1. CHRISTINA BRUMME [TWO OTHER GROUP MEMBER NAMES HAVE BEEN REMOVED FOR CONFIDENTIALITY] HarvestPlus Orange Sweet Potatoes in Mozambique

2. Nutrition Sensitive Interventions 2013 Lancet Nutrition Series Underlying determinants of nutrition Complementary sectors Help leverage and accelerate nutrition-specific interventions (Ruel & Alderman, 2013)

3. Nutrition-sensitive vs. Nutrition-specific Address underlying determinants of nutrition and development Agriculture & food security Social safety nets Women’s empowerment Schooling Water, sanitation, hygiene Family planning Address immediate determinants of nutrition and development Dietary diversification Preconception supplementation Optimum breastfeeding Dietary supplementation Micronutrient supplementation. Treatment of severe acute malnutrition

4. HarvestPlus HarvestPlus seeks to reduce hidden hunger and provide micronutrients to billions of people directly through the staple foods that they eat. We use a novel process called biofortification to breed higher levels of micronutrients directly into key staple foods.

5. HarvestPlus CropMicronutrientCountryTimeline BeanIronDR Congo, Rwanda2012 CassavaVitamin ADR Congo, Nigeria2011 MaizeVitamin ANigeria, Zambia2012 Pearl MilletIronIndia2012 RiceZincBangladesh, India2013 Sweet Potato Vitamin AMozambique, Uganda 2007 WheatZincIndia, Pakistan2013

6. What is Biofortification? Breeding staple food crops with a higher micronutrient content. Milestones: 1. Breeding objectives (micronutrient target concentration) 2. Retention and Bioavailability of micronutrients 3. Farmer adoption rates and intakes

7. Vitamin A deficiency Vitamin A accounts for > 600,000 deaths globally for children < 5 VAD: <0.7 µmol/l Africa:Prevalence of VAD is 42% children 6-59 months Mozambique: Prevalence of VAD is 69% in children 6-59 months Existing Vitamin A interventions High dose capsule twice per year 43% coverage in 2003

8. Orange Sweet Potato White-yellow varieties 2ppm beta carotene Orange Sweet Potato 30-200ppm beta carotene  2.5 times RDA of vitamin A for 4-8year old children (van Jaarsveld et al. 2005)

9. Why Orange Sweet Potatoes? (OSP) High beta carotene levels  50% of mean daily vitamin A requirement High consumption in Mozambique  Average consumption 200g/day Good source of Energy Drought resistant Long cultivation season Accepted by children

10. Mozambique Zambezia province Main staple crop—maize or cassava 33% of farmers grow sweet potatoes as seasonal secondary crop Pilot Effectiveness Study, 2007-2009  14,000 households in Zambezia province  10,000 households in Uganda

11. Partners & Donors ImplementationWorld Vision Hellen Keller International- Operations ResearchInternational Potato Center Harvest Plus Natural Resources Institute— University of Greenwich Impact EvaluationInternational Food Policy Research Institute DonorsBill and Melinda Gates Foundation HarvestPlus core funding Denmark, Sweeden, Syngenta Foundation, United Kingdom, USAID, and the World Bank

12. Intervention Components Agriculture Demand creation and behavior change Marketing

13. Agriculture Distribution of vines  Initial: 2kg to farm households at no cost  Continual: 8kg available for purchase  Repeated every year as necessary Training on best production practices  Avoidance of pests and diseases  Vine conservation between planting seasons  Both men and women were included

14. Demand Creation & Behavior Change Education  Maternal and child health and nutrition  Targeted to women Campaign for the general public  Raise awareness about OSP and Vitamin A  Community drama, field-day events  Radio programs

15. Marketing Training for OSP traders Urban and rural market development Distinct market stalls with OSP and information Not targeted to all growers  Small group of traders  Medium-scale growers  Business owners

16. Implementation Model 1, Model 2, or Control Randomized by cluster Clusters selected based on:  The number of households with children 6-35 months  Access to lowlands  No other agricultural interventions being implemented  Did not participate in previous OSP intervention  Impact evaluation clusters were 5km apart

