Chapter Eleven

The Power of Innovation
142

Alain Labrique
Director, JHU Global mHealth Initiative; Assistant Professor, Department of International
Health & Department of Epidemiology
Johns Hopkins Bloomberg School of Public Health
Baltimore, MD, USA

Marguerite B Lucea
Research Associate, Department of Community and Public HealthJohns Hopkins School of Nursing
Baltimore, MD, USA

Alan Dangour
Senior Lecturer, Department of Population HealthLondon School of Hygiene & Tropical Medicine (LSHTM) London, UK

“Discovery consists of seeing what everybody has seen andthinking what nobody has thought.”
Albert von Szent-Gyorgy

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Key messages
For centuries, innovations across the entire spanof human nutrition, from plant to population, havetargeted aspects of the farm-to-table continuum.
• For centuries, innovations across theThrough these innovations, humans have sought
entire span of human nutrition, from plantways to improve mechanisms to assess,to population, have targeted aspects ofunderstand and meet nutritional requirements,
the farm-to-table continuum. Throughboth locally and globally.
these innovations, humans have sought
Recenttransformative
innovations targetingways
to improve mechanisms
to assess,
distribution
systems,leveraging
public-private
understandand meetnutritional
partnerships,
andutilizing
technologicalrequirements, both locally and globally.
advances have the potential to catalyze research• Recent transformative innovations targetingand improve nutrition in both the developed anddistribution systems, leveraging publicdeveloping world.
private partnerships, and utilizing
technological advances have the potential
to catalyze research and improve nutrition inboth the developed and developing world.

Key messages

Introduction
In a world of over 7 billion people today, access to sufficientnutrition plays a crucial role in the well-being of the
population. Currently, nearly 45 percent of deaths inchildren under age 5 can be attributed to nutrition-related
factors. Others, who are undernourished but survive, face
health concerns such as stunted growth and limited
neurodevelopment, which impact livelihoods in adulthood.
Sir Gordon Conway, one of the world’s foremost experts on
global food needs, has stated: “Hunger is a daily reality fornearly a billion people. More than six decades after thetechnological discoveries that led to the Green Revolution
aimed at ending world hunger, regular food shortages,
malnutrition, and poverty still plague vast parts of the world.”
Innovation is essential to alleviate this enormous burden, as
it seeks to improve the mechanisms necessary to meet thedemands associated with the growth of the world’s
population and to thwart the morbidity and mortality
associated with malnutrition in children and adults.
Innovation in nutrition has occurred since the planting of
the first seeds intended to grow food for consumption. In
early agricultural societies, the selection of crops directly
affected the well-being of local populations, and local
solutions were developed for local problems. In the 21st
century we live in an interconnected society faced withclimate change and an ever-growing population. Increasing
yield, enhancing nutritional quality, ensuring diversity ofcrops and improving access to nutritional interventions
have become global priorities. At the same time, we arechallenged to define specific nutritional needs anddeficiencies at a population level so that programs andpolicies are responsive to local and regional needs.
This chapter presents examples of innovations that target
aspects of the farm-to-table continuum, from plant topopulation. Recent potentially game-changing innovations
are discussed that target distribution systems, leverage
public-private partnerships, and utilize technologicaladvances. We first present innovations in production anddistribution mechanisms. We then discuss collaborations in
the food industry as a mechanism to create an enabling
environment for enhanced nutrition. We also review
technological innovations that have improved the areas ofdiagnostics, delivery, and communication. We close with a
discussion of new frontiers and directions that further
address sustainable nutrition in the world today.

Chapter Eleven | The Power of Innovation | Alain Labrique, Marguerite B Lucea, Alan Dangour

Farm-to-table continuum
The five steps in the farm-to-table continuum provide several
access points for nutritional innovations (see Figure 1).
Throughout the chapter, we refer to this continuum, in
terms of both existing and potential innovations. Many
innovations couple one aspect of the continuum withanother, illustrating that the innovations along thecontinuum are most effective when not directed at one
aspect in isolation. For ease of reference, each case study
title contains the stages along the continuum most relevantto the given innovation.

Production
Farm production is the first stage in the continuum. In the pastwhen facing food deficits, the focus of innovation was on
simply producing an increased yield of staple crops such as
wheat and rice. However, surpassing the growth of demandwith greater production is a necessary but not sufficient
response for modern societies. The focus has turned tohighlight the nutritional benefits provided with a greater
variety and diversity of food as well as the economic
enhancement this diversity can bring to individuals,
corporations, and governments. In 2011, Rachel Nugent

noted that if farm and food systems are to meet human needs
and contribute to human health and longevity, they must
produce affordable, diverse, and healthy food. Decisionmakers at all levels, both public and private, must participate
in steering the food environment in such a direction*. As aconsequence, the priority agenda of donors and governments
has become one that increases not only the quantity but also
the quality and diversity of food production.
As a mechanism for altering food production in a sustainable
manner with more nutritional options, some innovations havebeen developed to combat malnutrition and related healthconcerns that are specific to certain geographic localities. The
first example is the development of β-Carotene-rich orangeflesh sweet potatoes, which have been biofortified throughconventional breeding rather than through transgenic
approaches. These biofortified potatoes have been introduced
in regions with populations suffering from vitamin A deficiency
and have been found to be an effective way of reducing
deficiencies in women and children (see Case Study 1).
A second case study presents an innovation in the fortificationof rice (see Case Study 2).
Souce: *Bringing agriculture to the table, Rachel Nugent, The Chicago Council on
Global Affairs, USA, 2011

