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In an inpatient treatment center for pediatric obesity, the effectiveness of an emotion regulation (ER) training on top of the multidisciplinary obesity treatment (MOT) was tested by means of an RCT. The ER training was evaluated on primary outcomes: ER and emotional eating, and secondary outcomes: well-being and weight loss, taking into account pre, post, and follow-up measurements. Of the 115 10- to-14-year old adolescents with obesity (52.2% girls), 65 were allocated to the ER training. Physicians measured their height and weight objectively (4 times). Participants also filled out questionnaires on ER competencies (ER abilities and ER strategies), emotional eating and well-being (3 times). Significant pre-post interactions were found for "emotional awareness," "problem solving," and "evoking a positive mood." Moreover, the positive effects of the ER training on emotion regulation strategies were maintained at follow-up. Concerning well-being, no significant pre-post interaction effects were found but a significant interaction effect was found when comparing pre with follow-up. Analyses show a significant main effect of time on weight loss, but this was not qualified by a Time × Condition interaction effect. The current RCT study shows limited but promising effects of adding an ER training to the MOT. Further research should investigate whether the positive short-term effects will be maintained.

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BACKGROUND: Integrating mobile health (mHealth) into paediatric obesity treatment can provide opportunities for more personalized and lifetime treatment. However, high attrition rates pose a significant challenge. The current study attempts to better understand attrition by exploring (1) attrition rates of a monitoring mHealth application for usage over 14 days and (2) testing predictors of attrition in adolescents with obesity. METHODS: Participants were 69 adolescents between 12 and 16 years old who engaged in a multidisciplinary obesity treatment centre (either outpatient or inpatient) in two countries (Belgium and France). To assess the attrition rates, frequency distributions were used. To test the predictors of attrition, zero-inflated negative binomial regression was performed. RESULTS: Attrition rates were high, in the outpatient group, more than half of the participants (53.3%) used the app for only 0-7 days. In the inpatient group, this percentage was 24.1%. Only deficits in initiating (a component of executive functions) were a negative predictor of attrition, indicating that deficits in initiating lead to lower attrition rates. CONCLUSIONS: This study provides evidence for high attrition rates in mHealth interventions for adolescents with obesity and was the first to investigate psychological predictors of attrition to an mHealth monitoring tool in adolescents with obesity in treatment. Findings regarding predictors of attrition should be approached with caution due to the small sample size.

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Research points to self-control as a possible mechanism for facilitating health behaviour and weight loss. The dual pathway model underpins the role of strong bottom-up reactivity towards food and weak top-down executive functions in obesity. Despite flourishing lab studies on attention bias modification or inhibition trainings, relatively few focused on training both processes to improve self-control in children and adolescents in inpatient multidisciplinary obesity treatment (MOT). Being part of the WELCOME project, this study investigated the effectiveness of Brain Fitness training (using the Dot Probe and Go/No-Go) as an adjunct to inpatient MOT in 131 Belgian children and adolescents. Changes in self-control (performance-based inhibitory control and attention bias as well as self-reported eating behaviour) in the experimental group were compared to sham training. Multiple Imputation was used to handle missing data. Inhibitory control and external eating improved over time (pre/post/follow-up), but we found no evidence for a significant interaction between time and condition. Future research should pay more attention to the role of individual variability in baseline self-control, sham training, and ecological validity of self-control training to improve real-life health behaviour and treatment perspectives for children and adolescents with weight problems.

