Last Updated: 03 July 2024

1. Key messages

2. Particulate matter

Particulate matter (PM) refers to all the fine particles suspended in the air. It is not a single chemical substance but a mixture of many different components and is usually referred to by its size. Generally, a distinction is made between PM with a diameter smaller than 10 micrometres (PM₁₀) and with a diameter smaller than 2.5 micrometres (PM_2.5). As PM_2.5 only contains the smaller particles of PM, its composition and health effects are different compared to PM₁₀.

Household heating is the most important direct source of fine particulate matter

According to the most recent Belgian figures (2021), the most important direct source of PM_2.5 is heating by households, which to a large extent use fossil fuels or wood products. Other major sources of direct PM emissions are transport, mostly from road traffic, and industry and waste treatment. Although road traffic is not the leading source of PM emissions, it is nonetheless significant for exposure as local emissions may be high in densely inhabited areas [1]. 

Regulations, such as the European emission standards, and the introduction of hybrid and electric vehicles, have proven successful in mitigating exhaust PM emissions. However, policies so far have largely overlooked the so-called non-exhaust emissions from motorized traffic, resulting from the wear of tyres and brakes and the abrasion of roads [2]. According to the Belgian figures reported for 2021, three quarters of road traffic PM_2.5 results from non-exhaust emissions, and this share rises to 85% for PM10 [3].

Aside from direct emissions, PM can also be formed from precursors through chemical reactions occurring in the air. The most important precursors of indirect PM are ammonia, nitrogen oxides and sulphur dioxide. Ammonia is primarily emitted by the agricultural sector, and especially by livestock. Sulphur dioxide, itself an air pollutant, originates mostly from heavy industry and energy production [1].

Exposure to particulate matter can lead to cardiovascular and respiratory diseases and lung cancer

When inhaled, PM can be absorbed by the lung tissue and cause respiratory disorders. The smaller of the absorbed particles can enter the bloodstream and harm other organs. PM contains toxic and carcinogenic components that are linked to a variety of adverse health effects.

It is well established that prolonged exposure to PM can cause respiratory diseases, more precisely emphysema, chronic bronchitis, and pneumonia [4,5]. PM exposure also causes cardiovascular diseases, with strong evidence of links to stroke and ischemic heart disease [4,6]. Other well-established effects include lung cancer [7] and type 2 diabetes [8]. The evidence also suggests an impact on mental health, namely an increased risk of depression [9]. All of these conditions are debilitating and can contribute to a severe loss in quality of life and premature death [4]. 

PM exposure puts women and their infants at risk as exposure has been linked to perinatal conditions including premature birth, lower birth weight, and miscarriage [10,11,12]. Children are also identified as a vulnerable group susceptible to the effects of PM. Exposure plays a role in the development of asthma, and can also trigger asthma attacks resulting in more emergency room visits and hospitalisation [13,14]. More recent evidence points to consequences for brain development, where exposure to PM during pregnancy and early life increases the risk of autism spectrum disorder [15].  

Particulate matter concentrations are higher in The Flemish Region and Brussels capital region compared to the Walloon region

To visualise exposure to PM in Belgium, yearly average PM_2.5 and PM₁₀ concentrations are mapped for each statistical sector. The values are shown relative to the WHO’s air quality guideline level for the pollutant, as an indication of exposure in the local community compared to the advised value: 5 µg m^-3 annual mean concentration for PM_2.5, and 15 µg m^-3 annual mean concentration for PM₁₀ [16].

As evidenced in the air quality map for PM_2.5, concentrations generally decrease from North to South. Pollution levels are relatively high in the Flemish Region and the Brussels Capital Region, and low to intermediate in the Walloon Region. The same pattern appears for PM₁₀, with the difference that relative pollution levels are generally lower compared to PM_2.5. 

This regional pattern is likely a result of differences in population density and vegetation. The Flemish Region is more densely-populated and has more PM sources (residential heating, transport, agriculture including intensive livestock) and less sinks (removal by vegetation) compared to the Walloon Region. While about half of the territory has pollution levels above the long-term WHO guideline value for PM₁₀, 97% of the area has levels above the guideline for PM_2.5.

Population exposure to particulate matter in Belgium is high but decreasing

Population exposure to PM can be summarised by a population-weighted average concentration and is used to compare regions and explore trends in time. Exposure to both PM_2.5 and PM₁₀ is decreasing in Belgium, and within all regions. Exposure to PM was initially highest in the Brussels Capital Region, but dropped below the Flemish Region to converge with the average value for Belgium. Exposure to PM has consistently been lowest in the Walloon Region.

Although air quality improved over the past decade, many Belgians are still confronted with unhealthy levels of PM exposure. In 2021, while about three quarters of the population was exposed to pollution levels exceeding the long-term WHO guideline value for PM₁₀, virtually the entire population breathes levels above the air quality guideline for PM_2.5.

Belgium has the fourth highest exposure to particulate matter compared to similar EU countries

Belgium has the fourth highest population-weighted concentration for both PM_2.5 and PM₁₀, compared to the other EU-14 countries. Although well below some countries, exposure to PM is higher in Belgium than the European average, and twice as high as in Finland [19].

3. Nitrogen dioxide

Nitrogen oxides (NO_X), including nitrogen monoxide (NO) and nitrogen dioxide (NO₂), are gases formed and emitted together as a result of combustion, which occurs in car engines and power plants. NO is mostly harmless at the amounts present in the atmosphere, while ambient NO₂ concentration can reach a point where it poses a serious health hazard.

Road traffic is by far the leading source of nitrogen dioxide emissions

Transport is the leading source of NO_x emissions, including NO₂, with road traffic by far the largest contributor, followed by shipping (both maritime and inland) and air traffic [1]. The severity of NO₂ exposure as a result of road traffic is further increased due to emissions occurring near surface level and often in densely inhabited areas, and because of street canyons, where the pollutant gets trapped in narrow roads flanked by tall buildings [20]. Other, less significant sources include industry and agriculture.

