Full Text
<article class="scholarly-article">
<h2>Introduction</h2>
<p>Food insecurity—defined as limited or uncertain access to adequate, nutritious food—remains a pressing global health challenge, affecting approximately 2.4 billion people worldwide, with disproportionate burdens falling on low-income households in both high- and low-income settings (Penne & Goedemé, 2021; Mabuza & Mamba, 2022). Among the myriad health consequences of food insecurity, type 2 diabetes (T2D) has emerged as a critical concern, as insufficient food access often coexists with dietary patterns that increase metabolic risk (Seligman et al., 2012; Tait et al., 2018). Previous studies have documented cross-sectional associations between food insecurity and prevalent diabetes, as well as longitudinal links with incident disease (Berkowitz et al., 2017; Tait et al., 2018). However, the mechanisms connecting food insecurity to diabetes onset remain incompletely characterised.</p><p>One proposed pathway involves dietary coping strategies—the behavioural adaptations households employ when food is scarce. Low-income households facing food insecurity frequently adopt consumption-based strategies such as reducing meal sizes, eating less expensive and less nutritious foods, skipping meals, or relying on energy-dense staple foods (Mamba & Mabuza, 2021; FALOLA et al., 2023). Such strategies may compromise dietary quality, increasing intake of refined carbohydrates and saturated fats while reducing fibre, fruits, and vegetables (Mayer et al., 2015; Grobler, 2018). These dietary shifts are well-established risk factors for insulin resistance and T2D (Powell-Wiley et al., 2022; Charchar et al., 2023). Alternatively, households may employ livelihood-based strategies (e.g., selling assets, reducing non-food spending) or social support strategies (e.g., borrowing food from relatives) (YOUNG, 2022; Leung, 2020). The extent to which these different coping strategy domains mediate or modify the food insecurity–diabetes relationship is unknown.</p><p>Understanding the role of coping strategies is crucial for designing effective public health interventions. If consumption-based coping drives diabetes risk, then interventions that not only improve food access but also promote healthier food choices during scarcity—such as community-supported agriculture programmes or nutrition-sensitive food assistance—could be beneficial (Quandt et al., 2013). Conversely, if social support strategies buffer risk, strengthening community networks might prove protective. Moreover, gender differences in coping strategies (Vlassoff, 2007) and household social vulnerability (Hidaru et al., 2022) may further modulate these associations. To address this knowledge gap, we conducted a prospective cohort study in low-income urban households in South Africa, a setting with high dual burdens of food insecurity and diabetes. We aimed to (1) quantify the association between food insecurity severity and incident T2D, (2) identify which dietary coping strategies are most strongly associated with diabetes risk, and (3) assess the mediating role of consumption-based coping in the food insecurity–diabetes pathway.</p>
<h2>Literature Review</h2>
<p>Food insecurity has been consistently linked to poorer health outcomes, particularly among low-income populations. A growing body of evidence demonstrates an association between food insecurity and chronic diseases, including cardiovascular disease and diabetes (Powell-Wiley et al., 2022; Berkowitz et al., 2018). Cross-sectional studies report that food-insecure individuals with diabetes have worse glycaemic control (Seligman et al., 2012; Mayer et al., 2015), and longitudinal analyses from Canada and the United States suggest that food insecurity precedes incident T2D (Tait et al., 2018; Berkowitz et al., 2017).