Advent of Neuroimmunology Highlights the Role of Food in Psychiatric Health

How a Non-Diagnostic Lifestyle Promotion Model Can Mitigate Preconditions for Suicide and Other Institutional Violence

By Kelton O'Connor
Director, Let Us Contribute Initiative

"Psychiatry is at an important juncture with the current pharmaceutically focused model having achieved modest benefits and addressing the burden of poor mental health worldwide."

The Lancet, March 2015

"It is indisputable that food has a huge impact on mental and physical health."

Nature Medicine, April 2023

EXECUTIVE SUMMARY

THE PROBLEM

Suicide rates in California prisons doubled over the past decade (from 15 → 30 in 2013). At the same time, recognized mental illness rates nearly tripled, rising from 12% to 32% between 2002 and 2018. These increases show no signs of slowing and progressively undermine institutional safety.

Critically, 25% of individuals who died by suicide in CDCR custody in 2024 had no recent involvement with mental health services or were not receiving services at all. This indicates that diagnostic interventions alone cannot address the full scope of the problem.

THE OPPORTUNITY: UNIVERSAL FOOD IS MEDICINE

Suicide prevention efforts are strengthened when key preconditions for suicide—such as depression—are reduced. Emerging neuroimmunology research implicates pro‑inflammatory diets as a cause of depression, while strongly affirming that improvements in diet are a reliable means of reducing depression.

The “food desert” conditions within California prisons force incarcerated people to consume pro‑inflammatory diets that promote mental illness:

  • A national survey found that prisons rely heavily on refined carbohydrates to meet caloric mandates.

  • Fortified powdered beverage mixes serve as the primary source of key nutrients.

  • Neuroprotective foods—such as dark leafy greens, fermented foods, and healthy fats—are scarce or nonexistent in the prison food environment.

Food is Medicine (FIM) programs represent a breakthrough in behavior‑modification methodologies aimed at improving patients’ adherence to health advice. FIM’s breakthrough formula combines healthy food subsidies with lifestyle education.

We propose a universal FIM model, coupled with a resident‑led food cooperative, to:

  • Transform access to fresh produce

  • Promote brain‑healthy lifestyles

  • Mitigate depression—a key precondition for suicide mortality

WHY UNIVERSAL (NON-DIAGNOSTIC) FIM

Standard FIM programs rely on diagnostic intake criteria, providing healthy food only to individuals under active disease management. CDCR medical professionals have expressed ethical concerns about implementing standard diagnostic FIM in custodial settings because it would effectively turn clinicians into gatekeepers of healthy food in an environment where food quality is frequently perceived as punishment.

Universal FIM model addresses:

  • Institutional Safety: 25% of 2024 suicides had no mental health involvement; a diagnostic‑only FIM model would miss these individuals.

  • Ethical Concerns: Ensures equal access to healthy food regardless of diagnosis, reducing moral and practical pressure on clinicians.

  • Cultural Shift: Community‑wide participation can create compounding effects on adherence to lifestyle advice.

EVIDENCE BASE

Neuroimmunology Findings:

  • A leading meta‑analysis found that each one‑point increase in Dietary Inflammatory Index is associated with a 6% change in depression rates at the population level.

  • Elevated inflammatory biomarkers in the blood are strongly associated with suicidality.

  • Populations consuming the most inflammatory diets show 23% higher depression rates.

  • Randomized controlled trials show that anti‑inflammatory diets are an effective intervention for reducing depression.

FIM Program Outcomes:

  • Adherence Breakthrough: 31‑point increase in Healthy Eating Index scores; 92% of participants adopted healthier eating habits

  • Geisinger Fresh Food Farmacy: $2,400 investment per patient per year = average $16,000 reductions in medical claims. For the most sick patients, expenses were reduced by $200,000 per year.

  • Johns Hopkins Psychiatric Study: Probiotic supplementation led to a 75% reduction in mania‑related hospitalizations for bipolar patients

  • National Projections: Scaling FIM to all Medicare/Medicaid beneficiaries with diabetes or heart disease is projected to save $50–$100 billion nationally.

Correctional Context:

  • Implementing FIM in a custodial setting would be a novel innovation for prisons worldwide.

  • Resident‑operated co‑ops within custodial settings align with international precedents, though they have not yet been implemented in U.S. prisons.