Exposure to nitrogen dioxide can cause cardiovascular and respiratory diseases and lung cancer

NO₂ is highly inflammatory and inhaling the gas can irritate the airways in the respiratory tract.

It is well established that prolonged exposure to NO₂ can cause respiratory diseases, including emphysema, chronic bronchitis and pneumonia [21]. Research also points to a relationship with cardiovascular disease, and more specifically with ischemic heart disease [22,23]. Other well-studied effects include lung cancer and type 2 diabetes [24,25]. Studies suggest that NO₂ can adversely affect mental health, showing an increased risk of depression [9,26]. These conditions can lead to a substantial loss of life quality and premature death [21].

NO₂ threatens the health of women and their infants as exposure is associated with perinatal conditions, including preterm birth and low birth weight [27,28]. Children too are disproportionally affected as NO₂ is linked to the development of asthma, and can also trigger asthma attacks resulting in more emergency department visits and hospitalisation [3,29].

Higher nitrogen dioxide concentrations in cities compared to rural areas

To visualise exposure to NO₂ in Belgium, yearly average concentrations are mapped for each statistical sector. The values are shown relative to the WHO’s air quality guideline level for the pollutant, as an indication of exposure in the local community compared to the advised value: 10 µg m^-3 annual average concentration [16].

As evidenced by the pollution map for NO₂, concentrations are generally higher in the Flemish Region and the north of the Walloon Region, including the Sambre-Meuse region, as compared to the Ardennes. Road traffic being the principal source of NO_x, the locations of large cities and major highways can be easily seen on the map. The Brussels Capital Region, a highly urbanised area, is severely polluted with the exception of the forested part in the southeast. About half of the sectors have pollution values above the long-term WHO guideline of 10 µg m^-3 annual average concentration.

Population exposure to nitrogen dioxide in Belgium is high but decreasing

Population exposure to NO₂ can be summarised by a population-weighted average concentration, and used to compare regions and explore trends over time. Exposure to NO₂ is decreasing in Belgium, and within all regions. Exposure to NO₂ is highest in the Brussels Capital Region, although the decline in pollution levels is somewhat steeper there compared to the other regions. Exposure to NO₂ is consistently lowest in the Walloon region, while Flemish levels stay close to the Belgian average. 

Although the trends are favourable, there is still room for improvement. Considering the most recent figures for 2021, more than 85% of the population is exposed to unhealthy levels of NO₂, exceeding the WHO’s long-term guideline value.

Belgium has the fifth highest exposure to nitrogen dioxide compared to similar EU countries

Belgium has the fifth highest population-weighted concentration for NO₂ compared to the other EU-14 countries, well above the average European concentration. Exposure levels are more than double the values of Nordic countries Denmark, Finland, and Sweden [19].

4. Ozone

Ozone (O₃) is a gas formed from oxygen (O₂) by the action of ultra-violet radiation or lightning. It exists in all layers of the atmosphere in various concentrations. Although its presence in the stratosphere, tens of kilometres high, protects lifeforms against the most damaging solar radiation, ground-level ozone poses a serious threat to health.

Ozone levels are higher during summer, especially on sunny days

O₃ in the lower atmosphere originates from chemical reactions under the influence of sunlight. It is formed from precursors, including nitrogen oxides, methane, and volatile organic compounds (VOCs). VOCs know many industrial applications, and this sector is responsible for the largest share of emissions in Belgium. Other major sources are agriculture, most notably livestock, and road traffic [1]. 

O₃ concentration is strongly dependent on weather, season, the time of the day, and emissions of precursors. On a short time scale, there will be more O₃ during daytime and on sunny days. Over the year, O₃ concentrations are higher in the summer, with the peak ozone season ranging from April to September in Belgium. O₃ reacts with NO to form O₂ and NO₂; the reverse reaction is also possible where O₂ and NO₂ react to form O₃. As a result, locations with high NO concentrations, such as cities and busy roads, generally have lower O₃ pollution [30].

Ozone peaks cause respiratory problems and can result in death

Ozone is a highly reactive and oxidative gas, which makes it harmful to both humans and ecosystems. Peak O₃ concentrations have been linked to a wide range of respiratory problems. Short-term exposure is associated with symptoms including coughing and wheezing, as well as asthma attacks and, in extreme cases, death [29,31]. 

Ozone affects individuals of every age group. Indeed, ambient O₃ poses a threat to mothers and their infants as exposure during pregnancy is associated with low birth weight, preterm birth, and stillbirth [27,28,32]. Prolonged exposure can lead to decreased lung function in children [33]. O₃ also impacts the elderly as they are more sensitive to its adverse effects compared to the general population [34].

Rural areas have higher ozone concentrations compared to cities

To visualise exposure to O₃ in Belgium, peak season concentrations are mapped for each statistical sector. The values are shown relative to the WHO’s air quality guideline level for the pollutant as an indication of exposure in the local community compared to the advised value: 60 µg m^-3 peak season average [16]. Because of its seasonal and diurnal character, the WHO guidelines for O₃ are based on a peak metric: the daily maximum 8-hour mean concentration averaged over the peak ozone season. This amounts to only daytime levels being taken into consideration and is limited to the summer season.

As evidenced by the pollution map for O₃, concentrations are generally higher in the Walloon Region compared to the Flemish Region and the Brussels Capital Region. The spatial pattern of O₃ appears to a large extent to be the inverse of the pattern of NO₂. The likely explanation is that the NO emitted together with NO₂ by cars and other vehicles breaks down ozone in traffic-busy areas. The result is that urban centres and the surroundings of highways experience lower concentrations compared to rural areas. Despite this urban-rural distinction, virtually the entire territory has long-term O₃ concentrations exceeding the WHO-recommended value.

