4. Discussion
REGRESSION, RECRUITMENT
In this pilot randomized trial, a technology-driven, health system-based family beverage choice intervention was found to be acceptable and feasible. Adult and child participants in both the intervention group and the control group self-reported favorable changes in their beverage consumption patterns over the six-month study period, with no between-group differences for children. Parental SSB consumption in the intervention group did decline more than the control at 3 months, but this difference was not sustained at 6 months. The control condition consisted of monthly parental outreach from the research team and clinic-based, EHR-driven beverage screening and information provided in printed after-visit summaries to parents.Our work builds on many prior studies that have examined strategies to address the overconsumption of sugary drinks and to promote water intake in families. A 2017 systematic review and meta-analysis by Vargas-Garcia and colleagues [A major goal of this pilot study was to establish whether our technology-based beverage choice intervention was feasible in our clinical setting and acceptable to a diverse patient population. Thus, a strength of the study was that the participant population was predominantly Black or Hispanic and was representative of the clinical population in our health system who have previously been identified to be at greater risk of over-consuming SSB and FJ [Our top-line finding in this pilot was null. Although the direction of effect for behavior changes generally favored the intervention group and was consistent across multiple outcome measures, there were no statistically significant differences between intervention and control children for change in SSB, FJ, or water intake at the end of the 6-month follow-up. Both groups had clinically meaningful decreases in sugary drink intake [An important and likely contributor to the finding of “no difference” between intervention and control children was that the control group also reported large decreases in child sugary drink consumption over follow-up. This finding could represent regression to the mean, or it may suggest that simply being in the study, with repeated outreach and beverage assessments with our study team to improve retention, may have sufficiently motivated control parents to change their child’s beverage intake. Additionally, our clinical context for this study was unique. As noted previously, our health system has implemented a routine point-of-care EHR-based sugary drink screening process [The changes in behavior that we observed in this study (e.g., a decrease in daily child SSB/FJ consumption of 6–8 ounces), in both the intervention and control groups, occurred despite essentially no observed change in parental knowledge, attitudes, and beliefs about family beverage choice. At baseline, most enrolled parents were already quite knowledgeable about the health impacts of sugary drinks and believed them to be unhealthy options for their families. The intervention did not improve this knowledge, perhaps because there was not much improvement to make. This finding highlights an important point about the potential emphasis of future beverage choice interventions aimed at families. It suggests that many parents do not need a lot of help or training understanding the “why” of reducing their family’s sugary drink intake and increasing water intake. Instead, interventions focused on “when” and “how” to make these changes might be more productive. As such, future intervention adaptations could consider incorporating a more robust set of evidence-based behavioral change techniques [One important final note about this pilot study was that it took place during the COVID-19 pandemic (recruitment during Spring and Summer of 2021). Despite this challenging clinical and societal context, we met recruitment and retention goals and had high intervention fidelity. Comparing our enrollment rate to prior studies is important, as this can be an important indicator of feasibility and external validity. However, participation rates are often underreported across intervention studies. For example, in a systematic review of 55 SSB interventions for children and adolescents, only (29%) reported this information; the mean participation rate was 66% [