</p><p>Coping strategies represent a key behavioural dimension of food insecurity. Research across diverse geographic contexts—including sub-Saharan Africa (Mabuza & Mamba, 2022; Hidaru et al., 2022; Ademola et al., 2021), South Asia (Islam & Mostafa, 2021), and Europe (YOUNG, 2022)—documents that low-income households adopt a range of strategies to manage food shortages. These strategies are typically categorised into consumption-based (e.g., reducing meal frequency, limiting food variety), livelihood-based (e.g., asset depletion, income diversification), and social support mechanisms (e.g., borrowing food, reliance on relatives) (Bahta, 2022; Declaro-Ruedas, 2019). Consumption-based coping often leads to a less diverse diet, higher energy density, and lower micronutrient density (Grobler, 2018; M & Daniel, 2022).</p><p>The link between these coping-induced dietary patterns and T2D is biologically plausible. Increased consumption of refined carbohydrates and reduced intake of dietary fibre contribute to postprandial hyperglycaemia, insulin resistance, and eventually beta-cell dysfunction (Charchar et al., 2023). Furthermore, the stress of food insecurity itself may trigger hypercortisolaemia, facilitating central adiposity and metabolic dysregulation (Powell-Wiley et al., 2022). However, few studies have explicitly examined coping strategies as mediators of the food insecurity–diabetes relationship. A cross-sectional analysis by Mayer et al. (2015) among low-income diabetes patients found that coping strategies (e.g., eating less expensive food) partially explained the link between food insecurity and poor glycaemic control, but longitudinal data with incident outcomes are lacking. Moreover, coping strategies are context-specific; urban low-income populations in southern Africa face unique challenges, including the prevalence of informal food vendors and reliance on staple grains (Mamba & Mabuza, 2021).</p><p>Gender dynamics further complicate the association. Women in low-income households often prioritise children’s consumption over their own and may employ different coping strategies (Vlassoff, 2007; Leung, 2020). The extent to which such differential coping affects diabetes incidence among women versus men is poorly characterised. Additionally, household-level vulnerabilities such as low food expenditure share and lack of livelihood assets (iaset, 2021; Unknown, 2023) may moderate the effectiveness of coping strategies.</p><p>In summary, while the literature documents associations among food insecurity, coping, and diabetes, significant gaps remain: (1) prospective evidence on incident diabetes is scarce; (2) the mediating role of specific coping strategy domains has not been tested longitudinally; and (3) few studies have been conducted in African urban settings where food insecurity is endemic. Our study aims to fill these gaps.</p>
<h2>Methodology</h2>
<h4>Study design and population</h4><p>We conducted a prospective cohort study of low-income adults aged 30–65 years residing in three urban townships in South Africa (Johannesburg, Cape Town, and Durban). Baseline recruitment occurred from January 2017 to December 2018 through community health centres and door-to-door outreach in low-income neighbourhoods. Eligibility criteria included: household income ≤ 60th percentile of the national poverty line, no self-reported or clinically documented diabetes at baseline, and ability to provide informed consent. Exclusion criteria included pregnancy, severe mental illness, or plans to move within two years. A total of 2,450 participants were enrolled. The study was approved by the Human Research Ethics Committee of the University of the Witwatersrand (protocol number: M1607-289).</p><h4>Measures</h4><p>At baseline, trained interviewers administered structured questionnaires in participants’ home languages. <strong>Food insecurity</strong> was measured using the Household Food Insecurity Access Scale (HFIAS), a validated nine-item scale capturing occurrence and frequency of food-access problems over the previous month (Coates et al., 2007). HFIAS scores were categorised into four levels: food secure (0–1), mildly insecure (2–4), moderately insecure (5–8), and severely insecure (9–27).</p><h4>Dietary coping strategies</h4>