Exposure to ozone has been steadily increasing over time in Belgium

Population exposure to O₃ can be summarised by a population-weighted average concentration and used to compare regions, and explore trends in time. Contrary to the other pollutants, exposure to O₃ in Belgium and its regions is rising. Considering the most recent figures for the year 2021, exposure in the Flemish Region is comparable to the Belgian average, while it is slightly higher in the Walloon Region and significantly lower in the Brussels Capital Region. Despite these regional differences, the entirety of the Belgian population is exposed to O₃ concentrations that exceed the WHO’s recommended value. 

Belgium has the sixth lowest exposure to ozone compared to similar EU countries

The European comparison of ozone exposure is not based on the average concentration, as is the case for the WHO’s guideline value, but on a metric called SOMO35: the sum of means (daily maximum 8-hour) over 35 ppb. As this is a cumulative figure, the values can become high as compared to metrics based on averages.

Belgium has the sixth lowest population-weighted SOMO35 for O₃ compared to the other EU-14 countries, well below the average European concentration [19].

5. Read more

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Background

Poor air quality constitutes the single biggest environmental health risk worldwide, responsible for millions of premature deaths and healthy life years lost. Exposure to air pollution has been associated with respiratory diseases, cardiovascular disorders, lung cancer, and diabetes, as well as perinatal, neurological and mental health effects. It disproportionally affects vulnerable groups, including women and their infants, children, the elderly and people with lung diseases and asthma. This page provides an overview of the exposure of Belgians to particulate matter, nitrogen dioxide, and ozone, pollutants that are considered to have a major health impact [16].

To improve air quality and protect and promote public health, the WHO publishes the Air Quality Guidelines, which are a set of recommended limit values for specific air pollutants. The guidelines were last updated with recent scientific evidence in 2021, and contain recommendations for daily concentrations as well as long-term averages. Aside from the WHO’s advised values, the European Union enforces legally binding air quality standards. The EU standards are less stringent than the corresponding WHO guidelines, as these are the result of political negotiations, and consider health as well as economic feasibility [16,35].

The air pollutants addressed in this sheet are particulate matter with diameters <2.5 µm and <10 µm (PM_2.5 and PM₁₀), nitrogen dioxide (NO₂), and ozone (O₃). Air quality assessment is based on pollution maps provided by IRCEL-CELINE, which depict the yearly average concentration for each location in Belgium. The pollution maps are the result of models, which are verified against actual measurements but are still subject to a degree of error. The population data used are provided by Statbel [17,18]. 

Definitions

Concentration, emissions and deposition 

The quality of air is determined by the concentration of air pollutants. This concentration is commonly expressed in the form of mass concentration, giving you the mass of a polluting substance present in a volume of air. As this mass is usually very small compared to the space it occupies, a common unit is microgram per cubic meter (µg m^-3; a microgram is equal to 1 millionth of a gram). 

The concentration of air pollutants is dependent on (direct or indirect) emissions and deposition. Sources either emit pollution directly or emit substances that turn into pollution (called precursors), in both cases leading to an increase in concentration. Deposition is the removal of pollution, where the pollutant settles on the earth’s surface or is washed out by rain, improving air quality. Emissions and deposition are commonly expressed as rates, for instance as kilogram per hour or tonne per year [36].

Population exposure

The exposure of people to ambient air pollution can be determined by linking their place of residence to outdoor concentrations of pollution. Exposure in local communities is approached here as the average pollutant concentration in their neighbourhood, in this case defined by the statistical sector. As these sectors are the smallest geographical unit in Belgium, and given that internal differences are limited, such a simple average can be considered representative of all inhabitants.

To measure population exposure on a national or regional scale, a population-weighted average concentration is derived. In the calculation, the population number at each location is taken into account as the weight for the corresponding concentration level. For large areas, this is preferred over a simple average concentration, as this value can be biased in case its inhabitants tend to live in the more or the less polluted parts.