The farm to table continuum

FarmTransportation

Processing
Source: USA Federal Drug Administration

Table

Retail144

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Case study 1
Continuum: Production and Table
β-Carotene rich orange sweet potatoes
Vitamin A deficiency (VAD) is a global problem, estimatedto affect over 200 million women and children and toaccount for over 600,000 deaths globally each year amongchildren under 5 years of age. Deficiency in vitamin A
increases the risk of mortality, xerophthalmia and night
blindness. Even subclinical deficiency can lead to increased
risk for infections, severe diarrhea, and anemia. African
regions account for the greatest number ofpreschoolchildren with night blindness and for more than
one quarter of all children with subclinical VAD.
Sweet potato remains a major staple food in several
African countries. A preponderance of the varieties grown
are white or pale yellow and contain no or relatively little
provitamin A carotenoids.In contrast, orange-fleshedvarieties of sweet potato (OSP) can contain large amountsof β-Carotene, which is a precursor for vitamin A.
Recently several large-scale intervention programs were
implemented in Mozambique and Uganda to evaluate theimpact of introducing orange sweet potato rich in
β-Carotene to rural communities.
Mozambique is a country with modest use of sweet potato
as a staple food. A 3-year-long, large-scale intervention inrural communities of Zambezia Province integrated threemajor components. An agricultural component supported
the distribution of vines as planting material for OSP andprovided training. A demand creation/behavior change
component included education on maternal and childhealth and nutrition topics targeted to women inparticipating households and a campaign for the generalpublic to raise awareness of the benefits of OSP as asource of vitamin A through community drama, field-day
events and radio spots and programs. A marketing andproduct development component included training for
OSP traders and the establishment of distinct market stalls
selling and providing information on OSP. Theintervention successfully integrated OSP into the diet of
women and children and significantly increased theadequacy of vitamin A intake. No significant differences
existed between more or less intensive intervention
designs, indicating that future interventions can use lessintensive models with the same success.
The large-scale intervention in Uganda resulted in asignificant increase in the dietary intake of OSP amongchildren and women in farmer group member households.
This resulted in a substantial increase in total vitamin A
intake from β-Carotene in all three age groups. It also
resulted in a significant decrease in the prevalence of
inadequate vitamin A intake among non-breastfed
12-35-month-old children. These children are at elevatedrisk of VAD, as breast milk is the primary source ofvitamin A and the vitamin A requirements for this groupare still relatively high; therefore this finding wasparticularly important. Increased vitamin A intake from
OSP led to improved vitamin A status in children andwomen and reduced the prevalence of marginal vitamin A
status in children by nearly 10%.
Because sweet potato is a seasonal crop, this type ofintervention will not provide the same amount ofadditional vitamin A throughout the entire year. However,in these communities, sweet potato is harvested 2 to 3
times per year, and OSP would be available for around 9
to 10 months of the year.
(Sources: ‘A large-scale intervention to introduce orange sweet potato inrural Mozambique increases vitamin A intakes among children and women’
Christine Hotz, Cornelia Loechl et al. Published in the British Journal of
Nutrition, 2011.
‘Introduction of β-Carotene-Rich Orange Sweet Potato in Rural Uganda
Resulted in Increased Vitamin A Intakes among Children and Women and
Improved Vitamin A Status among Children’ Christine Hotz, Cornelia
Loechle et al. Published in the Journal of Nutrition, 2012.
Low JW, Arimond M, Osman N, Cunguara B, Zano F, Tschirley D. A
Food-Based Approach Introducing Orange-Fleshed Sweet Potatoes Increased
Vitamin A Intake and Serum Retinol Concentrations in Young Children in
Rural Mozambique. Journal of Nutrition. 2007. 137(5):1320-7.)

The β-Carotene-rich sweet potato has a characteristicorange-colored flesh

Chapter Eleven | The Power of Innovation | Alain Labrique, Marguerite B Lucea, Alan Dangour

Case study 2
Continuum: Production, Transportation,
Retail and Table
Ultra Rice® Technology
PATH is an international nonprofit organization whose
work focuses on transforming global health throughinnovation. The organization’s Ultra Rice® technology isdesigned to be an effective micronutrient delivery systemthat is culturally appropriate and cost-effective. It uses awarm extrusion process to make rice grains from rice flour
fortified with vitamins and minerals, including iron, zinc,thiamin, and folic acid. The extruded grains called Ultra
Rice® resemble normal rice in size, shape, and color. Whenmixed with milled rice, usually at a 1:100 ratio, the fortified
rice is nearly identical to traditional rice in smell, taste, andtexture. Because the added micronutrients are inside thegrains, they are less vulnerable to nutrient loss during
preparation and cooking.
In India, a large local miller, Usher Agro, now has thecapabilities to produce Ultra Rice®. At the same time, PATH
is working within the state systems to widen the distributionof fortified rice within India’s public-sector food programs.
This work encompasses the Public Distribution System,
which provides subsidized commodities to families below
the poverty line.
In Brazil, Urbano Agroindustrial is one of the country’s
largest rice millers. PATH has transferred the Ultra Rice®
technology to this miller. In conjunction with the Global
Alliance for Improved Nutrition (GAIN), an organization
dedicated to fostering private sector investment in
adaptation to climate change, PATH and Urbano will be
introducing fortified rice through commercial retailers,
accompanied by a social marketing campaign to enhancedemand for the product.
These case studies illustrate how innovations implemented at
the production level can be coupled with enhancements to
subsequent steps in the continuum, including processing,transportation, retail and table, to directly address
malnutrition. Fortified rice and orange-flesh sweet potato areboth good examples of how improved production, in
conjunction with robust, targeted population supplementation
strategies, stands to increase the pace of progress against
malnutrition and its consequences. To bolster the uptake of
OSP, production was combined with a marketing strategy for
OSP traders, dedicated market stalls for OSP sellers, andcommunity education efforts for consumers. Partnering

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In Burundi, PATH has partnered with World Vision to
distribute fortified rice to children through a school meal
program. Supplementing the program, supported by theWorld Food Program (WFP), with fortified rice aims to
improve nutritional status of children who participate. The
impact in this country can provide data to support inclusionof Ultra Rice® as an approved commodity for the WFP.
Source: PATH, www.path.org, (June 2012. Ultra Rice® is a registered US
trademark of Bon Dente International, Inc.).