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Background: Inpatient pediatric obesity treatments are highly effective, although dropouts and weight regain threaten long-term results. Preliminary data indicate that leptin, adiponectin, and cardiometabolic comorbidities might predict treatment outcomes. Previous studies have mainly focused on the individual role of adipokines and comorbidities, which is counterintuitive, as these risk factors tend to cluster. This study aimed to predict the dropouts and treatment outcomes by pre-treatment patient characteristics extended with cardiometabolic comorbidities (individually and in total), leptin, and adiponectin. Methods: Children aged 8-18 years were assessed before, immediately after and 6 months after a 12-month inpatient obesity treatment. Anthropometric data were collected at each visit. Pre-treatment lipid profiles; glucose, insulin, leptin, and adiponectin levels; and blood pressure were measured. The treatment outcome was evaluated by the change in body mass index (BMI) standard deviation score (SDS) corrected for age and sex. Results: We recruited 144 children with a mean age of 14.3 ± 2.2 years and a mean BMI of 36.7 ± 6.2 kg/m2 corresponding to 2.7 ± 0.4 BMI SDS. The 57 patients who dropped out during treatment and the 44 patients who dropped out during aftercare had a higher pre-treatment BMI compared to the patients who completed the treatment (mean BMI, 38.3 ± 6.8 kg/m2 vs 35.7 ± 5.5 kg/m2) and those who completed aftercare (mean BMI, 34.6 ± 5.3 kg/m2 vs 37.7 ± 6.3 kg/m2) (all p<0.05). Additionally, aftercare attenders were younger than non-attenders (mean age, 13.4 ± 2.3 years vs 14.9 ± 2.0, p<0.05).Patients lost on average 1.0 ± 0.4 SDS during treatment and regained 0.4 ± 0.3 SDS post-treatment corresponding to regain of 43 ± 27% (calculated as the increase in BMI SDS post-treatment over the BMI SDS lost during treatment). A higher BMI and more comorbidities inversely predicted BMI SDS reduction in linear regression (all p<0.05).The absolute BMI SDS increase after returning home was predicted by pre-treatment leptin and systolic blood pressure, whereas the post-treatment BMI SDS regain was predicted by pre-treatment age, leptin, and adiponectin levels (all p<0.05) in multivariate linear regressions. Conclusion: Patients who need treatment the most are at increased risk for dropouts and weight regain, emphasizing the urgent need for interventions to reduce dropout and support inpatients after discharge. Furthermore, this study is the first to report that pre-treatment leptin and adiponectin levels predict post-treatment BMI SDS regain, requiring further research.

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Background: Currently available treatment programs for children with obesity only have modest long-term results, which is (at least partially) due to the poorer self-control observed within this population. The present trial aimed to determine whether an online self-control training, training inhibition, and redirecting attentional bias, can improve the short- and long-term treatment outcome of (in- or outpatient) child obesity treatment programs. Methods: In this double-blind multi-center randomized controlled trial (RCT), participants aged 8-18 years with obesity were allocated in a 1:1 ratio to receive an online self-control or sham training added to their in- or outpatient multidisciplinary obesity treatment (MOT) program. The primary endpoint was BMI SDS. Data were analyzed by linear mixed models and the main interactions of interest were randomization by time and randomization by number of sessions, as the latter was cumulatively expressed and therefore represents the effect of increasing dose over time. Results: One hundred forty-four inpatient (mean age 14.3 ± 2.2 years, BMI 2.7 ± 0.4 SDS, 42% male) and 115 outpatient children (mean age 11.9 ± 2.1 years, BMI 2.4 ± 0.4 SDS, 45% male) were included. Children's BMI lowered significantly during treatment in both the in- and outpatient treatment centers, p < 0.001. In a mixed model with BMI as dependent variable, randomization by time was non-significant, but the number of self-control trainings (randomization * number of sessions) interacted significantly with setting and with age (p = 0.002 and p = 0.047), indicating a potential effect in younger inpatient residents. Indeed, a subgroup analysis on 22 inpatient children of 8-12 years found a benefit of the number of self-control trainings on BMI (p = 0.026). Conclusions: The present trial found no benefit of the self-control training in the entire study population, however a subgroup of young, inpatient participants potentially benefited.