17. Implementation Year 1 was the same for Model 1 and 2 Years 2-3: Model 1  Refresher training on agriculture and nutrition continued*  Vine distribution continued  Marketing and promotional components continued Years 2-3: Model 2  Agriculture and Education components and support did not continue*  Vine distribution continued  Marketing and promotional components continued

18. Implementation World Vision and Helen Keller International HarvestPlus staff provided overall coordination Promoters  Community-based volunteers  Trained by project staff  Provided training and education to participants

19. Effectiveness Evaluation Nutrition Impact Survey Participants  Women and children surveyed at baseline and 2-5 years after  At follow-up additional children were surveyed Baseline: Nov-Dec 2006 Follow-up: May-June 2009

20. Effectiveness Evaluation 24-hr Recall  2 days collected for some  Used the multiple-pass method  Group training for participants Food Frequency  Common foods  Focus on Vit. A rich foods

21. Effectiveness Evaluation Anthropometry  Weight, length, height β-Carotene content  Samples of each farm  Samples of each variety tested for vit. A content after boiling

22. Coverage and Agricultural component 68% of famers in Mozambique adopted OSP  Adopted = retained OFSP vines for next season White and yellow sweet potatoes substituted with OSP

23. Increased Intake of OSP Low et al. (2006), after controlling for inflammation, demonstrated that increase intake of OSP increased serum retinol concentrations  Increased by 0.100 micromole/L 47-60% increase intake OSP

24. Difference in Proportion of Sweet Potato Intake ***=1% level

25. Increased Intake of OSP Low et al. (2006), after controlling for inflammation, demonstrated that increase intake of OSP increased serum retinol concentrations  Increased by 0.100 micromole/L 47-60% increase intake OSP 47% increase among women 63% increase among children (6-35 month)

27. Diff. in Retinal Activity Equivalents/Day

29. Model Comparison Model 1  Three years of Agricultural training and health and nutrition education (refresher training sessions)  More expensive Model 2  One year of Agricultural training and health and nutrition education Similar OSP adoption and intake between models

30. Cost Implication Lowest marginal cost and average cost were $17 and $52 per target beneficiary (children 6-59months and mothers) $15-20 per Disability-Adjusted Life Years (Uganda)  Measure of cost-effectiveness

31. Cost Implication Advantage of implementing Model 2  Less expensive Model 2 can be trimmed down when scale up  Marketing component does not enhance adoption or consumption  Could scale back intensity of demand creation component- nutrition messages had little affect on OSP consumption

32. Strengths Large-scale effectiveness Many partners Vine conservation Marketing Control group Transparent in sample size and vit. A analysis methods Acceptability

33. Weaknesses Self-report of intake Retinol not measured* Expensive compared to Uganda No discussion of sustainability of vines No discussion of government role Cost non-growers*

34. Future Directions Scaling-up Expand to other countries Others…?

35. Current Activities Currently expanding to: Angola, Kenya, Tanzania, Rwanda, Zambia, Ghana, Nigeria, and others Spillover countries: Burundi, Ethiopia, Ghana, Kenya, Malawi, Mali, Nigeria, Rwanda, South Africa, Tanzania, Zambia, Zimbabwe Sharing knowledge: http://www.sweetpotatoknowledge.org http://www.sweetpotatoknowledge.org

36. Current Activities

37. Future Directions

41. Thank you!

42. Questions?

43. Resources Hotz, C., Loechl, C., de Brauw, A., Eozenou, P., Gilligan, D., Moursi, M.,... Meenakshi, J. V. (2012). A large-scale intervention to introduce orange sweet potato in rural Mozambique increases vitamin A intakes among children and women. British Journal of Nutrition, 108(1), 163-176. doi: 10.1017/s0007114511005174 Asare-Marfo, D., Birol, E., Gonzalez, C., Moursi, M., Perez, S., Scharz, J., Zeller, M. (2013). Prioritizing Countries for Biofortification Interventions Using Country-Level Data. HarvestPlus Working Paper, 11. http://www.harvestplus.org/content/vitamin-sweet-potato http://www.sweetpotatoknowledge.org