The Live 5-2-1-0 Toolkit for family physicians: Mixed methods evaluation of a resource to facilitate health promotion in a primary care setting
Background: Sustainable Childhood Obesity Prevention Through Community Engagement is an initiative that engages stakeholders across multiple sectors to promote the Live-5-2-1-0 message (5 vegetables and fruits, 2 hours at most of recreational screen time, 1 hour of physical activity, 0 sugar-sweetened beverages each day) and implement action to support healthy behaviors. As part of this initiative, an intervention using the Live 5-2-1-0 Toolkit for family physicians (FPs) was piloted in two communities. This study aimed to identify barriers and aids to toolkit implementation, and to determine whether the toolkit improves physicians’ capacity to promote healthy childhood behaviors.
Methods: FPs completed preintervention and postintervention surveys and participated in semi-structured interviews after implementation of the Live 5-2-1-0 Toolkit intervention. Implementation occurred sequentially in two communities and involved a total of 21 FPs in six primary care clinics. Descriptive statistics were used for quantitative data, and content analysis was used for qualitative data.
Results: Of the 21 participating FPs, 14 completed the preintervention and the postintervention surveys (67%) and 7 completed the preintervention survey only (33%). FPs reported increased knowledge of medical evaluation of pediatric patients with obesity (from 14% preintervention to 36% postintervention), behavioral goal setting (from 36% to 93%), and motivational interviewing (from 57% to 79%). FPs’ perceived efficacy in addressing the subject of weight improved (from 43% preintervention to 93% postintervention). Increases were also observed in routinely addressing nutrition (from 43% preintervention to 79% postintervention), physical activity (from 50% to 79%), screen time (from 14% to 64%), and sugar-sweetened beverage consumption (from 29% to 71%). As a result of toolkit implementation, 71% of FPs felt their patients were more aware of long-term complications related to lifestyle, 64% felt patients were more willing to set behavioral goals with providers, and 50% felt patients were more able to self-manage issues related to lifestyle. The predominant barrier to implementation was lack of staff/clinic capacity to measure BMI; the most noted aid to implementation was access to ready-to-use Live 5-2-1-0 resources.
Conclusions: The Live 5-2-1-0 Toolkit facilitated health promotion to pediatric patients in the primary care setting. Increasing routine BMI measurement in primary care remains challenging due to clinical capacity issues. Results of this pilot study will be used to refine the toolkit prior to wider dissemination across British Columbia.
A pilot study in two BC communities found that a toolkit promoting healthy lifestyle behaviors helped FPs initiate discussions about pediatric obesity with patients and develop plans for monitoring.
The prevalence of childhood obesity continues to increase in Canada and worldwide, posing a major public health challenge.[1,2] Childhood obesity is complex, with several factors contributing to an obesogenic environment (e.g., exposure to energy-dense and nutrient-poor foods, limited physical activity opportunities, and increased screen time/sedentary activity). The 2015 Lancet series on obesity described patchy progress in prevention, globally. However, whole-of-community, multisetting, multistrategy interventions have shown promise in achieving population-level reductions in childhood overweight and obesity across the globe.[5-9] These interventions engage with the complexity of childhood obesity and address the various components of the obesogenic environment at several levels, thereby facilitating tailored, community-centric local action. Sustainable Childhood Obesity Prevention Through Community Engagement (SCOPE) is a Canadian example of such an intervention. SCOPE partners with communities to empower local stakeholders across multiple sectors (e.g., schools, media, businesses, health services, community/recreation centres, local governments) to share (via social marketing) and support (via policy, practice, and environmental change) the evidence-based Live-5-2-1-0 message:
- 5 vegetables and fruits every day.
- 2 hours at most of recreational screen time a day.
- 1 hour at least of physical activity each day.
- 0 sugar-sweetened beverages each day.[11,12]
Primary care serves as an ideal setting for monitoring children’s weight trajectories and addressing health behaviors/habits given the long-standing relationship between family physicians and families. However, primary care physicians have reported barriers to promoting healthy weights, including lack of self-efficacy, capacity, resources (e.g., staffing support and educational materials/counseling tools), and time.[14-17]
The SCOPE team worked with two communities to create, use, adapt, and evaluate the Live 5-2-1-0 Toolkit for family physicians (FPs) to address these barriers and empower primary care providers to promote healthy behaviors and weights. The toolkit, discussed in greater detail under Methods, integrates routine BMI tracking and growth monitoring, training on motivational interviewing, and resources to support assessment and discussion of healthy behaviors and facilitation of community program referrals. The objectives of our pilot study were to:
- Determine whether the toolkit improved physicians’ capacity to promote healthy childhood behaviors.