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INTRODUCTION: In order to grasp the complex etiology of childhood obesity, we aim to clarify the relationship between external eating and weight. Based on theory and empirical evidence, we claim that inhibition is an important moderator in this association. In our first research question we expected that high external eating would be related to a higher weight status, especially for those with high inhibition problems. Secondly, we explored the moderating role of inhibition in the association between external eating and weight change after a multidisciplinary obesity treatment. METHOD: We investigated n=572 participants (51% boys, aged 7-19) with moderate to extreme obesity recruited in a Belgian inpatient treatment center. At intake, parents reported on inhibition (BRIEF), while the children and adolescents reported on their eating behavior (DEBQ). Weight and length were objectively measured pre and post treatment (ADJUSTED BMI). Two hierarchical linear regression models were built to scrutinize the influence of inhibition on the association between external eating and both baseline weight and weight change. RESULTS: First, predicting baseline weight, we found no significant moderating effect of inhibition problems. Second, predicting weight loss, inhibition turned out to be a substantial moderator, specifically in adolescents. Some unexpected gender differences occurred in favor of adolescent boys, in a way that those with high external eating and low inhibition problems lost most weight. CONCLUSION: Inhibition problems act as a moderator explaining weight loss, but this only holds for adolescents. This suggests that external eating and inhibition play a complex role in weight loss in certain age and gender categories, and stresses the importance of identifying subgroups for tailoring interventions. For those with high inhibition problems, interventions aimed at increasing inhibition skills might be needed to optimize treatment outcomes.

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Training self-control as the assumed underlying mechanism for weight loss is a promising pathway for improving long-term outcomes of childhood multidisciplinary obesity treatment (MOT). The present study is the first to analyse adherence to e-health self-control training in paediatric obesity. We hypothesized that low adherence would relate to child characteristics and to contextual treatment barriers. Participants were recruited as a part of a larger randomized controlled trial, evaluating an e-health self-control training during inpatient MOT (intensive phase) and its outpatient aftercare (booster phase). A number of 68 youngsters with severe obesity between 11 to 19 years old were included in the present study. Excellent adherence was observed in the intensive phase during inpatient MOT, but rates decreased in the booster phase. As predicted, the low adherence group had a significantly higher weight status throughout the entire study period. Differences in contextual treatment barriers did not appear. Further in-depth analysis showed that the low adherence group frequently experienced practical obstacles. The end of inpatient MOT and high weight status can be considered important risk factors for low adherence in an additional self-control training aimed at facilitating weight loss.

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BACKGROUND: Obesity is a widespread problem that not only leads to medical and psychological diseases in adults, but also in children and adolescents at an early stage in life. Because of its global burden on both the individual and society, it is necessary to develop effective evidence-based treatments. Current "Multidisciplinary Obesity Treatments" (MOT) already provide significant weight loss, but still leave room for more long-lasting improvements. In this protocol paper, we outline the research goals of the WELCOME trial, based on a substantial proof of concept. METHODS: In this Randomized Controlled Trial (RCT) - conducted in both an inpatient and two outpatient treatment settings - existing MOT will be supplemented with an Executive Function (EF) training and compare effects on various parameters in an experimental versus an active control group of obese youngsters (8-18 years old). WELCOME aims to (a) train youngsters' executive functions to facilitate effects on weight loss, psychological and medical comorbidities, (b) to enhance the long-term effects by continuing the training in the daily home context with booster sessions, and (c) to investigate its effects until a 6-month follow-up. In comparison to the active control group, better progress is expected in the experimental group on following variables: weight, psychological comorbidities (unhealthy eating behavior, internalizing symptoms, impaired self-esteem) and medical comorbidities (metabolic syndromes, endothelia dysfunction, tonsillar hypertrophy and sleep obstruction). DISCUSSION: It is stated that this EF-training for enhancing self-control abilities is necessary for a long-lasting effect of childhood obesity treatment interventions. TRIAL REGISTRATION: The Study Procotol was registered on 10/05/2017 (n° ISRCTN14722584 ).