NutriRice™ Technology
A similar technology, created by DSM, uses hot extrusion tocreate fortified rice kernels with encapsulated
micronutrients. As compared to some other fortified rice,these grains look, taste and behave exactly like normal rice,and the embedded nutrients are well protected during
washing and cooking. The recomposed, vitamin-andmineral-enriched rice kernels have shown demonstrated
success in being incorporated into the usual diet. Thoseingesting the fortified rice have also seen improvement inhealth. In Beijing, the Chinese Center for Disease Control
and Prevention implemented a pilot project wherein they
introduced NutriRice™ into a school’s meal plan. The
students ate NutriRice™ and vitamin-A-enriched oil andiron-enriched soy sauce for eight months. The students’nutritional condition was improved, and micronutrient
deficiencies were reduced by 50%.
Similarly, in Bangalore, India, schoolchildren aged 6-12
participated in a trial of NutriRice™. After six months,
the children who were eating NutriRice™ had improved
vitamin B levels, and they experienced improvements inphysical performance, particularly pertaining to endurance.
Source: A breakthrough in rice fortification http://www.dsm.com/en_US/nip/public/home/pages/productsservices-nutririce.jsp

UltraRice™ with school meal programs (in Burundi) andgovernment and non-government distribution channels (India
and Brazil) coupled production with other components of thecontinuum. Aiming to establish an agriculture system that is
highly productive, stable, resilient and equitable with explicit
recognition of the critical role of smallholder agriculture isessential. Small-scale agriculture is once again playing animportant role in production that supports diverse food choices
and improved nutrition. Women are becoming more prominent
players in successful agricultural initiatives. Empowering womenin successful farming at local levels improves both their healthand their children’s health (see Case Study 3).

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Case study 3
Continuum: Production and Table
Women in small-scale agriculture
Helen Keller International (HKI) is well known in
Bangladesh for its homestead food production (HFP)
program. The program seeks to improve nutritional
outcomes for women and children through promoting
small-scale agriculture among women. Nutritional
outcomes of interest include dietary diversity andknowledge of maternal self-care and infant/young childfeeding practices.
The program was introduced in Bangladesh two decadesago, targeting women with limited land and promoting
an integrated package of home gardening, small
livestock production, and nutrition education. The
program’s design specifically seeks to combat
micronutrient deficiencies, including vitamin A, broughton by food insecurity and dietary monotony over time.
Project monitoring and evaluation data show that thiswork has directly benefited more than five million people
in rural Bangladesh. Among HFP farmers, vegetable yields
have improved greatly. At the “table” stage of the
farm-to-table continuum, HFP monitoring has shown amarked increase in the household-level consumption of
micronutrient-dense foods, particularly of iron- andvitamin-A-rich dark green leafy vegetables and eggs.

Distribution
Innovations to bridge the gap between production, market
availability, and household consumption can improve thediversity of choices available to consumers in remote, rural
populations. Yet, distribution is often seen as merely ameans to an end rather than a means to grow, develop andinnovate in the domain of nutritional access. Yet it is in thephases of the continuum that involve distribution (processing,transportation, and retail) where innovation has yielded
potentially life-saving initiatives in the field of nutrition.
One of the best illustrations of innovation in the area of
distribution also highlights how partnerships can yield
untold health and nutritional benefits. In this example,
pre-existing private-sector supply chain systems were
utilized to deliver health promotion commodities, keeping
the costs low but the coverage extensive. The ColaLife
project leveraged Coca-Cola’s existing distribution systems
to piggy-back the distribution of AidPods in a simple, smart
manner that ensured oral rehydration kit coverage in themost remote communities in Zambia (see Case Study 4).
While oral rehydration could be considered more of a healthintervention, similar partnerships could be leveraged to include
nutritional products such as micronutrient supplements.

Source: Hillenbrand, Emily (2010). Transforming gender in homesteadfood production. Gender & Development, 18(3), p411-425.

Aidpods utilizing the Coca-Cola distribution system
Source: A Refreshing Development by Andrew Marshall, Development Asia
www.development.asia, January–March 2012.

A woman farmer at work in Bangladesh
Source: CIAT

Chapter Eleven | The Power of Innovation | Alain Labrique, Marguerite B Lucea, Alan Dangour

Case study 4
Continuum: Transportation
Medicine via Coca-Cola“In remote, impoverished places where clean water andmedicine are hard to find, people can still buy a Coke. In
1988, when Simon Berry was a British aid worker in Africa,
he made two observations that would change his life.
“Fact 1: In remote parts of Zambia, where families
scratched out a subsistence living by farming, many
young children died of preventable diseases, such as
dehydration from diarrhea.
“Fact 2: In these same rural areas, you could almost
always buy Coca-Cola.”
Berry, then a technical cooperation officer for the British
aid program, posed a question of possible connections:“Could Coca-Cola’s unrivaled local distribution networks
be harnessed to deliver simple but potentially life-saving
medicines to hard-to-reach places?”“Twenty years later, in a concerted attempt to answer thatquestion, Berry and his wife Jane launched an independent
non-profit organization called ColaLife. The organization’s
goal was to leverage Coca-Cola’s distribution channels tocarry so-called social products – oral rehydration solution(ORS), zinc supplements, water purification tablets – thatlast mile in an effort to save lives.”
They developed the AidPod: a crush resistant, wedgeshaped canister that fits snugly between the necks of the
Coca-Cola bottles when in their crates. By using theunused space, the products can reach the same places that
Coca-Cola does. Rather than reinventing the process, theyfound a pre-existing, efficient mechanism to distribute thekits to the most remote of locations.
Source: A Refreshing Development by Andrew Marshall, Development Asia
www.development.asia, January–March 2012.