References

1. European Environment Agency. National Air Pollutant Emissions Data Viewer 2005-2021, 2023. https://www.eea.europa.eu/data-and-maps/dashboards/necd-directive-data-viewer-7.
2. OECD. Mortality Risk Valuation in Environment, Health and Transport Policies, 2012. https://doi.org/10.1787/9789264130807-en.
3. EMEP Centre on Emission Inventories and Projections. Data Viewer – Reported Emissions Data, 2023. https://www.ceip.at/data-viewer-2.
4. Chen, J.; Hoek, G. Long-Term Exposure to PM and All-Cause and Cause-Specific Mortality: A Systematic Review and Meta-Analysis, 2020. https://doi.org/10.1016/j.envint.2020.105974.
5. Park, J.; Kim, H.-J.; Lee, C.-H.; Lee, C. H.; Lee, H. W. Impact of Long-Term Exposure to Ambient Air Pollution on the Incidence of Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis, 2021. https://doi.org/10.1016/j.envres.2020.110703.
6. Alexeeff, S. E.; Liao, N. S.; Liu, X.; Van Den Eeden, S. K.; Sidney, S. Long‐Term PM2.5 Exposure and Risks of Ischemic Heart Disease and Stroke Events: Review and Meta‐Analysis, 2021. https://doi.org/10.1161/JAHA.120.016890.
7. Ciabattini, M.; Rizzello, E.; Lucaroni, F.; Palombi, L.; Boffetta, P. Systematic Review and Meta-Analysis of Recent High-Quality Studies on Exposure to Particulate Matter and Risk of Lung Cancer, 2021. https://doi.org/10.1016/j.envres.2020.110440.
8. Yang, Z.; Wang, Q.; Liu, P. Extreme Temperature and Mortality: Evidence from China, 2019. https://doi.org/10.1007/s00484-018-1635-y.
9. Borroni, E.; Pesatori, A. C.; Bollati, V.; Buoli, M.; Carugno, M. Air Pollution Exposure and Depression: A Comprehensive Updated Systematic Review and Meta-Analysis, 2022. https://doi.org/10.1016/j.envpol.2021.118245.
10. Yu, Z.; Zhang, X.; Zhang, J.; Feng, Y.; Zhang, H.; Wan, Z.; Xiao, C.; Zhang, H.; Wang, Q.; Huang, C. Gestational Exposure to Ambient Particulate Matter and Preterm Birth: An Updated Systematic Review and Meta-Analysis, 2022. https://doi.org/10.1016/j.envres.2022.113381
11. Ghosh, R.; Causey, K.; Burkart, K.; Wozniak, S.; Cohen, A.; Brauer, M. Ambient and Household PM2.5 Pollution and Adverse Perinatal Outcomes: A Meta-Regression and Analysis of Attributable Global Burden for 204 Countries and Territories, 2021. https://doi.org/10.1371/journal.pmed.1003718.
12. Zhu, W.; Zheng, H.; Liu, J.; Cai, J.; Wang, G.; Li, Y.; Shen, H.; Yang, J.; Wang, X.; Wu, J.; Nie, J. The Correlation between Chronic Exposure to Particulate Matter and Spontaneous Abortion: A Meta-Analysis, 2022. https://doi.org/10.1016/j.chemosphere.2021.131802.
13. Khreis, H.; Kelly, C.; Tate, J.; Parslow, R.; Lucas, K.; Nieuwenhuijsen, M. Exposure to Traffic-Related Air Pollution and Risk of Development of Childhood Asthma: A Systematic Review and Meta-Analysis, 2017. https://doi.org/10.1016/j.envint.2016.11.012.
14. Lim, H.; Kwon, H.-J.; Lim, J.-A.; Choi, J. H.; Ha, M.; Hwang, S.-S.; Choi, W.-J. Short-Term Effect of Fine Particulate Matter on Children’s Hospital Admissions and Emergency Department Visits for Asthma: A Systematic Review and Meta-Analysis, 2016. https://doi.org/10.3961/jpmph.16.037.
15. Lin, L.-Z.; Zhan, X.-L.; Jin, C.-Y.; Liang, J.-H.; Jing, J.; Dong, G.-H. The Epidemiological Evidence Linking Exposure to Ambient Particulate Matter with Neurodevelopmental Disorders: A Systematic Review and Meta-Analysis, 2022. https://doi.org/10.1016/j.envres.2022.112876.
16. World Health Organization. WHO Global Air Quality Guidelines: Particulate Matter (PM2.5 and PM10), Ozone, Nitrogen Dioxide, Sulfur Dioxide and Carbon Monoxide, 2021. https://www.who.int/publications/i/item/9789240034228.
17. IRCEL-CELINE. Air Quality Models. https://www.irceline.be/en/documentation/models.
18. Statbel. Bevolking per Statistische Sector. https://statbel.fgov.be/nl/open-data/bevolking-statistische-sector-9.
19. European Environment Agency. Air Quality Health Risk Assessments (NUTS3). https://www.eea.europa.eu/ds_resolveuid/45d9e01d512d44528cf6b933809883e5.
20. Fierens, F.; Vanpoucke, C.; Trimpeneers, E.; Dumoulin, R.; Maetz, P.; Hutsemékers, V.; Degrave, C. Jaarrapport Luchtkwaliteit in België 2022, 2023. https://www.irceline.be/nl/documentatie/publicaties/jaarrapporten/jaarrapport-luchtkwaliteit-in-belgie-2022/view.
21. Huangfu, P.; Atkinson, R. Long-Term Exposure to NO2 and O3 and All-Cause and Respiratory Mortality: A Systematic Review and Meta-Analysis, 2020. https://doi.org/10.1016/j.envint.2020.105998.
22. Huang, S.; Li, H.; Wang, M.; Qian, Y.; Steenland, K.; Caudle, W. M.; Liu, Y.; Sarnat, J.; Papatheodorou, S.; Shi, L. Long-Term Exposure to Nitrogen Dioxide and Mortality: A Systematic Review and Meta-Analysis, 2021. https://doi.org/10.1016/j.scitotenv.2021.145968.
23. Stieb, D. M.; Zheng, C.; Salama, D.; Berjawi, R.; Emode, M.; Hocking, R.; Lyrette, N.; Matz, C.; Lavigne, E.; Shin, H. H. Systematic Review and Meta-Analysis of Case-Crossover and Time-Series Studies of Short Term Outdoor Nitrogen Dioxide Exposure and Ischemic Heart Disease Morbidity, 2020. https://doi.org/10.1186/s12940-020-00601-1.
24. Stieb, D. M.; Berjawi, R.; Emode, M.; Zheng, C.; Salama, D.; Hocking, R.; Lyrette, N.; Matz, C.; Lavigne, E.; Shin, H. H. Systematic Review and Meta-Analysis of Cohort Studies of Long Term Outdoor Nitrogen Dioxide Exposure and Mortality, 2021. https://doi.org/10.1371/journal.pone.0246451.
25. Yang, B.-Y.; Fan, S.; Thiering, E.; Seissler, J.; Nowak, D.; Dong, G.-H.; Heinrich, J. Ambient Air Pollution and Diabetes: A Systematic Review and Meta-Analysis, 2020. https://doi.org/10.1016/j.envres.2019.108817.
26. Fan, S.-J.; Heinrich, J.; Bloom, M. S.; Zhao, T.-Y.; Shi, T.-X.; Feng, W.-R.; Sun, Y.; Shen, J.-C.; Yang, Z.-C.; Yang, B.-Y.; Dong, G.-H. Ambient Air Pollution and Depression: A Systematic Review with Meta-Analysis up to 2019, 2020. https://doi.org/10.1016/j.scitotenv.2019.134721.
27. Ju, L.; Li, C.; Yang, M.; Sun, S.; Zhang, Q.; Cao, J.; Ding, R. Maternal Air Pollution Exposure Increases the Risk of Preterm Birth: Evidence from the Meta-Analysis of Cohort Studies, 2021. https://doi.org/10.1016/j.envres.2021.111654.
28. Li, C.; Yang, M.; Zhu, Z.; Sun, S.; Zhang, Q.; Cao, J.; Ding, R. Maternal Exposure to Air Pollution and the Risk of Low Birth Weight: A Meta-Analysis of Cohort Studies, 2020. https://doi.org/10.1016/j.envres.2020.109970.
29. Orellano, P.; Quaranta, N.; Reynoso, J.; Balbi, B.; Vasquez, J. Effect of Outdoor Air Pollution on Asthma Exacerbations in Children and Adults: Systematic Review and Multilevel Meta-Analysis, 2017. https://doi.org/10.1371/journal.pone.0174050.
30. Monks, P. S.; Archibald, A. T.; Colette, A.; Cooper, O.; Coyle, M.; Derwent, R.; Fowler, D.; Granier, C.; Law, K. S.; Mills, G. E.; Stevenson, D. S.; Tarasova, O.; Thouret, V.; von Schneidemesser, E.; Sommariva, R.; Wild, O.; Williams, M. L. Tropospheric Ozone and Its Precursors from the Urban to the Global Scale from Air Quality to Short-Lived Climate Forcer, 2015. https://doi.org/10.5194/acp-15-8889-2015.
31. Orellano, P.; Reynoso, J.; Quaranta, N.; Bardach, A.; Ciapponi, A. Short-Term Exposure to Particulate Matter (PM10 and PM2.5), Nitrogen Dioxide (NO2), and Ozone (O3) and All-Cause and Cause-Specific Mortality: Systematic Review and Meta-Analysis, 2020. https://doi.org/10.1016/j.envint.2020.105876.
32. Zhang, H.; Zhang, X.; Wang, Q.; Xu, Y.; Feng, Y.; Yu, Z.; Huang, C. Ambient Air Pollution and Stillbirth: An Updated Systematic Review and Meta-Analysis of Epidemiological Studies, 2021. https://doi.org/10.1016/j.envpol.2021.116752.
33. Holm, S. M.; Balmes, J. R. Systematic Review of Ozone Effects on Human Lung Function, 2013 Through 2020, 2022. https://doi.org/10.1016/j.chest.2021.07.2170.
34. Bell, M. L.; Zanobetti, A.; Dominici, F. Who Is More Affected by Ozone Pollution? A Systematic Review and Meta-Analysis, 2014. https://doi.org/10.1093/aje/kwu115.
35. European Commission. EU Air Quality Standards. https://environment.ec.europa.eu/topics/air/air-quality/eu-air-quality-standards_en.
36. IRCEL-CELINE. What Is the Difference between Emission, Concentration, Exposure and Deposition? https://www.irceline.be/en/documentation/faq/what-is-the-difference-between-emission-concentration-exposure-and-deposition.