PROPOSED IMPLEMENTATION

Challenge: Universal FIM functions best as a subsidized produce program, but such programs require a marketplace, and prison commissaries generally do not sell produce or other perishables. The medical impact of subsidized produce programs is highly dependent on the cost, quality, and variety of foods available to participants.

Approach: Establish consumer food cooperatives operated by residents that distribute fresh produce, spices and herbs, and other healthful, brain‑protective foods. Food co‑ops significantly reduce retail mark‑ups because they are operated by and for their consumers. Maximizing these efficiencies will reduce costs and increase the medical impact of each subsidy dollar issued by the FIM program

Program Structure

  • Eligibility: All residents willing to participate in lifestyle education. No diagnostic intake criteria.

  • Subsidies: Monthly food stipend redeemable for healthful foods that fit with an anti‑inflammatory diet.

  • Education: Nutritional literacy classes, motivational workshops, exercise programs, peer‑to‑peer support groups targeted to diabetes, heart disease, brain health, chronic pain, etc.

POTENTIAL OUTCOMES

  • Reduced depression and anxiety—preconditions for suicide mortality

  • Improvements in key biometrics: A1C, fasting blood sugar, BMI, etc.

  • Reduced demand for medical care: FIM research demonstrates a 5x–80x return on investment.

  • Improved rehabilitative outcomes: By strengthening mental and physical health, FIM and co‑ops can support more successful rehabilitation trajectories.

STRATEGIC POSITIONING

Timing: The Rockefeller Foundation and American Heart Association have pledged $250 million to launch a Food is Medicine Research Initiative. The philanthropic community is committing billions specifically to FIM research to address food insecurity and health inequalities.

Innovation: Universal FIM has been called for by FIM leaders but not yet implemented anywhere. CDCR would pioneer this model while generating data on nutrition-mental health outcomes in correctional settings (currently absent from research literature).

Feasibility: No outstanding barriers exist. Universal FIM simplifies rather than complicates program design. Consumer food co-ops follow precedent set by worker co-ops operating in prisons worldwide.

Advent of Neuroimmunology Highlights the Role of Food and Psychiatric Health:

How a Non-Diagnostic Lifestyle Promotion Model Can Mitigate Preconditions for Suicide and Other Institutional Violence.

Suicide and Mental Illness in the Custodial Setting

Suicide mortality in California prisons has increased 100% over the last decade. In 2012, 15 incarcerated people chose to end their lives. By 2023, that number grew to 30(1). Increasing rates of suicide have coincided with the general rise in recognized mental illness within California's prison population. From 2000 to 2018, rates of recognized mental illness in California prisons rose from 12% to 32%(2). While some statistical change is thought to be driven by increased access to care and diagnostics, most changes are real and consequential.

A true rise in mental illness is occurring in California's prison system and more broadly in America. Between 2010 and 2013, the rate of children diagnosed with anxiety disorders increased by 72%. For the same group, depression increased by 47% and eating disorders rose by 29%(3). In 2017, a study of 32 children's hospitals identified that over a decade there had been a 100% increase in the rate of children and teens hospitalized for suicidal thoughts and actions(4). This population is now maturing into adulthood, carrying a higher prevalence of mental illness, depression, and suicidal tendencies into the prison system.

These trends pose a crisis for the correctional mental health system, as there is no reason to believe they will soon remit. In the absence of major improvements to the efficacy of suicide prevention strategies, they are expected to progressively undermine institutional safety.

In light of this, attention should be paid to any new clinical approach that holds out real promise of turning the otherwise inexorable tide of serious mental illness and preventing ever-growing occurrences of self-harm or suicide.

Neuroimmunology

The recently formed field of neuroimmunology represents a true paradigm shift in our understanding of the roots of mental illness. This is not a new theory, but a new science that forced a stunning rewrite of Gray’s Anatomy and humbled a generation of neurophysiologists. Most notably, this field proved that the immune system not only can cause emotional and mental illness but does so frequently.

For over a century, it was considered a medical fact that the brain was “immune privileged.” In plain terms, the human body filtered white blood cells out of the bloodstream before blood entered the brain, and thus the immune system was believed to be physically incapable of affecting mental health. Recent advances in technology, however, have allowed researchers to observe cellular activity in living brain tissue, and this changed everything. Between 2012 and 2017, two separate discoveries combined to prove the brain is not immune‑privileged and the immune system is closely involved in neurological health(5).