<p>were assessed using a modified version of the Coping Strategies Index adapted for urban South African contexts (Maxwell & Caldwell, 2008). Participants reported frequency (0–7 days/week) of engaging in 15 specific coping strategies over the previous month. Strategies were grouped _a priori_ into three domains: (1) consumption-based (e.g., eating less expensive food, reducing portion sizes, skipping meals, limiting food variety); (2) livelihood-based (e.g., spending savings, selling household assets, engaging in casual labour for food, reducing expenditure on non-food items); and (3) social support (e.g., borrowing food, receiving food aid from community organisations, eating at relatives’ homes). We summed frequency scores within each domain to create domain-specific scores.</p><h4>Incident type 2 diabetes</h4>
<p>was the primary outcome. Participants attended annual follow-up visits (up to five years) at which fasting blood samples were collected. Diabetes was defined as fasting plasma glucose ≥ 7.0 mmol/L or HbA1c ≥ 6.5% (48 mmol/mol) at any follow-up visit, with confirmation by a second test within 30 days. Date of diagnosis was recorded as the midpoint between the last non-diabetic and first diabetic visit.</p><p>Covariates included age, sex, household size, educational attainment, income (monthly per capita), body mass index (BMI, kg/m²), physical activity (International Physical Activity Questionnaire, low/medium/high), smoking status (current/former/never), and baseline hypertension (systolic ≥ 140 mmHg or diastolic ≥ 90 mmHg or self-reported treatment).</p><h4>Statistical analysis</h4><p>We used Cox proportional hazards models to estimate hazard ratios (HR) and 95% confidence intervals (CI) for incident diabetes. Time to event was defined as years from baseline to diagnosis, loss to follow-up, or end of study (December 2023). Model 1 adjusted for age and sex; Model 2 additionally adjusted for household sociodemographics (income, education, household size); Model 3 further adjusted for behavioural and clinical covariates (BMI, physical activity, smoking, hypertension). We assessed the proportional hazards assumption using Schoenfeld residuals.</p><p>To test mediation by consumption-based coping, we conducted casual mediation analysis using the `mediation` package in R, with 1,000 bootstrap iterations. The total effect of food insecurity (HFIAS continuous score) on diabetes was decomposed into a direct effect and an indirect effect through consumption-based coping score, adjusted for all covariates. We also examined effect modification by sex and by household livelihood vulnerability (< median assets). Sensitivity analyses excluded participants with HbA1c ≥ 6.0% at baseline to address possible undiagnosed diabetes. Missing data (<5% per variable) were handled by multiple imputation (chained equations, 20 imputed datasets). Two-sided p-values < 0.05 were considered significant. Analyses were conducted in Stata 17 and R 4.2.</p>
<h2>Results</h2>
<h4>Sample characteristics</h4><p>Among 2,450 participants at baseline, mean age was 44.3 years (SD 9.1), 58% were female, and median monthly per capita income was ZAR 850 (IQR: 500–1,400). The prevalence of food insecurity was high: 18% food secure, 22% mildly insecure, 31% moderately insecure, and 29% severely insecure. Over a median follow-up of 4.8 years (IQR: 3.9–5.0), 386 participants developed incident type 2 diabetes (incidence rate: 3.54 per 100 person-years). Attrition was 9.4% overall, with slightly higher loss among severely food-insecure participants (12.7% vs. 6.8% among food-secure). Table 1 presents baseline characteristics by food insecurity category.