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INTRODUCTION: Studies linked obesity with a large number of medical conditions including decreased cognitive functioning. The relation between BMI and cognition was proven in adults, but in adolescents the results are conflicting. Further, limited data are available on the impact of weight loss on cognition. This study analyzed the impact of a 30-week lasting weight loss program on cognition and determined the impact of changes in body composition and self-perceived fatigue on changes in cognition. METHODS: Sixty-two obese adolescents were evaluated at baseline and after 30 weeks. Stroop test (ST; selective attention), Continuous Performance Test (CPT; sustained attention) and Ray Auditory verbal learning test (RAVLT; short-term memory) were assessed. Additionally, body composition parameters and fatigue (MFI-20) were evaluated. RESULTS: Improved reaction times were found for ST and CPT after the intervention, but were independent for reductions in BMI, fat mass, fat%, and fatigue. Short memory also improved with decreased fatigue as an influencing parameter. Accuracy of ST and CPT showed no significant changes. CONCLUSION: A 30-week lasting inpatient weight loss program improved selective attention, sustained attention, and short-term memory. Changes in body composition did not explain the improvements in cognitive functioning. Decreased fatigue resulted in improved aspects of cognition.

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Ovarian stimulation with low-dose human menopausal gonadotrophin (HMG) is superior to clomiphene citrate in intrauterine insemination (IUI) cycles with respect to clinical pregnancy rate, but it is unclear whether HMG is also the more cost-effective option. The aim of this study was to compare the cost-effectiveness of ovarian stimulation with low-dose subcutaneously administred HMG (37.5-75 IU per day) to orally administred clomiphene citrate (50 mg/day from day 3-7) in an IUI programme for subfertile couples. A cost-effectiveness analysis was conducted using the results of a randomized trial, including 620 IUI cycles. The primary outcome was the incremental cost-effectiveness ratio (ICER) of using HMG versus clomiphene citrate. Results are presented from the healthcare payer perspective. The total cost per patient associated with one IUI treatment with HMG is €764, whereas it is €558 if clomiphene citrate is used, resulting in an incremental cost of €206 for HMG per treatment. The incremental clinical pregnancy rate of using HMG instead of clomiphene citrate, however, is also 5.7 percentage points higher, resulting in an ICER of HMG versus clomiphene citrate of €3615 per additional clinical pregnancy achieved. On average, HMG was found to be more cost-effective than clomiphene citrate.

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BACKGROUND: Antibiotic-associated diarrhea (AAD) is a common adverse effect of antibiotic (AB) treatment. This study aimed to measure the overall prevalence of AAD (including mild to moderate diarrhea) in hospitalized AB treated patients, to investigate associated risk factors and to document AAD associated diagnostic investigations, contamination control and treatment. METHODS: During 8 observation days (with time delay of 10-14 days between each observation day), all adult patients hospitalized at an internal medicine ward of 4 Belgian participating hospitals were screened for AB use. Patients receiving AB on the observation day were included in the study and screened for signs and symptoms of AAD using a period prevalence methodology. Clinical data were collected for all AB users and AAD related investigations and treatment were collected for the entire duration of AAD. Additionally, nurses noted daily the frequency of all extra care associated to the treatment of the diarrhea. RESULTS: A total of 2543 hospitalized patients were screened of which 743 were treated with AB (29.2%). Included AB users had a mean age of 68 yr (range 16-99) and 52% were male. Penicillins were mostly used (63%) and 19% received more than one AB. AAD was observed in 9.6% of AB users including 4 with confirmed Clostridium difficile infection. AAD started between 1 and 16 days after AB start (median 5) and had a duration of 2 to 41 days (median 4). AAD was significantly associated with higher age and the use of double AB and proton pump inhibitors. AAD patients had extra laboratory investigations (79%), received extra pharmacological treatment (42%) and 10 of them were isolated (14%). AAD related extra nursing time amounted to 51 minutes per day for the treatment of diarrhea. CONCLUSIONS: In this observational study, with one third of hospitalized patients receiving AB, an AAD period prevalence of 9.6% in AB users was found. AAD caused extra investigations and treatment and an estimated extra nursing care of almost one hour per day. Preventive action are highly recommended to reduce the prevalence of AAD and associated health care costs.