Jonathan Kipnis, Chair of the Department of Neuroscience at the University of Virginia, has said that by 2015 “You could ask any neurologist, and they would be the first to tell you that it was becoming clear to them that neurological disorders are all always associated with some degree of immune system dysfunction.”(5) What we know today is that many forms of mental illness are probably not disorders of the nervous system at all, but disorders of the immune system.

The two historic discoveries that combined to debunk the concept of immune privilege are: 1) Inflammatory messenger chemicals from the immune system enter the brain via the lymphatic system(5). 2) When these inflammatory messages enter the brain, they are received and acted upon by a previously unrecognized species of immune cell. These cells, known as microglia, are permanently embedded throughout brain tissue, where they carry out a breathtaking range of immunological services that are essential to human survival, neuroplasticity, and neuropsychiatric health.

Microglia are sometimes referred to as the “gardeners of the brain” because, when the immune system is at rest, microglia use lengthy, mobile tentacles to surveil neighboring brain cells, evaluate brain health, and generally care for the brain(6). Microglia help new synapses form and repair damaged neural networks(7, 8). They sense when to emit neuroprotective chemicals(9), and they help sculpt the brain during pivotal periods of human development(10, 11).

Just like white blood cells, however, microglia have the ability to attack and destroy pathogens. When the immune system senses a threat, it sends out pro‑inflammatory messages, and this triggers microglia to cease their neuro‑supportive activities and launch an immune defense process called neuroinflammation. When microglia are activated in this way, they change shape in order to engulf and destroy viruses, bacteria, and other pathogens(12).

Neuroinflammation is an important defense mechanism, but it also harms the brain. When microglia activate their neuroinflammatory capabilities, they spew neurotoxins into brain tissue(8), physically engulf and destroy synapses(13), and sometimes dismantle entire neural networks(8). Importantly, microglia are highly reactive and easily shift into a neuroinflammatory mode even when the brain is not threatened by pathogens(14, 15, 16). This can occur due to poor diet, disturbed gut flora, stress, allergens, and other environmental factors).

Neuroinflammation has been identified as a factor in depression(17), anxiety(18), mania(19), chronic pain(20), Alzheimer’s disease(21), OCD(22), bipolar disorder(23), autism(24), and schizophrenia(25). Causation will have to be debated on a disease‑by‑disease basis, however, there is no longer any doubt that neuroinflammation is causative to many cases of mental illness. It is now believed that most molecular pathways to depression are inflammatory in nature, and elevated levels of inflammatory chemicals in the body often precede onset of serious mental illness by years(26, 27).

Microglial hypersensitivity is not just an entry point for pathology, but also for therapy. Anti‑inflammatory drugs, a spectrum of therapies, improvements to gut flora, and healthful lifestyle practices help reduce inflammatory processes in the body, in turn influencing microglia to calm down, cease neuroinflammatory assaults, and return to the task of supporting neuroplasticity and overall brain health(5).

Microglia’s Jekyll‑and‑Hyde nature-as destroyer of brain cells and healer of brain cells-elevates these cells to a position of unique importance in the formation and treatment of mental illness.

A New Regime of Medical Fact

The view of the human body now delivered to us by neuroimmunology is not just another piece of the puzzle. It is a Rosetta Stone which has enabled us to decode a host of long‑standing mysteries.

We no longer struggle to understand why hospitalization for bacterial infection elevates a person’s risk for near‑term development of depression and bipolar disorder by 62%(28). We are no longer mystified when we learn a man received a bone marrow transplant from a schizophrenic man and “contracted” schizophrenia(29), or that a man was “cured” of schizophrenia when he received a marrow transplant from a mentally healthy man(30). Under the new regime of medical fact, there is nothing odd about these situations at all. Bone marrow is where white blood cells are made, and with new marrow the inflammatory profile of the recipient body is overhauled. If these particular marrow transplants did not precipitate some degree of psychiatric changes, that would be a mystery.

The immune system’s causative role in mental illness has come into sharp focus. Any safe and effective therapy that can inspire microglia to heal rather than harm will eventually find its way into the clinical repertoire of mainstream psychiatry. But it will take years for the pharmaceutical industry to develop, and bring to market, new drugs that target neuroinflammation.