Collaboration
Collaboration between public and private sectors has had an
unprecedented global impact on health in areas such as
vaccine delivery and medication access, but this synergy has
just begun to grow in the field of nutrition. At this point, thepotential opportunity for harnessing public-private
collaboration exists in several forms, including developing
food products and systems, scaling up effective nutrition
solutions, providing sustainable cost-effective solutions for
information sharing, and conveying much-needed educational
messages to consumers. Inroads to improve health andnutrition outcomes could be made on a global scale and canbe enacted at all stages of the continuum.
However, these partnerships have been slow to grow. At the
Building Effective Partnerships for Improved Nutrition
meeting in 2012, companies, donors, researchers, and funders
assessed the barriers and explored the potential for innovative
partnerships. Several barriers were identified but were notinsurmountable, provided buy-in from both sides could be
garnered. Partnerships would need to develop sharedobjectives and mutually meaningful targets. In order toaccomplish scalability, the food industry would need toconsider corporate social responsibility (CSR) projects as corerather than supplemental strategies. For the partnerships andinitiatives to be sustainable, firms need to see a valuable
return on investment (ROI) through sustained demand while
the public partners would need to see improved health andcapacity strengthening at the local level.
Private sector innovations in product development,
manufacturing, financial sustainability, message delivery,
behavior change and distribution can be applied to publichealth nutrition strategies. In Case Study 4, a public-private
partnership between Coca-Cola and ColaLife has resulted in
improved distribution of essential oral rehydration anddiarrhea prevention kits. Such a partnership could also be
used to distribute interventions more directly relevant tonutrition such as micronutrient supplements.
Successful innovations identify opportunities of value to boththe private sector and the public health community.
Collaborations between corporations and initiatives for public
nutrition expand the value of the corporations’ brands andpotentially expand the consumer base for the other products
manufactured by the company. An important caveat in thisrealm, however, is the potential for conflict of interest, where
public health programs are concerned about exposing alreadyvulnerable populations to commercial exploitation. In aneffort to find a more equitable and agreeable bottom-line, aninnovative financial model in the private sector is thelong-term investment known as ‘patient capital’, where
investors do not expect a quick return on their initialinvestment (see Case Study 5).

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Case study 5
Continuum: Farm
Acumen Fund
Acumen Fund is a venture capital fund that invests inenterprises dedicated to serving poor people in developing
countries. Patience regarding the speed in which the ROI is
felt has shown to pay off in the long run. Founder andchief executive Jacqueline Novogratz believes that suchpatience pays, giving the example of an investment
Acumen Fund made into an international development
project in India.
“In 2002, after nearly ten years of running a nonprofit tohelp poor farmers in India get the most out of their land,
Amitabha Sadangi was frustrated. Government aid toalleviate poverty had largely bypassed individuals earning
less than $1 day. Instead, it was subsidizing large farms
and being invested in technology he said his farmers didn’twant. Sadangi sought to treat the poor as customers, notpassive recipients of charity. He decided he would adapt awater-saving drip irrigation system to the specific needs ofIndian smallholders and sell it at an affordable price.
“Acumen Fund gave Sadangi’s nonprofit International
Development Enterprises India a US$100,000 grant andloans to experiment. In 2006, we invested $1 million in
equity in Global Easy Water Products (GEWP), a
for-profit spinoff Sadangi created in western India tofurther increase the technology’s reach among the poorand sell other products to them.
To date, GEWP and its parent nonprofit have sold
irrigation systems to some 350,000 farmers. Including thefarmers’ family members, roughly 2 million people are
now benefiting from higher income levels- for some, $5 to$6 a day instead of $1 to $2. With 101 employees andsales that have tripled since 2008, GEWP is now one of
Acumen’s most profitable enterprises. It has even begun topay dividends to its shareholders. By all measures, that is
the kind of return on investment we need to see in a world
with more than 2 billion people living in poverty.”
Source: (Bloomberg Businessweek, The Case for Patient Capital, May
2011, http://www.businessweek.com/smallbiz/content/may2011/
sb20110524_877194.htm

With private-public partnerships, some debate exists overwhether patents should be allowed on life-saving foodsupplements or other innovations. A balance may be able
to be achieved if the ROI is sufficient for firms, but not
being able to patent an innovation may reduce the
incentive to develop such supplements in the private sector.

Technology
In our efforts to satisfy the nutritional needs of the world’s
growing population, we put significant pressure on the
resources of our planet as well as on agricultural systems anddistribution networks. At the same time, if nutritional needsof populations are not addressed, the healthcare systems andbudgets of nations will come under intense stress as thecomplications of malnutrition are addressed in acute andchronic care. The systems are interconnected andinterdependent. For instance, agricultural systems may beaffected by climate extremes (droughts and floods), a deficit ofmanual labor, a lack of technical resources, or a lack ofexpertise. Healthcare systems, meanwhile, might be impacted
by lack of trained staff and equipment and an influx ofpatients with nutrition-related illnesses as well as
communicable and non-communicable diseases. While
technology is not the universal panacea, technologicalsolutions have been developed that have potential to bringabout positive and much needed change in several of thesesystems and at many stages of the farm-to-table continuum.
This section examines technological innovation in terms of
diagnostics, treatment and delivery (food fortification,
supplementation and increasing dietary diversity),
and communications.