- Identify barriers and aids to toolkit implementation.
The Live 5-2-1-0 Toolkit intervention was implemented in one urban and one rural community, both of which were existing SCOPE partner communities with primary care leadership involvement. Community A, population 80 000, is a city in British Columbia’s Fraser Valley, located 105 km east of Vancouver, the province’s largest urban centre. Community B, population 6600, is a rural community located in the Kootenay Rockies region of BC.
Family practice clinics in communities A and B were selected using convenience sampling, and were contacted by a member of the research team to gauge the clinics’ collective interest in participating in the study. Individual FPs in clinics that expressed interest were then invited to participate; participating FPs were required to have a current primary care practice in either community A or B, and participation was voluntary. In total, 21 FPs from six primary care clinics participated. A small sample size was accepted because this pilot study’s purpose was to evaluate feasibility of toolkit implementation in the clinical setting and inform toolkit refinement prior to larger-scale evaluation.
A preintervention and postintervention observational mixed methods study design was used. Data were collected from participating FPs before and after the intervention (9 months during 2014 in community A, and 12 months during 2015–16 in community B) using a survey adapted from the Maine Youth Overweight Collaborative’s “Keep ME Healthy” initiative that could be completed via an online link or on paper. Participants were guaranteed anonymity to reduce social desirability bias. To measure physicians’ capacity to promote healthy childhood behaviors, survey questions assessed physicians’ knowledge, beliefs, self-efficacy, and practices pertaining to BMI measurement, management of pediatric overweight and obesity, and discussion of healthy lifestyle behaviors. Physician demographic data were also collected. The intervention and surveys were first implemented in community A, and were subsequently modified based on lessons learned prior to implementation in community B.
All participating FPs were invited to complete a postintervention, semi-structured, in-person qualitative interview, approximately 20 to 30 minutes in length and conducted by a SCOPE researcher, to explore barriers and aids to project implementation and to elicit suggestions for improving the toolkit and implementation processes [Table 1]. Quantitative data derived from the surveys informed the qualitative interview questions related to changes in FP practice, observed behavior change among patients, barriers and aids to project implementation, project sustainability, toolkit usefulness, and overall project impact.
The toolkit intervention was based on recommendations by Barlow, and was consistent with recent recommendations on childhood obesity management and prevention in the primary care setting. Key components of the intervention included the following:
- Integrating routine BMI tracking and growth monitoring as an obesity prevention strategy. Growth monitoring/BMI tracking has been strongly recommended by the Canadian Task Force on Preventive Health Care given its low cost, feasibility, low probability of harm, and potential value in early identification of weight-related health conditions.
- Training on motivational interviewing as a patient-centred counseling technique that allows individuals to discover their own reasons for change. A number of randomized control trials on motivational interviewing in the primary care setting have illustrated its promise in eliciting positive behavior change[21,22] and reducing BMI in overweight pediatric patients.
- Providing tools and resources to support assessment and discussion of daily habits and lifestyle behaviors, and to facilitate community program referral through primary care in order to link affordable and available resources/services to individuals who may need additional support beyond that available through their family physician. Lack of available resources and community supports has frequently been described as a barrier for physicians attempting to address childhood obesity in the primary care setting.[16,24]
The toolkit intervention was implemented through an expert-led group training session for physicians and clinic staff. The training session was 2 hours and consisted of three presentations: (1) how to conduct motivational interviewing, conducted by a child psychologist, (2) how to respectfully discuss weight during patient interactions, conducted by the primary investigator, and (3) how to use the binder of toolkit elements and resources, conducted by the research manager.