In the meantime, this new paradigm in brain science also re‑contextualizes mountains of existing data in ways that are of immediate value to public health practitioners. We don’t have to wait for a new wave of drugs to arrive just to get busy calming our immune systems. Many well‑understood, effective, and safe methods of soothing the immune system consist of basic lifestyle advice that is already recommended to the public by trusted authorities on a daily basis.

Pro‑Inflammatory Diet, Depression, and Self Harm

Suicide mortality is driven by a complex set of preconditions, and no single precondition is reliably predictive of any particular act of self-harm. However, any reliable means of mitigating known preconditions of suicide are valuable to the mission of suicide prevention.

Depression, anxiety, and serious mental illness are preconditions of suicide mortality. Neuroimmunology has forcefully affirmed that pro-inflammatory diet is a driver of depression, anxiety, and possibly serious mental illness as well.

A pro‑inflammatory diet is characterized by:

  • Low intake of fresh produce

  • High intake of refined carbohydrates

  • High intake of unhealthy fats

  • High intake of processed meats

  • High intake of ultra‑processed junk foods

All the most credible large‑scale meta‑analyses on this topic confirm that pro‑inflammatory diets are associated with depression(31, 32, 33, 34). The most rigorous of these meta‑analyses reviewed 16 studies involving 92,242 individuals and found that pro‑inflammatory diet is associated with depression, anxiety, and schizophrenia(34). The relationship between pro‑inflammatory diet and mental illness is bidirectional, however…randomized controlled research shows increased intake of pro‑inflammatory foods is causing increases in neuroinflammation and depression(35). Conversely, randomized controlled studies and other large‑scale studies that address causation show that anti‑inflammatory diet applied interventionally reduce depression(36, 37, 38).

The Dietary Inflammatory Index (DII) is an instrument designed to assess the inflammatory capacity of an overall diet. A dose‑response correlation between the diet’s DII score and rates of depression within the population that consumes that diet is well established. Each 1‑increment increase in the DII score of a diet equates to a 6% increase in rates of depression in the population consuming that diet(34). A leading meta‑analysis shows that populations with dietary practices that score highest on the DII experience a 23% elevation in depression relative to those with the least inflammatory diets on this index(34).

Stressed Immune Function Associated with Suicidality

There's evidence that immune function and inflammatory responses within the body are a significant factor in suicidality. In 2017, researchers at Johns Hopkins School of Medicine showed that levels of inflammatory biomarkers in patients' blood are predictive of suicide attempts(39, 40). This research does not prove causation. Nonetheless, the explanation that fits the facts best is that neuroinflammation causes some people to feel so poorly they engage in suicidal ideation.

The leading documentarian and science translator specializing in neuroimmunology, Donna Jackson Nakazawa, has written that, “Simply activating an individual's inflammatory immune response as if they were fighting off a viral infection can trigger feelings of deep despair and even suicidal thoughts”(41).

Existing Systems Are Harming Institutional Safety

It is no secret that prison food is unhealthy, but the neuroimmunological revolution has confirmed our worst fears about the negative effects of prison food on mental health. Incarcerated people eat a diet that is undeniably pro‑inflammatory. Prison stores provide only preserved shelf foods and mostly junk food. Dining halls serve processed meat and refined carbohydrates with nearly all meals.

According to a national survey that included input from 43 correctional staff in 12 states “Most prisons now rely on refined carbohydrates (e.g., white bread, biscuits, and cake) to reach the mandated calorie count, and many have turned to fortified powdered beverage mixes as the primary source of essential nutrients-a cheap but woefully inadequate alternative to nutrient‑dense foods”(43). This report goes on to state that: “Incarcerated people are fed a diet that everyone else has been advised to avoid for decades.”

What incarcerated people actually eat is a diet that is devoid of dark greens, low in fresh vegetables, rich in fast carbs, rich in processed fats, and heavily supplemented with ultra‑processed junk food. Potently anti‑inflammatory, neuroprotective foods such as dark leafy greens, fermented foods, and healthy fats are neither served nor marketed.

This means, unavoidably, that the DII score of prisoners’ diets is harmfully elevated. For certain incarcerated individuals, consuming these pro‑inflammatory diets triggers microglia to shift into a neuroinflammatory mode that increases anxiety, depression, suicidality, and possibly other forms of serious mental illness. In a high‑stress correctional environment, pro‑inflammatory foods must be recognized as a factor that contributes to mental illness, relapse, and self‑harm.