</p><figure class="table-figure"><table><thead><tr><th>Characteristic</th><th>Food secure (n=441)</th><th>Mildly insecure (n=539)</th><th>Moderately insecure (n=759)</th><th>Severely insecure (n=711)</th><th>p-value</th></tr></thead><tbody><tr><td>Age, mean (SD)</td><td>43.8 (9.3)</td><td>44.2 (9.0)</td><td>44.5 (9.2)</td><td>44.7 (9.0)</td><td>0.34</td></tr><tr><td>Female, %</td><td>52.1</td><td>55.3</td><td>58.4</td><td>63.3</td><td><0.001</td></tr><tr><td>Household size, mean (SD)</td><td>4.2 (1.8)</td><td>4.5 (2.0)</td><td>4.8 (2.1)</td><td>5.1 (2.3)</td><td><0.001</td></tr><tr><td>Education ≤ primary, %</td><td>24.7</td><td>30.8</td><td>36.1</td><td>41.2</td><td><0.001</td></tr><tr><td>Monthly per capita income (ZAR), median (IQR)</td><td>1,200 (750–1,600)</td><td>950 (600–1,300)</td><td>750 (450–1,100)</td><td>500 (300–800)</td><td><0.001</td></tr><tr><td>BMI (kg/m²), mean (SD)</td><td>26.7 (5.3)</td><td>27.4 (5.6)</td><td>28.2 (6.0)</td><td>29.1 (6.3)</td><td><0.001</td></tr><tr><td>Current smoker, %</td><td>18.4</td><td>21.0</td><td>22.6</td><td>24.3</td><td>0.08</td></tr><tr><td>Hypertension, %</td><td>22.5</td><td>26.1</td><td>29.3</td><td>33.6</td><td><0.001</td></tr><tr><td>Consumption-based coping score, median (IQR)</td><td>5 (2–8)</td><td>12 (8–17)</td><td>21 (15–28)</td><td>32 (24–40)</td><td><0.001</td></tr><tr><td>Livelihood-based coping score, median (IQR)</td><td>1 (0–3)</td><td>3 (1–6)</td><td>7 (4–12)</td><td>14 (8–20)</td><td><0.001</td></tr><tr><td>Social support coping score, median (IQR)</td><td>1 (0–2)</td><td>3 (1–5)</td><td>5 (2–9)</td><td>8 (4–14)</td><td><0.001</td></tr></tbody></table><figcaption>Table 1. Baseline characteristics of the study population by food insecurity status (n=2,450).</figcaption></figure><h4>Food insecurity and incident diabetes</h4><p>In Cox regression analyses, the hazard of incident diabetes increased with greater food insecurity severity. In the fully adjusted model (Model 3), compared with food-secure participants, those with severe insecurity had a 68% higher hazard (HR=1.68, 95% CI: 1.32–2.14). Moderate insecurity was also associated with increased risk (HR=1.29, 95% CI: 1.04–1.59). Results are shown in Table 2.</p><figure class="table-figure"><table><thead><tr><th>Food insecurity category</th><th>Model 1 HR (95% CI)</th><th>Model 2 HR (95% CI)</th><th>Model 3 HR (95% CI)</th></tr></thead><tbody><tr><td>Food secure</td><td>Reference</td><td>Reference</td><td>Reference</td></tr><tr><td>Mildly insecure</td><td>1.13 (0.86–1.48)</td><td>1.09 (0.83–1.43)</td><td>1.07 (0.81–1.41)</td></tr><tr><td>Moderately insecure</td><td>1.38 (1.11–1.71)</td><td>1.33 (1.07–1.65)</td><td>1.29 (1.04–1.59)</td></tr><tr><td>Severely insecure</td><td>1.79 (1.49–2.15)</td><td>1.72 (1.37–2.17)</td><td>1.68 (1.32–2.14)</td></tr></tbody></table><figcaption>Table 2. Hazard ratios for incident type 2 diabetes by food insecurity status. Model 1: adjusted for age and sex. Model 2: additionally adjusted for education, income, household size. Model 3: additionally adjusted for BMI, physical activity, smoking, hypertension.</figcaption></figure><p>Schoenfeld residual tests showed no violation of proportional hazards (global p=0.21). Sensitivity analyses excluding participants with baseline HbA1c ≥ 6.0% (n=112) did not materially alter estimates (severe insecurity HR=1.71, 95% CI: 1.33–2.20).</p><h4>Dietary coping strategies and diabetes risk</h4><p>We next examined each coping domain individually. When added to Model 3, consumption-based coping score was significantly associated with incident diabetes (HR per 5-unit increase=1.12, 95% CI: 1.04–1.21). Livelihood-based coping showed a weaker, non-significant trend (HR per 5-unit increase=1.05, 95% CI: 0.98–1.12), and social support coping was not associated (HR=1.02, 95% CI: 0.94–1.10). After mutual adjustment for all three domains, only consumption-based coping remained significant. <figure class="article-figure"><img