Please cite this page as: Sciensano. Determinants of Health: Air quality, Health Status Report, 25 Mar 2024, Brussels, Belgium, https://www.healthybelgium.be/en/health-status/determinants-of-health/air-quality 

Last Updated: 21 August 2023

1. Key messages

2. Background

Health literacy is defined as “people’s knowledge, motivation and competencies to access, understand, appraise, and apply health information in order to make judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life during the life course” [1]. Limited health literacy is associated with adverse health outcomes, inadequate health-related behavior, health service use, treatment and medication adherence, self-care management, and higher mortality rates [2-4]. A Belgian study showed that low health literacy is associated with greater use of health care services, particularly the more specialized services [5]. It has also been hypothesized that health literacy has a mediating role between socioeconomic status and health disparities and can be a tool against health inequalities [6]. Health literacy is today recognized as an important health determinant and attracts more and more attention at international, national, and regional levels [7,8]. More information on health literacy actions in Belgium is available in the report of the KCE [9].

Health literacy was measured in Belgium in 2014 and 2016 using online surveys and a convenience sample from the members of a Belgian health insurance fund. In 2018, health literacy was included in the HIS 2018 and therefore measured for the first time using a nationally representative sample. The HIS 2018 used the HLS-EU-Q6 questionnaire, a generic and subjective instrument adapted to the European context. With this instrument a score of health literacy is first computed, then the scores are grouped into three categories: 

• Sufficient health literacy
• Limited health literacy
• Insufficient health literacy

First, the distribution of health literacy levels by region is presented, then the proportion of people with a poor level of health literacy is further analyzed in the population aged 15 years and over. A poor health literacy category is constructed by pooling the groups having “limited” and “insufficient” health literacy.

3. Distribution of health literacy levels

In 2018, 66.6% of the population aged 15 years and over had a sufficient level of health literacy, 27.8% a limited level, and 5.6% an insufficient level. Thus, one third of the population (33.4%) had a poor level of health literacy.

More people have a sufficient level of health literacy in Flanders (69.3%) than in Wallonia (62.7%) and Brussels (63.2%). The difference comes mainly from people with limited health literacy, as the proportion of people with insufficient health literacy is the same in the 3 regions.

4. Poor level of health literacy

Situation in 2018

Belgium

In Belgium, in 2018, 33.4% of the population had a poor level of health literacy. This proportion was lower for men (31.7%) than for women (35.0%). Poor health literacy was more prevalent among people aged 75 years and older (38.7% for men and 50.4% for women) and the younger people aged 15 to 24 (32.8% for men and 44.6% for women).

Regional differences

Among men, the prevalence of poor health literacy was higher in Brussels and Wallonia (37.7% and 36.0%, resp.) than in Flanders (28.8%).

Among women, the differences between regions were smaller; yet Wallonia still had a higher prevalence of poor health literacy.

Socio-economic disparities

The level of health literacy is strongly linked to educational level. People with the lowest educational level were nearly two times more likely to have low health literacy than people with the highest educational level. However, it is noteworthy that among people with tertiary education, 28.1% still have a low level of health literacy.

5. Read more

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HISIA: Interactive Analysis of the Belgian Health Interview Survey

Definitions

Age-adjusted prevalence

Most indicators are linked to age. Since the Belgian population is ageing over time and that differences in age-composition are observed between regions and between educational groups, the prevalence rates are standardized by age with the European standard population 2010 to allow for comparability.