Food Is Medicine (FIM) Systems: A Breakthrough in the Promotion of Healthful Diets

Depression is a known precondition for suicide mortality. Any reliable means of alleviating depression should be considered important to suicide‑prevention efforts. If decreasing a diet’s DII score by a single increment can reduce depression by 6%(34), we should increase incarcerated populations’ access to anti‑inflammatory foods such as greens, fermented foods, and healthy fats. However, poor access to healthful foods is not the only barrier to transforming mental health outcomes for incarcerated people. There is also the perennial problem of persuading individuals to adhere to lifestyle advice and actually increase their consumption of healthy or anti‑inflammatory foods.

In the long history of clinical strategies that have tried but failed to persuade the public to eat more wisely, Food Is Medicine (FIM) systems are recognized as the first real, evidence‑based breakthrough.

FIM systems are healthcare programs that:

  • Prescribe healthy food as a treatment for metabolic illness, initially diabetes, and heart disease but increasingly other illnesses as well.

  • Provide that food to patients free of charge, usually at the expense of insurers or anti‑hunger organizations.

  • Require that patients participate in a range of lifestyle‑education programs.

The lifestyle‑education programs which FIM systems require their patients to participate in are designed to improve health literacy, dietary choices, and physical activity. Lifestyle‑education components vary across providers but often involve motivational workshops, nutritional classes, culinary trainings, walking programs, and condition‑specific support groups.

FIM systems are diverse in scope and design. Common variants include:

  • Subsidized grocery programs that provide patients with food vouchers redeemable at participating markets for produce and other healthful foods.

  • Food pharmacies that distribute food‑supply packages from within clinical settings where patients are also offered a range of medical and social support.

  • Medically tailored meal programs that deliver meals customized for patients’ particular medical needs. These programs provide the least user agency but have proven to be highly effective in treating serious illnesses, including some forms of cancer.

The FIM formula—combining food subsidies with comprehensive lifestyle education—is a qualified breakthrough in boosting rates of adherence to health advice. A randomized crossover clinical trial performed in 2018 found a medically-tailored meal delivery program inspired a 31.4-point increase in its participants' consumption of healthy foods, measured on the Healthy Eating Index(45). Another study found that a produce prescription program caused 92% of its participants to adopt healthier eating habits(46). Results like these represent a Holy Grail-level breakthrough for lifestyle modification methodologies.

The benefits of improved adherence are substantial for patients' health and health insurers' bottom line. The Fresh Food Pharmacy, operated by Geisinger Health, a major provider-insurer network in the Pennsylvania area, is an instructive case study in FIM systems. In 2018, this pioneering food pharmacy reported that the 112 diabetic patients which had been receiving food subsidies and lifestyle support for 18 months had experienced the following improvements in key health indicators, as compared to baseline:

  • 9.8% reduction in cholesterol

  • 17.8% reduction in A1c

  • 26.9% reduction in fasting blood sugar

These changes are greater than those expected through the use of common medications, and they amount to a 40% reduction in the risk of death or serious complication(47).

These outcomes translated into major savings for Geisinger. At that time, in 2018, the program had reduced the medical claims of its most ill participants by 80%. In real terms, about $200,000 per patient per year. This was achieved by investing just $2,400 per patient per year. Average savings for all patients involved in the study at that point appeared to have been more modest, but still in the range of $16,000 a year(47). Studies like this turned the heads of insurance companies and spurred a proliferation of FIM pilot programs throughout the nation.

FIM programs are now identified as both cost-effective and cost-reductive(48). In 2022, the philanthropic community committed $8 billion to study how these systems can be refined, standardized, scaled, and integrated into healthcare systems nationally(49). Projections show that scaling even rudimentary FIM services to all Medicare and Medicaid recipients who face diabetes and heart disease would reduce healthcare spending by $50 to $100 billion(50).

Universal FIM: Designing for Prevention, Equal Access, and Safety

There is a clear need for FIM systems in the custodial setting due to elevated disease prevalence within incarcerated populations and the stark “food desert” conditions that pervade all custodial institutions. The known medical and physical benefits of FIM systems will certainly be reproduced in this setting. However, standard FIM programs deploy diagnostic intake criteria, which leads to improvements in food quality for only some individuals. This raises ethical concerns. Doctors do not wish to be turned into gatekeepers of healthy foods in an environment where food quality is perceived by many as a form of punishment. For this reason, medical professionals in CDCR have expressed a desire for a universal FIM model that operates on principles of equal access.