Diagnostics
Anticipating complex nutritional emergencies and intervening
appropriately depends on accurate and efficient analysis of a
population’s nutritional status and knowledge of the nutrient
content of foods. Understanding potential healthconsequences of nutritional deficits and how to address themearly is crucial in all settings. Preventive treatment can beprovided and resources properly allocated when reliable data
are available.
Deficiencies of key nutrients such as iron and vitamin A canhave dramatic health consequences, severely influencing
morbidity and mortality rates of populations. Anemia affects
more than 1.6 billion people globally and contributes to atleast 100,000 maternal deaths and 157,000 child deaths
annually. Vitamin A deficiency affects over 200 million
women and children and accounts for over 600,000 deaths
globally each year among children under 5 years of age.
At the beginning of the 20th century with the discovery ofvitamins, research began on the nutritional composition of foods.
Since then, multiple technological innovations in diagnostics haveenhanced our ability to analyze the nutrient content of foods,
and current methods allow the assessment of several
micronutrients rapidly and accurately (see Case Study 6)

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Case study 6

Case study 7aContinuum: Farm, Processing, Retail

Continuum: Table

iCheck and vitamin A

Screening for anemia

BioAnalyt is a manufacturer of equipment used foranalyzing micronutrients in food. It has just created aportable device, the iCheck FLUORO, which determines
levels of vitamin A in food. Its use has already been
incorporated by non-governmental organizations, thefood and food processing industry, laboratories,
universities and monitoring agencies. It extracts a sample
from any fortified food, such as flour, sugar, or premix,
as well as biological fluids, into a disposable extraction
vial containing necessary reagents for efficient extractionof vitamin A. Using fluorescence measurement throughLED technology accurately determines the vitamin A
concentration in food.
The device is said to be as reliable as the gold-standard
laboratory-based methods that require significant andcostly laboratory equipment and a substantial amount oftime. Its portability means that the iCheck FLUORO canbe used in multiple sites from the factory productionlines to markets in remote areas. The process is userfriendly and the three steps of injection, reaction, andmeasurement take only a few minutes to complete.
Source: http://www.bioanalyt.com/products/icheck-fluoro-and-iex-mila

Assessing the nutrient content in food is important forthe prevention of dietary deficiency, but technologicalinnovations are also required to assess the current
nutritional status of populations. Technological advances
have been rapid in this area, and include screening
diagnostics for both iron and vitamin A status (see Case
Study 7a and 7b).

A rapid, cost-effective, and culturally acceptablescreening mechanism was essential to identify individuals
in need of iron supplementation. In recent years,
advances in technology have brought about a number of
non-invasive screening devices that do not require thetraditional blood-draw. For instance, a portabletranscutaneous hemoglobin (Hb) meter uses a probe
applied to a clean fingertip or arm. The probe emits
infra-red light and uses photo-plethysmography andreflectance spectroscopy to establish the Hb absorption
pattern in the individual. Crowley and colleagues (2012)
tested two similar methods of non-invasive Hb screening
and found that both classes of non-invasive Hb recording
devices performed acceptably in field conditions.
In keeping with the common phrase, “There’s an app forthat,” a team of biomedical engineering undergraduates
at Johns Hopkins University in Baltimore, Maryland,
USA, have developed a mobile phone application forscreening for anemia. Their ‘prick-free’ device, theHemoGlobe, converts mobile phones of healthcare
workers into ‘hemoglobinometers’ at a cost of $10-20
per phone. The phone can then read the Hb levels, which
are displayed on the cellphone screen. Concurrently, an
automated text message sends the data to a central
server. The students received seed funding from global
health organizations and are currently testing thisinnovative “app” in the field.

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Case study 7b
Continuum: Table
Screening for vitamin A deficiency
Night blindness is a common manifestation of moderate
to severe vitamin A deficiency and is also associated witha host of poor health indicators.
In 2008, Congdon and colleagues demonstrated acorrelation between serum retinol and pupillary response,
advancing work in Dark Adaptometry pioneered by Waldand others in the 1930s. Basically, this earlier work
established that individuals with low circulating levels ofvitamin A (retinol) frequently suffered from night
blindness attributable to associated low levels of
rhodopsin, the molecule necessary for vision under
low-light conditions. In the 1930s through 1950s abattery of tests were developed to assess, subjectively, thelowest level of light at which dark-adapted individuals
could recognize shapes or words. In the 1990s fielddevices were used in a number of settings to evaluate thethreshold of light intensity required for a ‘major’ pupillary
response to be observed; these tests were not practical dueto the requirement for dark-room conditions in difficult
field settings, but also unpopular due to the subjective
nature of the data. In the late 2000s Labrique et al. of theJohns Hopkins Bloomberg School of Public Healthdeveloped the Portable Field Dark Adaptometer (PFDA),
harnessing digital technology to revitalize these principles.
While low-cost and accurate screening for key nutrients is a
crucial innovation to enhance our ability to respond to theglobal burden of malnutrition, nutritional status is now widely
recognized as the outcome of a highly complex and dynamic
body system. The field of nutrition now fully recognizes thiscomplexity and incorporates the fields of proteomics (study ofproteins expressed by a person’s genes), metabolomics(measurement of metabolites at a cellular level), andnutrigenomics (effects of food on gene expression).
These emerging fields enable us to identify biomarkers, or
biological specimens, that can be used as proxy indicatorsof nutritional status, revealing the intake of food energy, fat,protein, minerals, vitamins, and other components notclassed as nutrients. For instance, in the area of anemia
prevention, an antimicrobial-like peptide hormone called
hepcidin has emerged as the master regulator of ironmetabolism, controlling the absorption of dietary iron andthe distribution of iron among cell types in the body. Its
synthesis is regulated by both iron and innate immunity.