The toolkit binder included resources on employing motivational interviewing techniques, a flow chart on managing children with overweight or obesity (i.e., appropriate laboratory investigations and referral to relevant community- or hospital-based programs), and instructions for integrating World Health Organization growth charts and BMI measurements into an electronic medical record. Further, the toolkit binder included additional resources such as the Live 5-2-1-0 Healthy Habits Questionnaire to assess current behaviors, a community-specific Healthy Living Support Booklet that identified local and provincial programs that support healthy behaviors to which patients could be referred, and supplementary Live 5-2-1-0 resources such as prescription pads, fact sheets, posters, magnets, and goal-tracking tools. The elements of the toolkit binder are available online at www.live5210.ca/resources/health.
Ethics approval for the study was obtained from the University of British Columbia Children’s and Women’s Health Centre of British Columbia Research Ethics Board. Descriptive statistics were used to analyze quantitative data (proportions, means, and frequencies). Semi-structured interviews were audio recorded and transcribed verbatim. Directed content analysis was used to generate preliminary coding categories; a coding guide was generated by two researchers (SS, SP) who then independently reviewed all the transcripts before deliberating and finalizing the coding guide. A third researcher (SA) reviewed the transcripts independently using the finalized coding guide, after which all three researchers worked together to resolve inconsistencies. Key themes and subthemes were then identified.
Of the 21 participating FPs, 14 completed the preintervention and the postintervention surveys (67%) and 7 completed the preintervention survey only (33%). Six FPs from community A also completed postintervention semi-structured interviews (28%). The demographic and practice characteristics of survey respondents indicated that physicians who did not complete the postintervention survey were disproportionately male and younger than those who did [Table 2].
Family physician survey
Improvements were noted postintervention in (1) FPs’ self-reported knowledge of medical evaluation of pediatric patients with obesity, behavioral goal setting, and motivational interviewing [Figure 1]; (2) FPs’ perceived self-efficacy in addressing topics such as weight, nutrition, screen time, physical activity, and consumption of sugar-sweetened beverages [Figure 2]; and (3) FPs’ routine promotion of the Live 5-2-1-0 health behaviors [Figure 3]. Following the toolkit intervention, 71% of FPs felt their patients were more aware of long-term complications related to lifestyle, 64% felt patients were more willing to set behavioral goals with providers, and 50% felt patients were better able to self-manage issues related to lifestyle. An increase was also observed in routine annual BMI tracking for all pediatric patients (from 7% preintervention to 29% postintervention).
Three key themes emerged from the qualitative analysis:
- The Live 5-2-1-0 message facilitates practice change.
FPs found the Live 5-2-1-0 messaging “recognizable,” “clean,” “easy to remember,” “easy to explain,” and “a common language and a common ground to go on” (FP1, FP2).
FPs felt that the Live 5-2-1-0 message helped destigmatize discussions on healthy living and empowered physicians to be proactive with health promotion. The message allowed them to “open the discussion in a nonjudgmental way” (FP1) because it was “standardized” (FP6), and they were “doing this to all kids,” which “takes away the stigma associated with obesity” (FP1). Another physician said that the resources “made [them] far more proactive and therefore preventative,” and provided them “more leverage as a physician to open that conversation which, otherwise, [they]. . . wouldn’t have had” (FP5). One physician said, “I know what to do now when I get people to come back. . . whereas before if I was worried about their weight I’d get them to come back and then I didn’t really have a good plan of what to do, what blood work to do, to refer them, not to refer them, all that sort of stuff. Now I know” (FP6).
- Front-end office coordination and staff capacity are necessary.
FPs found they depended on administrative staff to conduct BMI measurements and administer the Healthy Habits Questionnaire. They reported that sustainability of toolkit implementation was contingent on the capacity of front-end administrative staff and that “secretaries were the main ones involved in starting the process. . . if they weren’t involved in this process this would never have happened” (FP1). FPs reported that measuring BMI in all pediatric patients was not sustainable, and that office support staff “were not going to continue doing it” (FP6) because measuring heights and weights in a private space and calculating BMI percentiles could be quite time-consuming.
- A collective approach that involves all sectors of a community is necessary.
FPs acknowledged the importance of a collective, consistent, community-wide approach to achieving healthy childhood weights: “education needs to not only be done in the doctor’s office but in the schools, in public health, in the leisure centres, in the rec centres, in everywhere that kids are going to be, in everywhere that families are going to be” (FP6). According to another physician, “using the same language” across a community “is going to hopefully reinforce the same messages. . . and if we repeat it often enough and people hear it often enough it might then be the key to, to making it happen” (FP2).
