Food insecurity and mental health in South Africa: Structural pathways linking socioeconomic position, behavioural risk factors and comorbidity.

Objective: To examine the prevalence of food insecurity in South Africa and the structural pathways linking it with mental health, hypertension-diabetes comorbidity, and socioeconomic and behavioural factors. Methods: We analysed nationally representative data from 3095 South African adults aged ≥16 years from the South African Social Attitudes Survey conducted in 2025. Survey-weighted generalized structural equation modelling estimated direct, indirect, and reciprocal associations between food insecurity, mental illness, socioeconomic status (SES), nicotine use, alcohol use, and hypertension-diabetes comorbidity. Results: Overall, 37.4% (95% CI: 34.5, 40.5) of adults reported household food insecurity. Mental illness was strongly associated with food insecurity (OR = 2.82, 95% CI: 1.54, 5.18), while the reciprocal pathway from food insecurity to mental illness was also statistically significant. Higher SES was protective (total effect OR = 0.40, 95% CI: 0.18, 0.86). Nicotine use showed direct associations with food insecurity, whereas alcohol use operated mainly indirectly through nicotine use. Hypertension-diabetes comorbidity was not independently associated with food insecurity. Conclusions: Although this cross-sectional study cannot infer causal direction, the findings are consistent with reciprocal relationships between food insecurity and mental health within broader socioeconomic and behavioural pathways. Integrated socioeconomic, mental health, and behavioural interventions are needed to reduce food insecurity.