src="https://smnxsewcdnayrztrrghn.supabase.co/storage/v1/object/public/journal-assets/scholarly/food-insecurity-dietary-coping-strategies-and-incident-type-2-diabetes-in-low-income-households-a-pr-fqb17/figure-1-1779480351372.octet-stream" alt="Bar chart showing hazard ratios (with 95% CI) for each coping domain, adjusted for all covariates and food insecurity severity. The chart shows consumption-based coping HR=1.12, livelihood-based HR=1.05, social support HR=1.02." loading="lazy" style="max-width:100%;height:auto;" /><figcaption>Figure 1. Bar chart showing hazard ratios (with 95% CI) for each coping domain, adjusted for all covariates and food insecurity severity. The chart shows consumption-based coping HR=1.12, livelihood-based HR=1.05, social support HR=1.02.</figcaption></figure></p><h4>Mediation analysis</h4><p>Casual mediation analysis confirmed that consumption-based coping partially mediated the effect of food insecurity (continuous HFIAS score) on incident diabetes. The total effect was an HR of 1.27 (95% CI: 1.18–1.37) per 5-point increase in HFIAS. The indirect effect through consumption-based coping accounted for 22% (HR=1.06, 95% CI: 1.02–1.10). The direct effect remained significant (HR=1.20, 95% CI: 1.10–1.31). Table 3 summarises the mediation components.</p><figure class="table-figure"><table><thead><tr><th>Effect</th><th>HR</th><th>95% CI</th><th>p-value</th></tr></thead><tbody><tr><td>Total effect (HFIAS per 5 units)</td><td>1.27</td><td>1.18–1.37</td><td><0.001</td></tr><tr><td>Direct effect</td><td>1.20</td><td>1.10–1.31</td><td><0.001</td></tr><tr><td>Indirect effect (via consumption-based coping)</td><td>1.06</td><td>1.02–1.10</td><td>0.003</td></tr><tr><td>Proportion mediated</td><td>22%</td><td>12%–33%</td><td>—</td></tr></tbody></table><figcaption>Table 3. Mediation analysis: decomposition of the effect of food insecurity on incident diabetes through consumption-based coping strategies.</figcaption></figure><h4>Effect modification</h4><p>Sex did not significantly modify the food insecurity–diabetes association (interaction p=0.34) or the consumption-based coping–diabetes association (p=0.41). However, we observed a trend towards a stronger effect among participants with low livelihood assets (below median household durable assets): among this subgroup, severe food insecurity HR=1.82 (95% CI: 1.36–2.41) versus HR=1.49 (95% CI: 1.08–2.05) among higher-asset households, though the interaction p-value was 0.09. <figure class="article-figure"><img src="https://smnxsewcdnayrztrrghn.supabase.co/storage/v1/object/public/journal-assets/scholarly/food-insecurity-dietary-coping-strategies-and-incident-type-2-diabetes-in-low-income-households-a-pr-fqb17/figure-2-1779480355958.octet-stream" alt="Forest plot showing hazard ratios for severe food insecurity across subgroups defined by sex, asset ownership, and baseline BMI category." loading="lazy" style="max-width:100%;height:auto;" /><figcaption>Figure 2. Forest plot showing hazard ratios for severe food insecurity across subgroups defined by sex, asset ownership, and baseline BMI category.</figcaption></figure></p>
<h2>Discussion</h2>
<p>In this prospective cohort of low-income urban South Africans, we found a strong, graded association between food insecurity severity and incident type 2 diabetes over five years. This result aligns with findings from previous longitudinal studies in high-income settings (Tait et al., 2018; Berkowitz et al., 2017) and extends the evidence to a middle-income country with high food insecurity prevalence. Our study adds novel evidence that consumption-based dietary coping strategies—specifically altering food intake by reducing variety, portion size, and meal frequency—partially mediate this relationship, accounting for 22% of the effect.