There does not appear to be examples of universal FIM in use within the community or within the custodial setting. However, leading voices in the FIM community have called for models that treat the entire community. Such models would serve undiagnosed and preventable cases of illness that diagnostic FIM cannot, institutional safety would be best served by a universal model, and some researchers have theorized that universal FIM could have a compound impact on patient adherence.

The call for universal FIM expressed by correctional physicians is echoed by authorities in the field of FIM, who have highlighted the need to develop FIM systems that serve entire communities(49). In a report by the Food Research and Action Center (FRAC), FIM program administrators stated

“Food is only medicine when it is successful for all,” and called for a “whole household approach” (not individual.)

This indicates there are two growth trajectories for FIM program design:

  • Toward more effective prescriptive models that address specialized needs.

  • Toward more inclusive, non‑prescriptive models that address food insecurity while shifting food culture at the community level.

If an FIM program were designed around the priority of reducing rates of depression and improving institutional safety, rather than simply improving an insurer’s bottom line, that program would naturally attempt to reduce rates of depression and mental illness for the entire community, not just for those who are in treatment.

There is considerable mental illness that goes undiagnosed, presenting risks that diagnostic FIM models cannot address. Roughly 25% of the individuals who committed suicide in CDCR custody in 2024 had not had recent involvement with mental‑health services or were not receiving services at all(1). This indicates that the universal FIM model is an institutional‑safety model.

FIM researchers have theorized that there may be various hidden benefits to expanding treatments to the entire household or the entire community. Geisinger Fresh Food Farmacy originally provided meals to all family members who lived with program participants. This was meant to prevent impoverished program participants from taking the prescribed food home just to feed their children, rather than consuming it as prescribed. This precaution was later considered for its possible medical benefits.

Providing FIM services to entire households or entire communities might have a compound effect on adherence to lifestyle advice if this approach shifts food culture in a way that reinforces the decisions of individuals. If the universal FIM approach has such a compound effect on food culture and adherence, it would represent a significant advance in public‑health methodology, with likely applicability both inside and outside custodial institutions.

In light of these ethical, medical, and safety benefits—which the FIM model will in some cases provide and in other cases likely provide—it is recommended that this model be explored for application in a custodial setting.

Subsidized Produce Programs Present a Practical Basis for Universal FIM

A universal FIM program can be created by altering the intake criteria of any standard FIM program variant so that it offers services to all residents of an institution, community, or policyholder pool, with the single requirement of willingness to participate in lifestyle education. Technically, any FIM model could be modified in this way, although medically tailored‑meal programs and food pharmacies are poorly suited to this agenda, since their strengths (prescriptive specificity and physical proximity to the clinic) are mainly valuable to individuals who are under active disease management.

Alternately, the FIM variant known as a subsidized grocery program is geared to support general shifts towards healthier food culture. This variant would be the most practical basis for the creation of a universal FIM model.

A Universal Subsidized Produce Program (USPP) would issue subsidies to anyone, regardless of health status, as long as they were willing to undertake lifestyle education. The lifestyle components available to participants of a USPP would not include clinical services of any kind. Instead, lifestyle components would consist entirely of peer‑to‑peer support groups, motivational workshops, exercise programs, or other programs that do not require clinical involvement.

In a well‑designed USPP, however, participants would not be subject to a single generalized educational curriculum. They would be free to join a class (or classes) of their preference from amongst a spectrum of specialized courses. These courses would be designed to increase health literacy regarding metabolic issues common to the incarcerated population—for example, diabetes, heart disease, neurological degeneration, depression, anxiety, pain, food addiction, etc.

This arrangement would eliminate clinical involvement and reduce administrative costs, as well as some legal liabilities, while maintaining the food‑incentive structure and lifestyle‑education features that are fundamental to the FIM approach.

Operating a medically effective USPP in the custodial setting, however, would require that institutions allow incarcerated people the opportunity to purchase fresh produce on a daily or near‑daily basis. Prisons and jails do not presently accommodate this need.

When Food Is Medicine, the Price of Food Is Part of the Medical Model

The price, quality, and variety of produce available for purchase within an institution will have an enormous impact on the medical benefit achieved by a produce‑prescription program.

