Contributors to co-occurring chronic loneliness and depression and anxiety and the role of adverse childhood experiences.

Food insecurity and micronutrient malnutrition (the inadequate intake of essential vitamins and minerals) remain a challenge in many settings worldwide. As of 2021, 2 of 5 people in the world (about 3.1 billion people) cannot afford a healthy diet, an experience that is most common in lower-income countries of Asia and Africa. Sustainable Development Goal No. 2 (“end hunger, achieve food security and improved nutrition and promote sustainable agriculture”) calls for actions to expand access to nutritious food. Specifically, target 2.1 focuses on the extent of access to safe and nutritious food, while target 2.2 focuses on the prevalence of malnutrition. Toward this end, large-scale food fortification programs are increasingly being adopted. These programs, which add select micronutrients to commonly consumed foods during processing, aim to improve the nutritional status of the food supply, which is expected to improve target 2.1 and, subsequently, target 2.2. Thus far, 126 countries have mandatory fortification of salt. This value is 90 for wheat flour, 33 for vegetable oil, and 19 for maize flour. The introduction of large-scale food fortification programs in countries such as Uganda and Zambia demonstrate that this approach to delivering much needed micronutrients is feasible even in relatively low-income settings, and programs for iron and folic acid have been found to reduce rates of anemia and neural tube defects in low- and middle-income countries. Nevertheless, large-scale food fortification programs have had a mixed record in terms of delivery, coverage, and sustainability, with greater success seen with non-targeted initiatives that cover the whole population, domestic ability to test for fortified product, and low cost of procuring (often imported) pre-mix. Further research is needed in diverse settings to understand whether and how these programs are effective. Despite recent improvements, malnutrition rates in Kenya remain high, and the Government of Kenya has embraced large-scale food fortification to promote micronutrient adequacy. In 2012, the National Food Security and Nutrition Policy mandated the fortification of maize flour (as well as wheat flour and vegetable oils/fats), and the standards were made explicit in 2015 in CAP 254, Notice No. 157. Maize flour is widely consumed in Kenya and is the main ingredient in , a soft porridge commonly eaten for breakfast, and , a stiff porridge eaten for lunch and dinner. This mandate applies to all packaged dry milled maize products, regardless of the size of the processing firm, and the mandated micronutrients for maize flour fortification include iron, zinc, folic acid, and vitamins A, B1, B2, B3, B6, and B12. Although compliance to national standards in terms of the level of each micronutrient is low, Kenya’s fortification program remains strategically important, and there is a growing commitment to strengthen enforcement and increase millers’ capacity to comply with fortification standards.