This new method
uses lightweight,
head-mounted ‘lightstimulus andpupillary response’
goggles run by alaptop computer toexpose participants
to a series ofcalibrated lightstimuli and digitallymeasuring pupillary
diameter changes. The Portable Field Dark Adaptometer(Labrique, West & Sommer), being validated
The device requires in Kenyan schoolchildren as a proxy forserum-based assessments of VAD.
no dark room
environment and is 2010 Alain B. Labriqueboth novel and time saving, a potential alternative toexisting invasive biochemical assessments of vitamin A
status which require drawing blood and laboratory
analytics. This device is in the process of being validated
as a proxy for vitamin A status in a number of South
Asian and African populations.
Sources: Validity and correspondence of non-invasively determinedhemoglobin concentrations by two trans-cutaneous digital measuring
devices. By Caitlin Crowley, Gabriela Montenegro-Buthaneart, Noel W.
Solomons and Klaus Schuman.
Article on HemoGlobe innovation, NewsMedical, July 25 2012
An advanced, Portable Field Dark Adaptometer for assessing functional
vitamin A deficiency. By Alain B. Labrique, Keith P West Jr, Parul Christianand Alfred Sommer.

Once low-cost and accurate screening tools for these new
biomarkers are developed, major advances in health andnutrition programs may result.
In the field of proteomics, analysis of the entire complementof proteins in cells, tissues, or organisms, has led to thedevelopment of diagnostic tests that will not diagnose justone major nutrient deficiency, but have the capacity toassess multiple micronutrient deficiencies in populations.
Significant further development is required in this area but
such innovations could
provide another vital toolwith which to tackle
nutrient deficiencies.

Everyone should have access tothe health benefits of fruit andvegetables
Source: Gates Foundation

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Case study 8
Continuum: Table
Proteomics in research and food science
A new proteomics approach utilizing mass-spectrometry
technologies is revolutionizing our understanding of
diagnostics in food science. The proteome is thecomplement of proteins expressed at a cellular level andis dynamic and highly positional in character.
Stephen Barnes and Helen Kim pointed out in their 2004
review paper that the study of proteomes and theirinteraction networks is crucial in understanding
biological systems, and tissue and fluid proteomes
provide novel biomarkers for the detection andprogression of disease. In their conclusion they state:“Clearly, proteomics and protein mass spectrometry
technologies can provide rich resources to investigators
in nutrition and related areas of biomedical research.
Those who are able to include their technologies in theirexperiments will make the meaningful contributions overthe next decade.”
Nutritional scientists recognize the problem of the‘hidden’ aspect of micronutrient deficiencies. The new
field of proteomics could hold the key. Groups are
currently working on establishing the validity of a‘plasma nutriproteome,’ which could be the basis fordeveloping tests that assess multiple micronutrient
deficiencies in populations on a single methodologicalplatform. Senechal and Kussmann (2011) state thepossibilities when they wrote,

DeliveryTechnological advances discussed in this section have more
to do with delivery of micronutrients through mechanisms
such as biofortification than the enhancement of delivery/
distribution systems discussed previously. Current
understanding of the complexity of nutritional processes
has led to a significant change in nutritional interventions
aiming to improve nutritional status. Improving nutrient
intake in this area can occur through nutrient
supplementation and food biofortification.
A shift has occurred away from interventions that provide
single nutrient supplements and toward those innovations
that provide multiple nutrients simultaneously. Industrial
food fortification is a convenient method of delivery for
multiple nutrient interventions at the population level.
Foods such as breakfast cereals, rice, margarine andcooking oils have been targeted for the delivery of multiple
micronutrients, with favorable results so far. For instance,
Nestle’s ‘Maggi’ cube, fortified with iron and iodine, can befound on the shelves of shops and market stalls throughout
West and Central Africa.
Nutrient-dense and safe foods in the form of ready-to-use
therapeutic foods (RUTF) are now also being delivered tochildren suffering from malnutrition. These high-energy
nutrientdense foods are typically delivered in small sealed
packages and fed directly into the mouths of children. The
foods are often made from groundnuts or other locallyavailable staple foods, and mixed with oils and nutrients.
One of the first RUTFs to be developed, called Plumpy’nut®,
resulted from a public-private partnership (see Case Study 9).

“Nutritional proteomics holds great promise to (a)profile and characterize body and dietary proteins,
including digestion and absorption of the latter; (b)identify biomarkers of nutritional status and health/disease conditions; and (c) understand functions of
nutrients and other dietary factors in growth,
reproduction and health.”
Sources: Nutriproteomics: Identifying the Molecular Targets of Nutritive
and Non-nutritive Components of the Diet 2004. Stephen Barnes andHelen Kim Assessing Multiple Micronutrient Deficiences In
Undernourished Populations Through The Plasma Nutriproteome2010.
Ingo Ruczinski, West, Cole et al Nutriproteomics: technologies andapplications for identification and quantification of biomarkets andingredients. 2011. Sandra Senechal and Martin Kussmann

Rice fields in Uruguay
Source: CIAT

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Case study 9
Continuum: Retail and Table
Ready-to-use Plumpy’nut®
Plumpy’nut®, a ready-to-use therapeutic food (RUTF),
was conceived in 1999. It was developed by a publicprivate partnership between Nutriset, a French private
firm specializing in therapeutic food, and the Institute of
Research for Development, a French public research
institute. A groundnut-based protein-packed, nutrientdense paste, Plumpy’nut® needs neither refrigeration nor
preparation. The ongoing use of Plumpy’nut® to fightchild malnutrition is regarded as a success story in
Ethiopia, based on 2008 field research.
A key to its success was the community-based
management of its provision, using some existing andsome new community networks. Another key was
Nutriset’s willingness to share knowledge and to allow
manufacture through franchises.
However, while Plumpy’nut® was successful in Ethiopia,
a 2010 study in a slum area in Dhaka found that eightout of ten women did not like it as a food supplement.
This shows the importance of adapting RUTF to the
local context for acceptability.
Sources: Management of Moderate Acute Malnutrition with RUTF in
Niger. Innovation to Fight Hunger: The case of the Plumpy’nut®. Jose
Guimon, University of Madrid. Engy Ali et al, Kamrangirchar Slum

Information & Communications
The global proliferation and widespread reach of mobile
phones over the past decade has led to several innovationsin information and communication strategies and nutrition.
New mobile technologies can be applied in a variety ofinnovative ways to impact the farm-to-table continuum andbeyond, through supporting farming (mAgriculture) andhealthcare systems (mHealth).
Applied to mAgriculture, mobile technologies can be used
to share important information among farmers. Much likemodern agricultural extension which began during the 19th
century Irish potato famine when agricultural instructors
traveled out to teach farmers about alternate crops, mobile
technology has become a 21st century extension worker. It
is a mechanism by which essential information can bedisseminated in a time-efficient and effective manner.