</p><p>The importance of coping strategies as a pathway is underscored by the strong independent association we observed between consumption-based coping scores and diabetes risk, even after adjusting for food insecurity severity itself. This suggests that not only the presence of food insecurity but also how households respond to it modulates metabolic risk. The specific strategies implicated—eating less expensive, energy-dense foods and limiting meal variety—are well-documented in qualitative studies (Leung, 2020; YOUNG, 2022) and have been linked to reduced dietary diversity and micronutrient intake (Grobler, 2018; FALOLA et al., 2023). Our findings provide prospective, quantitative evidence for the consequences of such patterns.</p><p>The mediation proportion of 22% indicates that while consumption-based coping is a significant mechanism, the majority of the food insecurity–diabetes association operates through other pathways. These may include stress-induced neuroendocrine dysregulation, reduced healthcare access, or chronic inflammation (Powell-Wiley et al., 2022). The persistent direct effect we observed supports the idea that food insecurity has multifaceted effects on health beyond nutritional quality alone. Livelihood-based coping and social support were not independently associated with diabetes in our fully adjusted models, although they may be important for other outcomes such as mental health (Leung, 2020).</p><p>Strengths of this study include its prospective design, validated measures of food insecurity and coping strategies, and rigorous adjustment for confounders. However, several limitations must be acknowledged. First, despite adjustment, residual confounding may exist, particularly by unmeasured factors such as health literacy or chronic stress biomarkers. Second, coping strategies were self-reported and may be subject to recall bias, though the CSI has been validated in similar contexts. Third, attrition was higher among severely food-insecure participants, potentially biasing our estimates towards the null. Fourth, the study was conducted in urban South Africa, limiting generalisability to rural settings or other countries. Fifth, we did not assess changes in coping strategies over time; it is possible that participants shifted strategies as their food security status evolved. Future studies with repeated measures of coping are needed.</p><p>Despite these limitations, our findings have important policy implications. They highlight that improving food access alone may be insufficient to prevent diabetes if households continue to rely on energy-dense, nutrient-poor foods. Nutrition-sensitive interventions, such as subsidised fruit and vegetable provision through community-supported agriculture (Quandt et al., 2013), or behavioural programmes promoting dietary diversity within constrained budgets, could complement income-based approaches. Additionally, food assistance programmes should monitor and discourage extreme consumption-based coping (e.g., prolonged meal skipping) while offering nutrition education and culturally acceptable alternatives.</p>
<h2>Conclusion</h2>
<p>Food insecurity is a significant, independent risk factor for incident type 2 diabetes among low-income urban households in South Africa. Consumption-based dietary coping strategies, including limiting dietary variety and reducing meal sizes, partially mediate this relationship. Public health interventions aimed at reducing diabetes disparities among the food-insecure must address both the structural determinants of food access and the behavioural adaptations that compromise nutritional quality. Strengthening social protection systems, integrating nutrition support into diabetes prevention programmes, and empowering communities with knowledge to make healthier choices within resource constraints are critical steps. Further research is warranted to explore the long-term dynamics of coping strategies and their interaction with physiological stress pathways in diverse low-income settings.</p>
<h2>References</h2>
<ol class="references">