HLS-EU-Q6 questionnaire

The European Health Literacy Survey (HLS-EU) was developed by the HLS-EU Consortium to measure and compare health literacy in European countries based on the definition and conception model proposed by Sorensen et al. [10]. The original version is compounded of 47 items; a shorter version of 6 items was constructed to facilitate the inclusion of the questionnaire in population surveys. The correlation of results between the 47 items-questionnaire and the 6 items-questionnaire was 0.896 [11]. The questionnaire evaluates the three domains of health literacy, i.e. healthcare, prevention, and health promotion, and the 4 dimensions of health literacy, i.e. acquiring and obtaining consistent health information, understanding the information, evaluating, and judging the information, and the actual application and use of the information.

References

1. Sorensen K, Pelikan JM, Röthlin F, Ganahl K, Slonska Z, Doyle G, et al. Health literacy in Europe: comparative results of the European health literacy survey (HLS-EU). Eur J Public Health. 2015;25(6):1053-8.
2. Okan O, Bauer U, Levin-Zamir D, Pinheiro P, Sørensen K. International Handbook of Health Literacy: Research, practice and policy across the lifespan. Policy Press; 2019. pp. 766.
3. Nutbeam D. Defining and measuring health literacy: what can we learn from literacy studies? Int J Public Health. 2009;54(5):303–5.
4. Van den Broucke S. Health literacy: a critical concept for public health. Arch Public Health. 2014;72(1):10.
5. Vandenbosch J, Broucke SV den, Vancorenland S, Avalosse H, Verniest R, Callens M. Health literacy and the use of healthcare services in Belgium. J Epidemiol Community Health. 2016;70(10):1032-8.
6. Stormacq C, Van den Broucke S, Wosinski J. Does health literacy mediate the relationship between socioeconomic status and health disparities? Integrative review. Health Promot Int. 2019;34(5):e1-17.
7. Quaglio G, Sørensen K, Rübig P, Bertinato L, Brand H, Karapiperis T, et al. Accelerating the health literacy agenda in Europe. Health Promot Int. 2017;32(6):1074-80.
8. Kickbusch I, Pelikan JM, Apfel F, Tsouros AD, World Health Organization, editors. Health literacy: the solid facts. Copenhagen: World Health Organization Regional Office for Europe; 2013. pp. 73.
9. Rondia K, Adriaenssens J, Van Den Broucke S, Kohn L. Health literacy: what lessons can be learned from the experiences of other countries? Health Services Research (HSR) Brussels: Belgian Health Care Knowledge Centre (KCE); 2019. KCE Reports 322. D/2019/10.273/63.
10. Sorensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z, et al. Health literacy and public health: a systematic review and integration of definitions and models. BMC Public Health. 2012;12:80.
11. Sorensen K, Van den Broucke S, Pelikan JM, Fullam J, Doyle G, Slonska Z, et al. Measuring health literacy in populations: illuminating the design and development process of the European Health Literacy Survey Questionnaire (HLS-EU-Q). BMC Public Health. 2013;13:948.
12. Charafeddine R, Demarest S, Berete F. Enquête de santé 2018: Littératie en santé [Internet]. Brussels, Belgium: Sciensano; 2020. Report No.: D/2019/14.440.72. Available from: https://www.sciensano.be/en/projects/health-interview-survey

Please cite this page as: Sciensano. Determinants of Health: Health literacy, Health Status Report, 21 Aug 2020, Brussels, Belgium, https://www.healthybelgium.be/en/health-status/determinants-of-health/health-literacy 

Last Updated: 03 July 2024

1. Key messages

2. Current and daily smoking - adults

The proportion of occasional smokers stays stable

In 2018, 19% of the population were current smokers, among them, 15% were daily smokers (including 4.7% of heavy smokers, i.e., smoking more than 20 cigarettes a day) and 4% were occasional smokers. The time trend is reassuring with a 40% decrease in daily smokers between 1997 and 2018. A decreasing part of smokers were heavy smokers, they were 4.7% of the population in 2018 (-52% compared to 1997).

In Belgium, more men are daily smokers than women

In 2018, more men (18%) than women (12%) smoked daily. The prevalence of daily smoking in men aged 25 to 64 years is still concerning, as it reaches more than 20%. In women, the prevalence increases with age up to 64 years, where 17% are daily smokers. Between 15 and 44 years of age, twice as many men smoke compared to women. Between 45 and 64, fewer men and more women are daily smokers compared to the previous ages. At older ages, the proportion of daily smokers is lower, with similar rates in both sexes. This can be to some extent due to a health selection effect, for instance, because non-smokers live longer.

The percentage of daily smokers is higher in Wallonia

Daily smoking prevalence was higher in Wallonia (18%) than in Brussels (16%) and in Flanders (13%).

A sharp decline in smoking has been observed since 1997

Since 1997, a relative reduction of 38% in men and 32% in women was observed in the prevalence of daily smoking in Belgium. Among youngsters (15-24), an important decrease of daily smokers (-35%) was observed in 2018 compared to 2013. Among women, an increase was initially observed in 2013, causing more young women to smoke than men in 2013; in 2018 this trend has reversed with an important decrease (-59%) in the prevalence of daily smoking.

Daily smoking prevalence has decreased in all regions and in both sexes since 1997; the decline was higher in men in Flanders and in women in Brussels.

People with lower levels of education are more likely to smoke daily

After adjustment for age, people with a lower secondary education had the highest prevalence of daily smokers, and were 3.1 times more likely to be daily smokers than people with the highest educational level in 2018, while people with the lowest educational level were 2.3 times more likely to be daily smokers than people with the highest educational level. The prevalence of daily smoking decreased in nearly all educational levels (except for the lower secondary education). From those successive cross-sectional surveys, one cannot know which part of the trends is due to a change in smoking behavior, or to a health selection effect.

Belgian women are less likely to be daily smokers than the EU-15 average

The prevalence of daily smoking was lower in Belgium compared to the EU-15 average for 2019. 

3. Regular use of e-cigarettes - adults

Young people use e-cigarettes more than their elders

In 2018, the prevalence of regular e-cigarette use in Belgium (4.1%) was higher in men (5.5%) than in women (2.7%). It is the highest in young men (15-34) and the lowest after the age of 65 years.

