The pilot trial will be conducted in the highlands of Ecuador in a mixed indigenous and non-indigenous population of pregnant women. Nationally, the stunting prevalence among young children is 25.3%, but large disparities within the country especially indigenous communities where stunting prevalence is nearly double, 42.3% (Freire et al., 2014). Incidence of low birthweight (8%) also varies by population in Ecuador, and may represent in utero growth restriction (IUGR) and other harmful exposures during pregnany (UNICEF 2012). While a large proportion of women have at least one antenatal care visit (84%), Only 58% of women in Ecuador meet the the WHO recommended 4+ antenatal care visits. This pilot project will leverage learnings from the Lulun Project and a previous antenatal health study (Gallegos et al. 2017) to design a social marketing campaign that encourages participation and high compliance. For this pilot RCT, the investigators will recruit pregnant women accessing antenatal care from Centro de Salud El Quinche in Pichincha province. Our target population will include those from poor households in particular (who access free public health services) with higher risks for IUGR and undernutrition during pregnancy.

The evolutionary nutrition package includes two key components: 1) one full meal per day from the evolutionary nutrition (EN) plate; 2) targeted messaging for high quality nutrition and removal of ultra-processed foods from the diet. The EN plate includes five food groups identified from the literature on evolutionary diets: animal source foods (ASF); berries and other fruits; tubers; vegetables, herbs and spices; and nuts and other legumes. In order to adapt the food groups to the Ecuador context, the investgators first developed a list of foods appropriate for the Ecuador context within each food group (Table 1). The food list draws on evidence from the Ministry of Health in Ecuador and USFQ for commonly consumed foods, notably among indigneous populations (Gallegos et al. 2010). Criteria for the full list of foods were the following: culturally appropriate; economically affordable and accessible; and environmentally sustainable. As was the experience with eggs in the Lulun Project, application of these criteria better ensure translation of findings within communities in the future.

Pregnant women will be recruited during first trimester of pregnancy and randomized to intervention group (EN plate + nutrition messaging + standard of care supplements) or control group (standard of care supplements). The intervention period will occur during second and third trimesters. Food supplies sufficient for one EN plate per day for 7 days will be delivered to pregnant women on a weekly basis. Under the supervision of the nutrition-trained field director, foods from each food group in pre-specified nutrient proportions will be secured from local food producers. Consideration will be given to including foods that do not require refrigeration over a one-week period. Careful documentation will be made of the foods contained in the weekly box in order to calculate exact quantity of nutrients provided. Due to concerns about food sharing that were evident in our qualitative research findings, additional food supplies will be provided for other household members in a separate container. Suggested menus and recipes will be provided with each delivery depending on the included foods.

Nutrition messages, developed in tandem with the social marketing campaign described below, will emphasize the importance of the food provisions for the participating pregnant women, but communicate the value of the EN plate for all household members. Messaging each week will reinforce the importance of eliminating ultraprocessed foods from the diet and reducing rice consumption. The absence of ultra processed foods is integral to our hypothesized effect and critical for confronting the dual burden of over- and under-nutrition in Ecuador (Freire et al. 2014). During each weekly food delivery visit, data will be collected on adherence and morbidities.