Farmer with his mobile phone in Buhar, India
Source: CIMMYT - TBC

New technologies have made information more accessible toall, including the smallest scale of farmers. “Plantwise” (www.
plantwise.org) is an initiative focused on benefitting small-scale
farmers through improving food security for the rural poor byhelping them to reduce crop losses. As a modern twist on the
19th and 20th century agriculture extension work,community-based plant clinics share the latest information andresearch and offer practical advice. The clinics also store
feedback information from the farmers in a central knowledgebank. Farmers can access the knowledge bank, which includes
information such as the local pest distribution, at the clinic or
via a community computer.
Additionally, mobile technology can facilitate the initial stepsof getting food from farm-to-table. An illustration in action is
the purjee system in Bangladesh (see Case Study 10).

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Case study 10

154

Continuum: Farm and Processing
e-Purjee system and sugarcane farmers
Communication is key to successful small-scale agriculture,and in Bangladesh the lives of sugarcane farmers havebenefitted from the use of SMS technology. Traditionally, a‘purjee’ is a legal permit given to the sugarcane farmers by
the sugar mill, informing them that they wish to buy theircrops. On receiving it, the farmers then have three days togather their sugarcane and deliver it to the mill. It is asystem that has been in place for over 200 years, since
Bangladesh was a British colony.
However, the process has always had flaws. In manycases, the purjees would take more than two days toreach the farmers, who then would not have sufficient
time to prepare their crops and bring them to the mills.
The purjee system was also fraught with corruption: inthe delivery process and in price manipulation.

Drying maize in Himachal Pradesh
Source: CIAT

A system set up as a joint initiative between the Accessto Information (A2I) Program at the Bangladesh Prime
Minister’s Office and the Bangladesh Sugar and Food
Industries Corporation (BSFI), known as e-Purjee,
intends to resolve some of the issues. Using SMS, thepurjee is sent direct to the farmer’s mobile phone, alongwith information on when/where to deliver, how much,and such. The intention with this mobile system is to
bypass the myriad problems of the past system.
Source: http://manthanaward.org/section_full_story.asp?id=986

Harvesting cauliflowers in Himachal Pradesh

In addition, mobile networks can be mobilized to assistin efficient delivery and distribution of food in crisis
situations. Whether helping to organize the multiple
actors who are mobilized in times of natural disasters
and humanitarian emergencies or simplifying the
distribution of emergency foodstuffs, mobile technologies
have shown to impact nutrition of those impacted bythese situations (see Case Study 11).

Source: CIAT

A farmer in Nicaragua
Source: CIAT

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Case study 11
Continuum: Transportation, “Retail”,
and Table
Texts and Food Aid
About two million Iraqis have fled their country since2003, and an additional 60,000 are leaving each month.
Prior to the Syrian civil war following the Arab Spring,
Syria received the majority of these refugees. At lastestimate, there were 1.4 million Iraqis in Syria, many ofwhom needed food aid, according to the World Food
Program (WFP) To meet this need, as part of the WFP
program in conjunction with the Syrian Red Crescent,eligible refugee families could receive monthly rations.
Each family would receive basic food commodities, such as
rice, lentils, and oil, and other items such as sugar, tea,
pasta, tomato paste, and bulgur.
As the organization responsible for distribution, WFP
alerted eligible families about food rations and directed
them to the appropriate distribution centers. Ordinarily,
the WFP uses local non-governmental organizations(NGOs) working with the refugees to notify groups
when aid became available. However, in this instance,
because not all eligible families had regular contact withlocal NGOs, the strategy needed updating.
In 2007, the UN agency developed and implemented atext messaging program to notify refugees when andwhere food aid became available. WFP bought text
messages in bulk, thereby securing a volume discount,
and accessed a list of phone numbers held by the UN
High Commissioner for Refugees (UNHCR) to target its
text-based food distribution alerts. Initially, text
messages to 800 families were piloted. Proving
successful in reaching the desired participants, theprogram expanded dramatically. By the end of the firstsix months of operation in 2007, 35,000 text messages
had reached 140,000 eligible people, the equivalent of
one message per WFP-registered family.
Source: Humanitarian Assistance, Wireless Technology for Social Change:
Trends in Mobile Use by NGOs.

In the arena of mHealth, mobile systems have also beendeveloped to enhance the capacity of field workers tomonitor the growth and nutritional status of children, an
outcome of the farm-to-table continuum. The mobile

phones have a place in diagnostics and the reporting ofscreening results (as illustrated in Case Studies 7a and 7b).
Information collected can be analyzed immediately totrigger a response, and accumulated data can be
aggregated to produce reports for policy decision-makers
and program managers.
Another mHealth application is the use of Rapid-SMS, atext-message-based data platform developed by UNICEF
and partners, for nutrition surveillance in sub-SaharanAfrica. Increasingly used in field settings to support thedelivery of interventions, Rapid-SMS allows formonitoring, data collection and information-sharing on alarge scale, using mobile telephones. SMS messages havethe advantage that they can be sent to multiple recipients,
so are ideal for informing a large group very quickly. For
data collection, the speed of SMS response means reporting
can happen in real time, with no delay while the monitors
return from the field. SMS messaging helps information
sharing, and the speed means that gaps, for example, in
medical supplies or food aid in one area can be identified
quickly and also remedied. It is hoped that Rapid-SMS will
help to reduce child mortality by shortening the lag time
between identifying nutritional emergencies and scaling up
treatment in affected areas.