Flanders has the highest proportion of e-cigarette users 

The prevalence of regular e-cigarette use was higher in men in Flanders (5.9%) and in Wallonia (5.5%) than in Brussels (3.5%). It was higher in women in Flanders (3.0%) and Brussels (2.9%) than in Wallonia (2.2%).

People with lower levels of education are more likely to use e-cigarettes

People with secondary education were 2.4 times more likely to be regular e-cigarette users than people with tertiary education.

More Belgians use e-cigarettes than the EU-15 average

Eurobarometer 458 constitutes the only comparable source of information about the usage of electronic cigarettes in Europe but the comparison should be interpreted with caution due to the limited samples. In 2017, Belgium had a higher prevalence of users than the average EU-15 countries.

4. Current and daily smoking - adolescents

In 2018, 3.8% of secondary school adolescents aged 11-18 were daily smokers

Belgian HBSC studies show that in 2018, 17% of adolescents reported having at least tried tobacco once. Notably, a greater proportion of boys (19%) had engaged in this compared to girls (16%).

In secondary school, 3.8% of adolescents were daily smokers. An increase is observed by age, with adolescents aged 17-18 years old smoking at the highest rates. The difference between boys and girls is particularly marked in this age group, where boys (15%) are more likely to smoke daily than girls (11%). 

Adolescents from the French Community are more likely to be daily smokers 

The median age of tobacco experimentation is 14 years in the French Community and 15 years in the Flemish Community. More adolescents in the French Community were daily smokers than in the Flemish Community (4.4% vs. 3.4%). 

Daily smoking has significantly decreased in 2018 compared to 2006

In both Communities, the prevalence of boys and girls reporting smoking daily decreased between 2006 and 2018. In 2006, 9.3% of girls and 10% of boys were daily smokers, down to 3.2% of girls and 4.5% of boys in 2018.

During 2018, there was a slightly higher prevalence of daily smoking among boys and girls from the French Community compared to those from the Flemish Community.

Adolescents in vocational education are more likely to be daily smokers in both Communities

In both Communities, there are differences in educational track for patterns of daily smoking. In the French Community, students in vocational education smoke at higher rates (19%), followed by students in technical schools (14%) and those in general education (4.1%).In the Flemish Community, general education students smoked at the lowest rates (1,5%), compared to students in technical education (7,5%) and vocational education (13%).

Belgian adolescents compared favorably to the EU-15 average of current use of tobacco 

In the EU-15 countries, 15% of 15-year-old girls and 14% of 15-year-old boys reported smoking at least once in the past 30 days. Belgium is below the average with 12% of 15-year-old boys and 11% of 15-year-old girls reporting having smoked during this period.

5. Use of electronic cigarettes - adolescents

In Belgium in 2018, 19% percent of adolescents had ever tried an e-cigarette in their life, a higher proportion than for conventional cigarettes. Overall, more boys (24%) than girls (15%) had reported trying one.

The Flemish Community's HBSC survey for 2022  already shows that e-cigarette use has risen sharply in 2022 compared with 2018.

E-cigarette use increases with age among boys

In 2018, the prevalence of boys who had used an e-cigarette in the 30 days preceding the survey was highest among the older age groups (17-18 years old). Among girls, it was the 15-16 year-olds who used them most during this period.

More adolescents in the French Community use e-cigarettes than in the Flemish Community

Overall, 4.9% of girls and 9.9% of boys had used an e-cigarette in the 30 days preceding the survey. Girls and boys in the French Community used e-cigarettes more than those in the Flemish Community. 

Adolescents in general education are the least likely to use e-cigarettes

When it comes to e-cigarette use by educational track, adolescents in general education reported the least use (5,8%). Adolescents in vocational education used e-cigarettes the most (13%), followed by those in technical education (11%). Regional disparities were seen especially in technical and general education, where adolescents from the Flemish Community used e-cigarettes less than those from the French Community.

6. Read more

View the metadata for this indicator

HISIA: Interactive Analysis of the Belgian Health Interview Survey

HBSC Fédération Wallonie-Bruxelles

HBSC Vlaanderen

Background

Tobacco use is one of the most important health-related risk factor and leads to high numbers of avoidable deaths and diseases. It is the major cause of lung cancer, is involved in the development of other kinds of cancer, and increases the risk of cardiovascular, respiratory, and other diseases. Smoking habits started at a young age are more difficult to quit and lead to more years exposed to tobacco. Exposure to nicotine in children and adolescents can have long-lasting, damaging effects on brain development. Young people who smoke are also at risk of asthma and impaired lung function and growth, and their physical fitness in terms of both performance and endurance is also reduced because of smoking [7]. Reducing tobacco use is a priority target for health policy. The 'Interfederal Strategy 2022-2028 for a tobacco-free generation' launched in 2022 targets young people in particular, and has set itself the following objectives: 1) to reduce the number of daily tobacco users in the 15-24 age group to 6% by 2028 and 2) reduce the number of people starting to use tobacco products to (almost) 0% by 2040 [8].

In this report, we first present the evolution of the smoking behaviour: occasional, daily, and heavy smoking for adults. We then put the focus on daily smokers (adults and adolescents), since this has internationally been selected as a key health indicator (OECD, Sustainable Development Goals).

Electronic cigarettes were first developed as a mean to quit smoking tobacco. Nowadays, the range of products has broadened, e-cigarette has gained in popularity, and adolescents more often start using electronic cigarettes before smoking tobacco. For many, e-cigarette use is a precursor to tobacco use. It is still too early to assess the long term health effects of this practice, but it is advised that non-smokers do not start vaping. Several questions have been integrated for the first time in Belgian Health Interview Survey 2018 to estimate the prevalence of users and their profiles. In this report, we focus on the indicator 'regular use of e-cigarette', i.e. the use of an e-cigarette at least once a week for adults and on the indicator ‘ used electronic cigarette in the past 30 days’ for adolescents.