The implementation of whole-community, multisectoral, childhood obesity prevention using the Live 5-2-1-0 Toolkit was found to enhance physicians’ knowledge and self-efficacy when managing pediatric patients with obesity, and caused positive changes in physicians’ health promotion practices. The predominant aid to implementation for FPs was the simplicity and clarity of the Live 5-2-1-0 message, while a major barrier to implementation was the lack of front-end staff capacity. Finally, the importance of a whole-community approach that mobilized all sectors was identified as an important theme.
A systematic review of primary care interventions for managing childhood obesity supports our study finding that empowering providers through training (e.g., in motivational interviewing) and education leads to increased knowledge, skills, and confidence in managing pediatric obesity. Empowering providers also increases adherence to expert committee recommendations. Studies of other similar primary care interventions built on the Live 5-2-1-0 guidelines have reported positive changes in physicians’ practices related to child and adolescent obesity.[18,27,28] Gibson, for example, noted significant increases in behavioral education/counseling (from 9% to 87%) within two rural health clinics.
Routinely using Live 5-2-1-0 resources to address behaviors was found to empower physicians in our pilot study by destigmatizing weight and standardizing the process of brief counseling sessions for weight- and health-related behavior. This seemed to lessen commonly reported barriers faced by physicians when discussing childhood obesity, which include the sensitive nature of the topic and lack of knowledge, comfort, and self-efficacy.[15-17,29,30] We observed increases in physician-reported knowledge and self-efficacy that translated into practice change, with an increase in the routine promotion of healthy behaviors and the use of behavioral goal setting. Similar improvements in self-efficacy that translated into practice changes were found by Barlow and colleagues after brief training and support for primary care providers. However, only half the participating FPs in our study felt that their patients were better able to self-manage issues of lifestyle as a result of the intervention, which underscores the potential impact that external environmental and systemic barriers can have on individual habits. This in turn reinforces our qualitative finding that physicians feel complementary community-wide health promotion efforts and supports are also necessary, a finding borne out by other studies.[32,33]
Our qualitative findings also showed that the Live 5-2-1-0 message and accompanying resources were major drivers of physician-related changes. Several studies that outline barriers to pediatric obesity prevention and management in primary care report the need for better tools to support counseling and communication with patients and families.[16,17,24] The Live 5-2-1-0 message, tools, and resources may fill this gap by providing primary care physicians with the means to open conversations with families about weight and health behaviors in a simple and nonjudgmental manner.
Our study had several limitations, including the lack of a control group, a small sample size, the lack of completed postintervention surveys from 7 of 21 participating physicians, and a short intervention period that varied between study sites. Self-selection bias may have skewed the sample and led to the recruitment of only those FPs who are passionate about health promotion. If this were the case, we would expect physicians without a special interest in health promotion to benefit even more from the toolkit than those who participated in our study. The duration of toolkit use in both communities was based on the capacity of the clinics at the time of the pilot study. We would not expect that the variability of the study periods between communities would impact the comparability of the findings between communities. Lastly, social desirability bias may have influenced survey responses. Given the various limitations, results from this pilot study are not easily generalizable.
Childhood obesity continues to increase in Canada and worldwide, posing a major public health challenge. A pilot study in two BC communities found healthy behaviors that prevent childhood obesity can be achieved in the primary care setting by using a simple Live 5-2-1-0 message: 5 vegetables and fruits, 2 hours at most of recreational screen time, 1 hour of physical activity, 0 sugar-sweetened beverages each day. The Live 5-2-1-0 Toolkit intervention was found to destigmatize discussions about weight and healthy habits and provide a foundation for brief counseling sessions. Further research is needed to explore interventions and strategies that reduce the burden of routine BMI measurement on office staff.
This article has been peer reviewed.
1. Lobstein T, Jackson-Leach R, Moodie ML, et al. Child and adolescent obesity: Part of a bigger picture. Lancet 2015;385(9986):2510-2520.
2. Rodd C, Sharma AK. Recent trends in the prevalence of overweight and obesity among Canadian children. CMAJ 2016;188:E313-320.
3. Commission on Ending Childhood Obesity. Report of the Commission on Ending Childhood Obesity. Geneva: World Health Organization; 2016.
