Dams enable the production of food and renewable energy, making them a crucial tool for both economic development and climate change adaptation in low- and middle-income countries. However, dams may also disrupt traditional livelihood systems and increase the transmission of vector- and water-borne pathogens. These livelihood and health impacts diminish the benefits of dams to rural populations dependent on rivers, as hydrological and ecological alterations change flood regimes, reduce nutrient transport and lead to the loss of biodiversity. We propose four agricultural innovations for promoting equity, health, sustainable development, and climate resilience in dammed watersheds: (1) restoring migratory aquatic species, (2) removing submerged vegetation and transforming it into an agricultural resource, (3) restoring environmental flows and (4) integrating agriculture and aquaculture. As investment in dams accelerates in low- and middle-income countries, appropriately addressing their livelihood and health impacts can improve the sustainability of modern agriculture and economic development in a changing climate.