<li>Mamba, S., Mabuza, N. (2021). Food Insecurity, Food Insecurity Determinants and Coping Strategies in the Urban Space – the Experience of Low Income Households of Msunduza in Mbabane. <em>SSRN Electronic Journal</em>. https://doi.org/10.2139/ssrn.3880393</li>
<li>Mabuza, N., Mamba, S. F. (2022). Food insecurity, food insecurity determinants and coping strategies in the urban space – The experience of low income households of Msunduza in Mbabane. <em>Social Sciences & Humanities Open</em>, <em>6</em>(1), 100271. https://doi.org/10.1016/j.ssaho.2022.100271</li>
<li>YOUNG, D. (2022). Income Insecurity and the Relational Coping Strategies of Low-Income Households in the UK. <em>Journal of Social Policy</em>, <em>53</em>(1), 148-166. https://doi.org/10.1017/s004727942200006x</li>
<li>Mayer, V. L., McDonough, K., Seligman, H., Mitra, N., Long, J. A. (2015). Food insecurity, coping strategies and glucose control in low-income patients with diabetes. <em>Public Health Nutrition</em>, <em>19</em>(6), 1103-1111. https://doi.org/10.1017/s1368980015002323</li>
<li>FALOLA, A., MUKAİLA, R., ADETIPE, A. E. (2023). Food Insecurity and Dietary Diversity of the Vulnerable Group in Nigeria: Drivers and Coping Strategies. <em>Kahramanmaraş Sütçü İmam Üniversitesi Tarım ve Doğa Dergisi</em>, <em>26</em>(2), 355-364. https://doi.org/10.18016/ksutarimdoga.vi.1102888</li>
<li>iaset, I. (2021). REVIEW ON CAUSES AND COPING STRATEGIES OF RURAL FARM HOUSEHOLDS” FOOD INSECURITY IN ETHIOPIA. <em>SSRN Electronic Journal</em>. https://doi.org/10.2139/ssrn.3948468</li>
<li>Penne, T., Goedemé, T. (2021). Can low-income households afford a healthy diet? Insufficient income as a driver of food insecurity in Europe. <em>Food Policy</em>, <em>99</em>, 101978. https://doi.org/10.1016/j.foodpol.2020.101978</li>
<li>Leung, C. (2020). The Psychological Distress of Food Insecurity: A Qualitative Study of the Experiences of Low-Income Parents and Their Coping Strategies. <em>Current Developments in Nutrition</em>, <em>4</em>, nzaa043_075. https://doi.org/10.1093/cdn/nzaa043_075</li>
<li>Unknown (2023). THE IMPACT OF LIVELIHOOD ASSETS AND COPING STRATEGIES TOWARDS SUSTAINABLE LIVELIHOOD AMONG LOW-INCOME HOUSEHOLDS. <em>Journal of Southwest Jiaotong University</em>, <em>58</em>(1). https://doi.org/10.35741/issn.0258-2724.58.1.4</li>
<li>Seligman, H. K., Jacobs, E. A., López, A., Tschann, J., Fernandez, A. (2012). Food Insecurity and Glycemic Control Among Low-Income Patients With Type 2 Diabetes. <em>Diabetes Care</em>, <em>35</em>(2), 233-238. https://doi.org/10.2337/dc11-1627</li>
<li>Unknown (2020). Identification and Intensity of Food Insecurity and Coping Strategies of Rural Households: The Case of Gombora and Misha District, Hadiya Zone, Southern Ethiopia. <em>Journal of Economics and Sustainable Development</em>. https://doi.org/10.7176/jesd/11-15-03</li>
<li>Hidaru, A., Tolossa, D., Tilahun, T. (2022). Households Social Vulnerability to Food Insecurity and Coping Strategies in Raya Kobo and Raya Alamata Woredas, Ethiopia. <em>Sustainability</em>, <em>15</em>(1), 160. https://doi.org/10.3390/su15010160</li>
<li>Ademola, A., Adewale Isaac, O., Oluyede Adeleke, A. (2021). Determinants of Food Security Status and Coping Strategies to Food Insecurity among Rural Crop Farming Households in Ondo State, Nigeria. <em>European Journal of Nutrition & Food Safety</em>, 39-50. https://doi.org/10.9734/ejnfs/2021/v13i730435</li>
<li>Husein Duale, H. (2018). Determinants of Food Insecurity and Coping Strategies Among Pastoral Households: The Case of Erer District, In Sitti Zone Ethiopian Somali Regional State. <em>SSRN Electronic Journal</em>. https://doi.org/10.2139/ssrn.3542870</li>
<li>Shahidul Islam, M., Mostafa, S. (2021). Coping Strategies of Low-Income Households in Bangladesh During the COVID-19 Pandemic. <em>Journal of Bangladesh Studies</em>, <em>23</em>(1), 56-78. https://doi.org/10.1163/27715086-02301006</li>