4. Roberto CA, Swinburn B, Hawkes C, et al. Patchy progress on obesity prevention: Emerging examples, entrenched barriers, and new thinking. Lancet 2015;385(9985):2400-2409.
5. Ducimetière P, Basdevant A, Tafflet M, et al. Downward trends in the prevalence of childhood overweight in the setting of 12-year school- and community-based programmes. Public Health Nutr 2008;12:1735-1742.
6. Hyatt RR, Nelson ME, Economos CD, et al. Shape Up Somerville two-year results: A community-based environmental change intervention sustains weight reduction in children. Prev Med (Baltim) 2013;57:322-327.
7. Sanigorski AM, Bell AC, Kremer PJ, et al. Reducing unhealthy weight gain in children through community capacity-building: Results of a quasi-experimental intervention program, Be Active Eat Well. Int J Obes 2008;32:1060-1067.
8. Millar L, Kremer P, de Silva-Sanigorski A, et al. Reduction in overweight and obesity from a 3-year community-based intervention in Australia: The “It’s Your Move!” project. Obes Rev 2011;12(suppl 2):20-28.
9. de Silva-Sanigorski AM, Bell AC, Kremer P, et al. Reducing obesity in early childhood: Results from Romp & Chomp, an Australian community-wide intervention program. AM J Clin Nutr 2010;91:831-840.
10. Karacabeyli D, Allender S, Pinkney S, Amed S. Evaluation of complex community-based childhood obesity prevention interventions. Obes Rev 2018;19:1080-1092.
11. Amed S, Naylor PJ, Pinkney S, et al. Creating a collective impact on childhood obesity: Lessons from the SCOPE initiative. Can J Public Health 2015;106:e426-433.
12. Amed S, Shea S, Pinkney S, et al. Wayfinding the Live 5-2-1-0 initiative—At the intersection between systems thinking and community-based childhood obesity prevention. Int J Environ Res Public Health 2016;13:1-16.
13. Schwartz RP, Hamre R, Dietz WH, et al. Office-based motivational interviewing to prevent childhood obesity. Arch Pediatr Adolesc Med 2007;161:495-501.
14. Pelletier-Fleury N, Le Vaillant M, Rosman S, et al. French pediatricians’ knowledge, attitudes, beliefs towards and practices in the management of weight problems in children. Health Policy (New York) 2009;91:195-203.
15. King LA, Loss JHM, Wilkenfeld RL, et al. Australian GPs’ perceptions about child and adolescent overweight and obesity the Weight of Opinion study. Br J Gen Pract 2007;57:124-129.
16. Sesselberg TS, Klein JD, O’Connor KG, Johnson MS. Screening and counseling for childhood obesity: Results from a national survey. J Am Board Fam Med 2010;23:334-342.
17. Perrin EM, Flower KB, Garrett J, Ammerman AS. Preventing and treating obesity: Pediatricians’ self-efficacy, barriers, resources, and advocacy. Ambul Pediatr 2005;5:150-156.
18. Polacsek M, Orr J, Letourneau L, et al. Impact of a primary care intervention on physician practice and patient and family behavior: Keep ME Healthy—The Maine Youth Overweight Collaborative. Pediatrics 2009;123(suppl 5):S258-266.
19. Barlow SE. Expert Committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: Summary report. Pediatrics 2007;120(suppl 4):S164-192.
20. Canadian Task Force on Preventive Health Care. Recommendations for growth monitoring, and prevention and management of overweight and obesity in children and youth in primary care. CMAJ 2015;187:411-421.
21. Taveras EM, Blaine RE, Davison KK, et al. Design of the Massachusetts Childhood Obesity Research Demonstration (MA-CORD) Study. Child Obes 2015;11:11-22.
22. Davoli AM, Broccoli S, Bonvicini L, et al. Pediatrician-led motivational interviewing to treat overweight children: An RCT. Pediatrics 2013;132:e1236-1246.
23. Resnicow K, McMaster F, Bocian A, et al. Motivational interviewing and dietary counseling for obesity in primary care: An RCT. Pediatrics 2015;135:649-657.
24. Tucker C, Shah N, Ukonu N, et al. Views of primary care physicians regarding the promotion of healthy lifestyes and weight management among their patients. J Clin Outcomes Manag 2017;24:259-266.
