: Auvinen A, Marcinkevage J, Mornick C,
et al. Improving the food environment in Washington State-run correctional facilities: the Healthy
Commissary Project. Am J Public Health. 2021;111(8):
1439–1442.

6. US Dept of Agriculture Food and Nutrition Services.
A guide to smart snacks in school. 2016. Available
at: https://fns-prod.azureedge.net/sites/default/
files/resource-files/USDASmartSnacks_508_62019.
pdf. Accessed May 17, 2021.

grams. CI’s operating procedure can be

the HCP’s success, the DOH, DOC, and CI
continued collaboration in 2018 to
address meals, which affect most incarcerated individuals.

PUBLIC HEALTH
SIGNIFICANCE
Correctional facilities provide an exceptional opportunity for implementing
public health nutrition interventions
because of the controlled nature of the
food environment. Research suggests

Acceptance Date: March 16, 2021.
DOI: https://doi.org/10.2105/AJPH.2021.306292

CONTRIBUTORS
A. Auvinen and J. Marcinkevage conceptualized the
study, and A. Auvinen wrote the first draft of the
article with input and edits from C. Mornick, J.
Marcinkevage, M. Daniel, J. Dolan, B. Carney, and C.
Prather. S. Nambuthiri performed data analysis,
and S. Nambuthiri and J. Marcinkevage interpreted
the data for the article. A. Auvinen, J. Marcinkevage,
B. Carney, and C. Prather participated in the intervention research on which this article is based. All
authors approved the final version of the article.

that many incarcerated individuals gain
excess weight while incarcerated and
experience higher rates of chronic
medical conditions compared with the
general population.3,4 Nutrition interventions are therefore especially
important to implement in the correctional setting.

ACKNOWLEDGMENTS
Funding for this project was provided by the Centers for Disease Control and Prevention (CDC;
cooperative agreements NU58DP005531 and
NU58DP006504).
Note. The contents of this article are solely the
responsibility of the authors and do not represent
the official views of the CDC.

CONFLICTS OF INTEREST

The HCP demonstrates the feasibility

The authors have no conflicts of interest to report.

of partnerships between health departments, corrections, and advocacy
organizations to implement effective
nutrition interventions in correctional

HUMAN PARTICIPANT
PROTECTION
The Washington State institutional review board
deemed evaluation activities exempt from review.

facility commissaries. This project also
serves as a model for implementing
nutrition interventions in additional food
service venues, such as mealtimes, to
1442

3. 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. https://doi.org/10.1136/jech.
2009.090662

5. Rosenboom LM, Shlafer RJ, Stang JL, Harnack LJ.
Evaluation of the nutritional quality of commissary
foods offered in American women’s prisons. J Correct Health Care. 2018;24(3):264–275. https://doi.
org/10.1177/1078345818782474

country that have commissary pro-

August 2021, Vol 111, No. 8

Alyssa Auvinen, Jessica Marcinkevage, Chris Mornick, Susmitha Nambuthiri, and Mary Daniel are
with the Prevention and Community Health Division, Washington State Department of Health,
Tumwater. Brent Carney is with the Health Services
Division, Washington State Department of Corrections, Tumwater. Charles Prather and Jamie Dolan
are with Correctional Industries, Washington State
Department of Corrections, Tumwater.

2. American Diabetes Association. Diabetes management in correctional institutions. Diabetes Care.
2014;37(suppl 1):S104–S111. https://doi.org/10.
2337/dc14-S104

Correspondence should be sent to Alyssa Auvinen,
PO Box 47848, Olympia, WA 98504 (e-mail: alyssa.
auvinen@doh.wa.gov). Reprints can be ordered at
http://www.ajph.org by clicking the “Reprints” link.

other correctional facilities across the

AJPH

ABOUT THE AUTHORS

gov/family/council.htm#statewide-family-council.
Accessed July 2, 2020.

Notes From the Field

Auvinen et al.

REFERENCES
1. Washington State Dept of Corrections. Family
Council. 2020. Available at: https://www.doc.wa.

7. Bernal JL, Cummins S, Gasparrini A. Interrupted
time series regression for the evaluation of public
health interventions: a tutorial. Int J Epidemiol. 2017;
46(1):348–355.