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AIM: This study evaluated the effects of a 10-month multidisciplinary residential treatment programme on the perceptual-motor function of obese children and compared them to children with a healthy weight. METHODS: We studied 26 obese Belgian children (10 girls and 16 boys) with a mean age of 10.1 years (±1.4 years), who followed a residential treatment programme consisting of moderate dietary restriction, psychological support and physical activity. The results were compared with 26 healthy weight children matched for age and gender. The anthropometrics and performance of both groups were assessed on two occasions, 10 months apart, based on simple and choice reaction time tasks and a tracking task using a stylus and tablet. Time by body mass index group interactions were investigated using repeated measure ANCOVAs, with age included as a covariate. RESULTS: No significant interaction effect occurred in either task. In contrast, the obese participants showed a significant improvement in tracking performance over time during the stylus and tablet tests, demonstrating mean deviation from the ideal curve. No difference in performance between baseline and follow-up was observed in the healthy weight controls. CONCLUSION: Taking part in a multidisciplinary residential treatment programme improved the perceptual-motor function of obese children.

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BACKGROUND: Obese youth are at increased risk for peer victimization, which may heighten their risk of psychosocial problems and physical activity avoidance, and lower the effectiveness of professional and lifestyle weight-loss initiatives. Little is known about obese adolescents' risk for victimization from cyber-bullying and how this relates to psychosocial functioning and healthy lifestyle barriers. The purpose of the study was to assess traditional and cyber-victimization among adolescents with severe obesity and its relation to psychosocial distress and barriers to healthy lifestyles. METHODS: A sample of 102 obese adolescents (mean age=15.32±1.71) in residential treatment was matched with 102 normal-weight youngsters from the Health Behavior in School-aged Children (HBSC) study (mean age=15.30±1.73). RESULTS: Adolescents with obesity were significantly more often cyber-victimized than normal-weight peers. Obese youth victimized by traditional bullying experienced lower quality of life, lower motivation for physical activity and higher avoidance and emotional coping towards healthy lifestyles than those non-victimized. Obese cyber-victims experienced significantly higher suicidal ideation. CONCLUSIONS: Traditional and cyber-victimization may hinder treatment effectiveness and healthy lifestyle change in adolescents with obesity. Health professionals should pro-actively address peer victimization and psychosocial functioning during multidisciplinary obesity treatment. Schools could contribute to a better physical and psychosocial health of obese youth by implementing multi-behavioral health-promotion programs.

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This study investigated weight status related differences in executive functions and movement execution to determine whether or not childhood obesity is associated with impaired perceptual-motor function. Nineteen obese (OB) children (10 ♂ and 9 ♀, aged 6-12 years) and nineteen gender and age matched healthy-weight (HW) peers performed two computer-based reaction time tasks. For both the simple and four choice reaction time (SRT/CRT) task condition, absolute mean reaction time (RT) and movement time (MT) were determined and expressed as a percentage of total response time (RsT). During the SRT task, OB children were intrinsically slower than their HW peers as reflected by a significantly higher absolute RT, MT and RsT. In the CRT task, however, between-group differences were only present for RT and RsT, whereas absolute MT was comparable among OB and HW participants. As a result, the relative temporal structure of RsT significantly differed between BMI groups, with a greater RT percentage among the OB children. During the CRT condition, OB children probably await final decision-making with regard to the execution of their response movement, which then no longer needs to be adjusted. Our results therefore indicate the use of a more conservative strategy within the OB group, suggesting that childhood obesity is associated with impaired perceptual-motor function. Besides the widely accepted mechanical explanation, a better understanding of the mechanisms underlying OB children's motor incompetence is needed to set up appropriate interventions to tackle this deficit and indirectly address associated health-related problems.