25. Hsieh H, Shannon S. Three approaches to qualitative content analysis. In: Qualitative Health Research. Thousand Oaks: Sage; 2005. p. 1277–1288.
26. Jacobson DL, Gance-Cleveland B. A systematic review of primary healthcare provider education and training using the Chronic Care Model for childhood obesity. Obes Rev 2011;12:e244-256.
27. Gibson SJ. Translation of clinical practice guidelines for childhood obesity prevention in primary care mobilizes a rural Midwest community. J Am Assoc Nurse Pract 2016;28:130-137.
28. Cygan HR, Baldwin K, Chehab LG, et al. Six to success: Improving primary care management of pediatric overweight and obesity. J Pediatr Health Care 2014;28:429-437.
29. Bourgeois N, Brauer P, Simpson JR, et al. Interventions for prevention of childhood obesity in primary care: A qualitative study. CMAJ Open 2016;4:E194-199.
30. O’Donnell JE, Foskett-Tharby R, Gill PS. General practice views of managing childhood obesity in primary care: A qualitative analysis. JRSM Open 2017;8:1-9.
31. Barlow SE, Salahuddin M, Butte NF, et al. Improvement in primary care provider self-efficacy and use of patient-centered counseling to address child overweight and obesity after practice-based changes: Texas Childhood Obesity Research Demonstration Study. Child Obes 2018;14:518-527.
32. Gortmaker SL, Polacsek M, Letourneau L, et al. Evaluation of a primary care intervention on body mass index: The Maine Youth Overweight Collaborative. Child Obes 2015;11:187-193.
33. Summerbell C, Brown T. Childhood obesity: The guideline for primary care should form part of a whole-system approach. CMAJ 2015;187:389-390.
Dr Karacabeyli is an internal medicine resident at the University of British Columbia. Ms Shea is a current medical student at the University College Cork in Ireland. Ms Keidar is a research coordinator at the BC Children’s Hospital Research Institute. Ms Pinkney is a research manager at the BC Children’s Hospital Research Institute. Ms Bepple is executive director of the Chilliwack Division of Family Practice. Ms Edwards is a programs lead in the Chilliwack Division of Family Practice. Dr Hale is a clinical assistant professor at the University of British Columbia and a family physician in the East Kootenay Division of Family Practice. Ms Suleman is a research coordinator at the BC Children’s Hospital Research Institute. Dr Amed is a clinical associate professor in the Department of Pediatrics at the University of British Columbia and an investigator at the BC Children’s Hospital Research Institute.
Derin Karacabeyli, MD, Stephanie Shea, MPH, Shelly Keidar, MPH, Susan Pinkney, MA, Katrina Bepple, BSc, Danielle Edwards, MA, Ilona Hale, MD, FCFPC, Selina Suleman, MPH, Shazhan Amed, MD, MScPH. The Live 5-2-1-0 Toolkit for family physicians: Mixed methods evaluation of a resource to facilitate health promotion in a primary care setting. BCMJ, Vol. 62, No. 6, July, August, 2020, Page(s) - Clinical Articles.
Above is the information needed to cite this article in your paper or presentation. The International Committee
of Medical Journal Editors (ICMJE) recommends the following citation style, which is the now nearly universally
accepted citation style for scientific papers:
Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.
About the ICMJE and citation styles
The ICMJE is small group of editors of general medical journals who first met informally in Vancouver, British Columbia, in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Vancouver Group. Its requirements for manuscripts, including formats for bibliographic references developed by the U.S. National Library of Medicine (NLM), were first published in 1979. The Vancouver Group expanded and evolved into the International Committee of Medical Journal Editors (ICMJE), which meets annually. The ICMJE created the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals to help authors and editors create and distribute accurate, clear, easily accessible reports of biomedical studies.
An alternate version of ICMJE style is to additionally list the month an issue number, but since most journals use continuous pagination, the shorter form provides sufficient information to locate the reference. The NLM now lists all authors.
BCMJ standard citation style is a slight modification of the ICMJE/NLM style, as follows:
- Only the first three authors are listed, followed by "et al."
- There is no period after the journal name.
- Page numbers are not abbreviated.
For more information on the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals, visit www.icmje.org