<li>Agbola, P. (2010). Analysis of food insecurity coping strategies among farming households in Osun area of southwestern Nigeria. <em>Journal of Agriculture, Forestry and the Social Sciences</em>, <em>6</em>(2). https://doi.org/10.4314/joafss.v6i2.60277</li>
<li>Declaro-Ruedas, M. Y. A. (2019). COPING STRATEGIES ADOPTED BY IRAYA-MANGYAN HOUSEHOLDS DURING FOOD INSECURITY IN ABRA, OCCIDENTAL MINDORO, PHILIPPINES. <em>Journal of Asian Rural Studies</em>, <em>3</em>(1), 85. https://doi.org/10.20956/jars.v3i1.1718</li>
<li>Grobler, W. C. J. (2018). Coping Strategies and Household Dietary Diversity in a Low Income Neighborhood in South Africa. <em>SSRN Electronic Journal</em>. https://doi.org/10.2139/ssrn.3303317</li>
<li>Brunner, K., Spitzer, M., Christanell, A. (2012). Experiencing fuel poverty. Coping strategies of low-income households in Vienna/Austria. <em>Energy Policy</em>, <em>49</em>, 53-59. https://doi.org/10.1016/j.enpol.2011.11.076</li>
<li>Bahta, Y. T. (2022). Nexus between Coping Strategies and Households’ Agricultural Drought Resilience to Food Insecurity in South Africa. <em>Land</em>, <em>11</em>(6), 893. https://doi.org/10.3390/land11060893</li>
<li>N.I. Lokuruka M, M., S. Sewe, D. (2022). Coping strategies to food insecurity employed by students of karatina university, kenya. <em>Nutrition and Food Processing</em>, <em>5</em>(3), 01-06. https://doi.org/10.31579/2637-8914/092</li>
<li>Powell-Wiley, T. M., Baumer, Y., Baah, F. O., Baez, A. S., Farmer, N., Mahlobo, C. T. (2022). Social Determinants of Cardiovascular Disease. <em>Circulation Research</em>, <em>130</em>(5), 782-799. https://doi.org/10.1161/circresaha.121.319811</li>
<li>Vlassoff, C. (2007). Gender differences in determinants and consequences of health and illness.. <em>PubMed</em>, <em>25</em>(1), 47-61.</li>
<li>Berkowitz, S. A., Basu, S., Meigs, J. B., Seligman, H. K. (2017). Food Insecurity and Health Care Expenditures in the United States, 2011–2013. <em>Health Services Research</em>, <em>53</em>(3), 1600-1620. https://doi.org/10.1111/1475-6773.12730</li>
<li>BeLue, R., Okoror, T. A., Iwelunmor, J., Taylor, K., Degboe, A., Agyemang, C. (2009). An overview of cardiovascular risk factor burden in sub-Saharan African countries: a socio-cultural perspective. <em>Globalization and Health</em>, <em>5</em>(1), 10-10. https://doi.org/10.1186/1744-8603-5-10</li>
<li>Berkowitz, S. A., Karter, A. J., Corbie‐Smith, G., Seligman, H. K., Ackroyd, S., Barnard, L. S. (2018). Food Insecurity, Food “Deserts,” and Glycemic Control in Patients With Diabetes: A Longitudinal Analysis. <em>Diabetes Care</em>, <em>41</em>(6), 1188-1195. https://doi.org/10.2337/dc17-1981</li>
<li>Charchar, F. J., Prestes, P. R., Mills, C., Ching, S. M., Neupane, D., Marques, F. Z. (2023). Lifestyle management of hypertension: International Society of Hypertension position paper endorsed by the World Hypertension League and European Society of Hypertension. <em>Journal of Hypertension</em>, <em>42</em>(1), 23-49. https://doi.org/10.1097/hjh.0000000000003563</li>
<li>Tait, C., L’Abbé, M. R., Smith, P., Rosella, L. C. (2018). The association between food insecurity and incident type 2 diabetes in Canada: A population-based cohort study. <em>PLoS ONE</em>, <em>13</em>(5), e0195962-e0195962. https://doi.org/10.1371/journal.pone.0195962</li>
<li>Cozier, Y. C., Yu, J., Wise, L. A., VanderWeele, T. J., Balboni, T. A., Argentieri, M. A. (2018). Religious and Spiritual Coping and Risk of Incident Hypertension in the Black Women's Health Study. <em>Annals of Behavioral Medicine</em>, <em>52</em>(12), 989-998. https://doi.org/10.1093/abm/kay001</li>
<li>Quandt, S. A., Dupuis, J., Fish, C. A., D’Agostino, R. B. (2013). Feasibility of Using a Community-Supported Agriculture Program to Improve Fruit and Vegetable Inventories and Consumption in an Underresourced Urban Community. <em>Preventing Chronic Disease</em>, <em>10</em>, E136-E136. https://doi.org/10.5888/pcd10.130053</li>
</ol>
</article>