Abstract
Background: Food insecurity is a pervasive social determinant of health, disproportionately affecting low-income households and contributing to chronic disease risk. However, the role of dietary coping strategies—the behaviours households adopt to manage insufficient food—in the pathway to incident type 2 diabetes remains poorly understood. This study examined the association between food insecurity, specific coping strategies, and incident type 2 diabetes over a five-year follow-up period. Methods: We conducted a prospective cohort study among 2,450 low-income adults (aged 30–65 years) without diabetes at baseline, recruited from community health centres in three urban areas of South Africa (2017–2018). Food insecurity was assessed using the Household Food Insecurity Access Scale (HFIAS). Dietary coping strategies were captured via a validated questionnaire covering consumption-based, livelihood-based, and social support strategies. Incident type 2 diabetes was ascertained through annual fasting plasma glucose and HbA1c measurements. Cox proportional hazards models estimated hazard ratios (HR) for incident diabetes, adjusting for sociodemographic, behavioural, and clinical covariates. Results: Over a median follow-up of 4.8 years, 386 participants developed type 2 diabetes. Severe food insecurity was associated with a 68% increased hazard of diabetes (HR = 1.68; 95% CI: 1.32–2.14) compared with food-secure households. Consumption-based coping strategies (e.g., limiting meal variety, reducing portion sizes) mediated 22% of this association (mediation p < 0.01). Reliance on high-calorie, low-nutrient staple foods and reduced fruit/vegetable intake were linked to higher diabetes risk (HR per unit increase in dietary restriction score = 1.12; 95% CI: 1.04–1.21). Social support coping strategies (e.g., borrowing food) were not independently associated with diabetes. Conclusions: Food insecurity elevates incident type 2 diabetes risk among low-income adults, partly through maladaptive dietary coping strategies that degrade nutritional quality. Interventions should target both food access and the dietary behaviours adopted during scarcity to mitigate diabetes risk.
Keywords
food insecurity, dietary coping strategies, type 2 diabetes, low-income households, social determinants of health, cohort study, nutrition, South Africa