New frontiers
One of the biggest challenges facing the agriculture systemcurrently and looking into the future is how it will respondto climate change. ‘Climate-smart agriculture’ that increases
productivity and resilience to environmental pressures while
reducing greenhouse gas emissions requires urgent
innovations. The former Director General of the United
Nations Food and Agriculture Organization, Jacques Diouf,
has given examples of the changes needed to makeagriculture climate-smart such as crop diversification,
seaweed farming and urban farming, and many of these
innovations could be increased in scale in years to come.
The breeding of plant cultivars more able to respond tochanging climates may prove a critical innovation for the
future. A variety of maize with significantly increased
resilience to drought, and a variety of rice able to withstandlong periods of flooding (Scuba-rice) are excellent examples
of such innovative breeding that are already being used.
Some innovations, such as the use of algorithms to provide
tailored insurance policies for farmers (see Case Study 12),have yet to be instituted in developing countries, but theirpotential can already be seen.

Chapter Eleven | The Power of Innovation | Alain Labrique, Marguerite B Lucea, Alan Dangour

Case study 12
CASE STUDY 12 (Continuum: Farm)consumption present important challenges for the future,requiring continued innovations to develop, produce anddeliver optimal nutrition to the continuously expanding
human population.

Agriculture and algorithms
In India, where delayed onset of monsoons can bringabout crop failure, farmers often struggle to repay thedebts they incurred to purchase seeds. More than 15,000
commit suicide every year in desperation. Farming has
always been a gamble, but the growing number of
unusual weather events, as experts call these changes
attributed to global warming, makes seeding, farming,and harvesting an even riskier business.
The Climate Corporation, based in Silicon Valley, wants
to reverse the trend and reduce farmers’ financial risks
by crossing agriculture with information technology’s
trend of big data. The firm collects all kinds ofinformation, including on weather patterns, climate
trends and soil characteristics, and analyses the data
down to an individual field. These insights are then used
to offer farmers tailored insurance policies against thedamage from extreme weather events.
So far, the Climate Corporation offers its policies only in
the United States. If its combination of agriculture andalgorithms succeeds there, however, it has potential toapply these methods on a global scale. Australia, Canada
and Brazil are next on its list of countries to apply theassessments. Perhaps insurance policies based on thesekind of analytics will one day also protect Indian farmers
against the changing weather patterns.

Cattle raised within a silvopastoral system, in which trees are planted
at wide spacings into grazed pastures
Source: CIAT

Source: http://www.economist.com/blogs/schumpeter/2012/11/
weather-insurance

Conclusions
Innovations across the entire span of human nutrition, fromplant to population, have impacted and improved aspects ofthe farm-to-table continuum. In doing so, humans havesought ways to improve mechanisms to meet growing
nutritional requirements, on local and, more recently, global
scales. The game-changing innovations discussed in thischapter target farming and distribution systems, develop
collaborations, leverage public-private partnerships andutilize technological advances. They have the potential to
improve nutrition in both the developed and developingworld. Transformative innovations are often born ofinterdisciplinary collaboration and increasingly, a ‘systems’approach is necessary to address intractable problems inglobal nutrition. The interdependencies from production to

Biofortified beans
Source: CIAT

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Our personal view
The process of innovation has been most successfulwhen driven by public health need. Whether in reference
to new technologies, transformative methods ofcultivation, or simple system processes, innovations thatare grounded firmly in the contextual realities of the
populations which they aim to serve stand the greatest
chance of successful scale. Some have recently criticizedthe development space as suffering from “technologic
solutionism”, referring to the tendency of technologies,
developed in relatively isolated settings, to search forentrenched problems to solve.
Another often neglected perspective is that of theend-users or beneficiaries of the innovations we seek todevelop. Increasingly, researchers are identifying thevalue of substantial inclusion of these stakeholders in theprocess of priority-setting, identifying barriers andconstraints to optimal outcomes and in the design andimplementation of innovations themselves. Not only is
the likelihood of achieving better “fit” with the target
populations increased, but a local ownership of thestrategy is fostered through such methods.
Finally, the importance of continued prioritization andinvestment in high-quality research cannot be
understated. Donors and implementing agencies must
focus considerable energy not only on “implementation
science”, that is exploring how best to deliver what weknow is efficacious, but also on developing and testing
the efficacy of new solutions. To quote Dean Emeritus
Alfred Sommer of the Johns Hopkins Bloomberg Schoolof Public Health, “Today’s research forms the basis for
tomorrow’s programs.” Investment is necessary into
research that is rigorous, problem-driven, collaborative,
interdisciplinary and which seeks to build and engage
local capacity.

Further reading
Hilary Green J, Van Bladeren PJ, Bruce German J.
Translating Nutrition Innovation into Practice.
Institute of Food Technologies. www.ift.org.
Eggersdorfer M. Tackling poverty with nutrition
innovations. The Chicago Council on Global Affairs.
Inclusive Agriculture Sector Growth. Feed the Future,
the US government’s global hunger and food security
initiative.
Ash C, Jasny BR, Malakoff DA, Sugden AM. Feeding
the future. Science Magazine.
Mobile agriculture. Float Mobile Learning website:
floatlearning.com/magriculture
Brugger F. Mobile Applications in Agriculture.
Syngenta Foundation.
Woodill G, Udell C. The Application of Mobile
Computing to the Business of Farming. Float Mobile
Learning.