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BACKGROUND: Within the Self-Determination Theory (SDT) framework, the first major study aim was to investigate the SDT tenets in an obese adolescent population by examining the factor structure of the Behavioural Regulation in Exercise Questionnaire-2 (BREQ-2) and by investigating associations between physical activity (PA) and motivation in obese adolescents. The second aim was to study differences in motivation according to adolescents' educational level, since lower educated obese adolescent are a sub-risk group for lower PA levels among the obese adolescents. The third aim was to investigate whether attending a residential obesity treatment program could lead to an increase in autonomous motivation towards PA and to see if the treatment effect on motivation was different in low versus high educated youth. METHODS: For the first study aim, the sample comprised 177 obese adolescents at the start of a 10-month multidisciplinary residential obesity treatment program (BMI = 35.9 ± 6.0 kg/m², 15.1 ± 1.5 years, 62% girls). A subsample of 65 adolescents (stratified by educational level) were divided into low (n = 34) versus high educated (n = 31) as part of the second and third study aim. Motivation was assessed using the BREQ-2 and PA using the Flemish Physical Activity Questionnaire. RESULTS: Exploratory factor analysis showed sufficient validations with the original factor for 17 out of 19 BREQ-2 items. Significant positive correlations were found between PA and the composite score of relative autonomy (r = 0.31, p < 0.001), introjected (r = 0.23, p < 0.01), identified (r = 0.31, p < 0.001) and intrinsic regulation (r = 0.38, p < 0.001). Higher educated adolescents scored higher on the composite score of relative autonomy, introjected, identified and intrinsic regulation at the start of treatment (F = 3.68, p < 0.001). The composite score of relative autonomy, external, identified and intrinsic regulation significantly increased during treatment for all adolescents (F = 6.65, p < 0.001). Introjected regulation significantly increased for lower educated adolescents (F = 25.57, p < 0.001). CONCLUSIONS: The BREQ-2 can be used in an obese adolescent population. Higher levels of autonomous motivation towards PA were related to higher PA levels. Adolescents had increases in both autonomous and controlled forms of motivation during treatment. Special attention for lower educated adolescents during treatment is needed, as they have a lower autonomous motivation at the start of treatment and an increase in introjected regulation during treatment.

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This study evaluated the short-term effectiveness of a multidisciplinary residential obesity treatment program by describing changes in body weight, related measures, and gross motor co-ordination. Secondarily, it was examined to what extent the amount of relative weight loss achieved by overweight and obese (OW/OB) participants explained the projected improvement in gross motor co-ordination. Thirty-six OW/OB children (aged 10.5 ± 1.4 years, 12 girls and 24 boys) were recruited at the Zeepreventorium VZW (De Haan, Belgium), where they followed a specific program consisting of moderate dietary restriction, psychological support, and physical activity. For reference purposes, an additional group of 36 age- and gender-matched healthy-weight (HW) children was included in the study. Anthropometric measures were recorded and gross motor co-ordination was assessed using the Körperkoordinationstest für Kinder (KTK) on two occasions with an interval of 4 months. Regardless of the test moment, OW/OB participants displayed significantly poorer KTK performances (P < 0.001). However, treatment was found to be efficacious in decreasing body weight (Δ 17.9 ± 3.1%, P < 0.001) and generating a significant progress in gross motor co-ordination performance, with a greater increase in KTK score(s) from baseline to re-test as compared to HW peers (P < 0.01). Within the OW/OB group, the amount of relative weight loss explained 26.9% of the variance in improvement in overall KTK performance. Therefore, multidisciplinary residential treatment and concomitant weight loss can be considered an important means to upgrade OW/OB children's level of gross motor co-ordination, which in turn may promote physical activity participation.