The most reliable market model for reducing the cost of healthful foods while also maintaining the quality of those foods is known as the consumer food co‑op. Consumer co‑ops significantly reduce retail markup because they are operated by and for their consumers.

Cooperative models are used in childcare and home‑care services to improve continuity of care, affordability, and cultural responsiveness. The University of Wisconsin Center for Cooperatives documents that health and social‑service co‑ops are part of a broader ecosystem that addresses social determinants of health, especially in aging, rural, and low‑income populations(51). The consumer food‑co‑op model is not presently identified.

The consumer food model is not presently identified in the literature as part of that ecosystem. But as FIM systems continue to be promulgated throughout the mainstream clinical space, it is inevitable that the unique power of food co-ops to reduce the cost of food is identified as an important medical effect multiplier for FIM programs.

Food co-ops should be used to boost the impact of FIM systems in the custodial setting and anywhere else that subsidized grocery programs are implemented within the community.

Prison Co-ops Improve Institutional Safety Around the World

Food co-ops do not yet exist anywhere in the custodial setting. However, more logistically complicated cooperatives, known as “worker co-ops,” are operated by incarcerated people in many prisons outside the US, from England and Canada to Puerto Rico and Italy. Even in high-security prisons in nations where recidivism is comparable to the US, prison co-ops generate goods and services for the open market, they provide skills and dignified pay, they are thought to reduce recidivism, and they appear to improve institutional safety(52, 53).

The literature suggests that prison co-ops promote institutional safety by strengthening workers’ self-esteem, providing financial incentives to maintain good behavior, and by providing a healthy outlet for physical and mental energy. In Italy, one of the most successful prison co-ops is a bakery operated in a high-security prison where some of Italy’s most dangerous men are provided regular access to a full industrial kitchen. Though one might presume this would lead to increased production of weapons and violence, the men provided this opportunity have proven they are far more interested in winning local culinary contests.

When researchers interviewed members of that Italian cooperative bakery, as well as correctional staff from that same prison, they found that staff and incarcerated people both felt that the co-op did not create security concerns. Instead, the perception was that of reduced tension and mitigated conflict(52).

Coupling Universal FIM Programs and Consumer-Led Markets in the Custodial Setting Will Benefit Public Health and Institutional Safety

For correctional healthcare leaders, the findings discussed in this paper underscore that mental illness and rates of suicide are rising across the US and within our custodial institutions. This public health crisis has major implications for society and institutional safety. Neuroimmunology has affirmed the power of anti-inflammatory diets to reduce depression, a well-known precondition for suicide mortality. Additional breakthroughs in lifestyle-promotion methodologies, known as Food as Medicine systems, offer an evidence-based means of increasing adherence to lifestyle recommendations. Consumer food co-ops present an opportunity to boost the medical impact of each dollar invested into FIM food subsidies.

Taken on the whole, this means that nutritional quality is directly connected to behavioral health outcomes and institutional stability. Coupling consumer-driven food markets with universal FIM in order to promote anti-inflammatory diets in the custodial setting presents a prime opportunity for dynamic transformation of food culture and health outcomes for incarcerated people. Providing more consistent access to anti-inflammatory, probiotic, nutrient-dense foods should be adopted as a low-cost, low-risk intervention that supports population-level mental health and aligns with broader goals of safety, rehabilitation, and reduced healthcare burdens.

There does not appear to be any outstanding barriers that would bar FIM models from being deployed in the custodial setting. Overcoming issues of unequal access to innovation through a non-diagnostic universal FIM subsidy does not require increased program design complexity. In fact, it entails simplification of design. Overcoming issues of availability and affordability through the application of a consumer food co-op model will be at once pioneering and in line with precedents set by worker co-ops, which are operated in prisons in many nations throughout the world.

This is the right moment to implement and research a project of this kind. The philanthropic community is committing billions specifically to FIM research because it is a means of addressing the rise of food insecurity and health inequalities in the US. The Rockefeller Foundation and American Heart Association alone pledged $250 million commitments to launch a Food Is Medicine Research Initiative.

It is advances in FIM systems, just like the one proposed here, that will help address hunger in the U.S. in a way that fosters a citizenry that is better informed, more physically active, and more mentally disciplined.

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2 Stanford Justice Advocacy Project, 2017.

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