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Previous research has suggested that perceptual-motor difficulties may account for obese children's lower motor competence; however, specific evidence is currently lacking. Therefore, this study examined the effect of altered visual conditions on spatiotemporal and kinematic gait parameters in obese versus normal-weight children. Thirty-two obese and normal-weight children (11.2±1.5 years) walked barefoot on an instrumented walkway at constant self-selected speed during LIGHT and DARK conditions. Three-dimensional motion analysis was performed to calculate spatiotemporal parameters, as well as sagittal trunk segment and lower extremity joint angles at heel-strike and toe-off. Self-selected speed did not significantly differ between groups. In the DARK condition, all participants walked at a significantly slower speed, decreased stride length, and increased stride width. Without normal vision, obese children had a more pronounced increase in relative double support time compared to the normal-weight group, resulting in a significantly greater percentage of the gait cycle spent in stance. Walking in the DARK, both groups showed greater forward tilt of the trunk and restricted hip movement. All participants had increased knee flexion at heel-strike, as well as decreased knee extension and ankle plantarflexion at toe-off in the DARK condition. The removal of normal vision affected obese children's temporal gait pattern to a larger extent than that of normal-weight peers. Results suggest an increased dependency on vision in obese children to control locomotion. Next to the mechanical problem of moving excess mass, a different coupling between perception and action appears to be governing obese children's motor coordination and control.

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BACKGROUND: little or no research has been done in the overweight child on the relative contribution of multisensory information to maintain postural stability. Therefore, the purpose of this study was to investigate postural balance control under normal and experimentally altered sensory conditions in normal-weight versus overweight children. METHODS: sixty children were stratified into a younger (7-9yr) and an older age group (10-12yr). Participants were also classified as normal-weight (n=22) or overweight (n=38), according to the international BMI cut-off points for children. Postural stability was assessed during quiet bilateral stance in four sensory conditions (eyes open or closed, normal or reduced plantar sensation), using a Kistler force plate to quantify COP dynamics. Coefficients of variation were calculated as well to describe intra-individual variability. FINDINGS: removal of vision resulted in systematically higher amounts of postural sway, but no significant BMI group differences were demonstrated across sensory conditions. However, under normal conditions lower plantar cutaneous sensation was associated with higher COP velocities and maximal excursion of the COP in the medial-lateral direction for the overweight group. Regardless of condition, higher variability was shown in the overweight children within the 7-9yr old subgroup for postural sway velocity, and more specifically medial-lateral velocity. INTERPRETATION: in spite of these subtle differences, results did not establish any clear underlying sensory organization impairments that may affect standing balance performance in overweight children compared to normal-weight peers. Consequently, it is believed that other factors account for overweight children's functional balance deficiencies.

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OBJECTIVE: To calculate the variable costs involved with the process of delivering erythropoiesis stimulating agents (ESA) in European dialysis practices. METHODS: A conceptual model was developed to classify the processes and sub-processes followed in the pharmacy (ordering from supplier, receiving/storing/delivering ESA to the dialysis unit), dialysis unit (dose determination, ordering, receipt, registration, storage, administration, registration) and waste disposal unit. Time and material costs were recorded. Labour costs were derived from actual local wages while material costs came from the facilities' accounting records. Activities associated with ESA administration were listed and each activity evaluated to determine if dosing frequency affected the amount of resources required. RESULTS: A total of 21 centres in 8 European countries supplied data for 142 patients (mean) per hospital (range 42-648). Patients received various ESA regimens (thrice-weekly, twice-weekly, once-weekly, once every 2 weeks and once-monthly). Administering ESA every 2 weeks, the mean costs per patient per year for each process and the estimates of the percentage reduction in costs obtainable, respectively, were: pharmacy labour (10.1 euro, 39%); dialysis unit labour (66.0 euro, 65%); dialysis unit materials (4.11 euro, 61%) and waste unit materials (0.43 euro, 49%). LIMITATION: Impact on financial costs was not measured. CONCLUSION: ESA administration has quantifiable labour and material costs which are affected by dosing frequency.

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Many obese adolescents show intense body shape and weight concerns that render them vulnerable to cognitive biases, psychological distress and eating disorders. Current treatments, however, generally do not address negative body image in obese adolescents. The present pilot study tested if body exposure and describing one's body in a neutral way is an effective approach for increasing body satisfaction in obese adolescents. The exposure was shown to be a powerful strategy to decrease anxiety and to increase body satisfaction. Also body weight at post-treatment was a significant predictor of positive feelings. These results indicate that adding body exposure and neutral description of one's body to a weight reduction programme might be an effective way to increase body satisfaction in obese adolescents.

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