Definitions

Age-standardized prevalence

Since smoking behaviors are strongly influenced by age, comparisons among regions and educational levels need to be standardized by age to have a similar age structure.

Current smokers

Current smokers are people who currently smoke, including daily and occasional smokers.

Electronic cigarette (e-cigarette)

An electronic cigarette (e-cigarette), or similar devices like e-pipe/e-cigar/e-chicha, are small electronic devices that allow simulating the act of smoking but do not burn tobacco and produce vapor from liquids instead. They can contain nicotine or not. A similar definition was used in the Health Interview Survey 2018 and in the Eurobarometer 458.

EU-15

The EU-15 corresponds to all countries that belonged to the European Union between 1995 and 2004: Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, the Netherlands, Portugal, Spain, Sweden and the United Kingdom. We compare the Belgian health status to that of the EU-15 because these countries have similar socioeconomic conditions.

Heavy smokers

Heavy smokers are people who smoke 20 or more cigarettes per day.

Prevalence of daily smoking

The prevalence of daily smoking is the percentage of the population that smokes every day.

References

1. Health Interview Survey, Sciensano, 1997-2018. https://www.sciensano.be/fr/projets/enquete-de-sante
2. OECD Health Data, 2019 ou année la plus proche. http://stats.oecd.org/
3. Baromètre européen 458: Attitudes des Européens envers le tabac et les cigarettes électroniques, 2017. https://data.europa.eu/euodp/en/data/dataset/S2146_87_1_458_ENG
4. HBSC Fédération Wallonie-Bruxelles, ULB, 2018. http://sipes.ulb.ac.be/
5. HBSC Vlaanderen, UGent, 2018. https://www.jongeren-en-gezondheid.ugent.be/ 
6. Spotlight on adolescent health and well-being. Findings from the 2017/2018 Health Behaviour in School-aged Children (HBSC) survey in Europe and Canada. International report. Volume 2. Key data, WHO Regional Office for Europe, 2020. https://www.who.int/europe/health-topics
7. Smoking still a core challenge for child and adolescent health reveals WHO report, 2020. https://www.who.int/europe/news/item/05-06-2020-smoking-still-a-core-challenge-for-child-and-adolescent-health-reveals-who-report
8.  Plan de lutte contre le tabagisme, ministère fédéral belge de la santé, 2022. https://organesdeconcertation.sante.belgique.be/sites/default/files/documents/20220323_strategie_interfederale_tabac_note_de_base_fr.pdf

Please cite this page as: Sciensano. Determinants of Health: Tobacco use, Health Status Report, 29 September 2023, Brussels, Belgium, https://www.healthybelgium.be/en/health-status/determinants-of-health/tobacco-use 

Last Updated: 03 July 2024

1. Key messages

2. Background

Excessive alcohol consumption leads to a considerable health burden: it is associated with mental disorders, liver cirrhosis, cancer, cardiovascular disease, as well as trauma, and is a leading cause of premature death. Alcohol consumption in European countries is largely above the world average. Reducing excessive alcohol consumption through appropriate strategies is a priority for public health.

At the international level, estimations of alcohol consumption are often based on sales data. While those average estimates are useful to assess long-term population trends, they do not allow identifying harmful drinking patterns. Survey-based data are more appropriate to describe problematic alcohol consumption, although self-reported consumption is subject to under-reporting and social desirability bias.

In this report, we describe three survey-based indicators of excessive alcohol consumption and one indicator based on sales:

1. Hazardous alcohol consumption: weekly consumption exceeding 21 drinks containing the equivalent of 10 g of pure alcohol in men and 14 drinks in women;
2. Weekly Risky Single Occasion Drinking (WRSOD): consumption of 6 drinks or more in a single occasion, at least once a week;
3. Past year problematic alcohol consumption: people experiencing problematic drinking in the last 12 months defined by the CAGE instrument;
4. Average alcohol consumption per capita: estimations by the World Health Organization, used here for international comparisons.

3. Hazardous drinking

Situation in 2018

Belgium

In 2018, in the whole population aged 15 years and over, the proportion of hazardous drinkers (more than 21 and 14 drinks per week respectively in men and women) was 5.9%. Twice as many men than women are considered to be hazardous drinkers. As the threshold for defining hazardous alcohol consumption in women is lower than in men, those results indicate a much lower consumption in women.

The highest prevalence is observed in the age group 55-64 and the lowest in the age group 75+.

Regional differences

In 2018, the highest rate was observed in Brussels both for men and women, while the prevalence was lower in Flanders.

Trends

At Belgian level, the prevalence of hazardous alcohol consumption continues to decline. A decrease of 12% in men and 8% in women was observed between 2013 and 2018.

Regional specificities

In men, the prevalence was the highest in Wallonia between 2004 and 2013, and the lowest in Brussels between 2004 and 2013. Since 2004 a continuous decrease of the prevalence in men was observed in Flanders and Wallonia, while in Brussels the decrease stopped in 2008 then markedly increased between 2013 and 2018, resulting in the highest prevalence of the three regions in 2018.

In women, the prevalence has been highest in Brussels in all HIS waves. A slight decrease was observed in Flanders, starting in 2001, with no clear trends in the other regions.

Socio-economic disparities

There is no clear socio-economic gradient in the prevalence of hazardous drinking.

4. Weekly risky single occasion drinking

Situation in 2018

Belgium

The prevalence of weekly risky single occasion drinking (WRSOD) was 7.6% in Belgium in 2018. It was much more frequent in men (11.5%) than in women (3.9%). The age group 15-24 had the highest prevalence of WRSOD (10.4%) followed by the 55-64 (9.2%) and the 25-34 (9%).

Regional differences

In 2018, a slightly higher percentage of risky single occasion drinkers was observed in Flanders for men, in Brussels for women, but those differences were not statistically significant.

Trends

At Belgian level, after age-adjustment, the prevalence of WRSOD decreased in men (-18%) and remained stable in women between 2013 and 2018.

Regional differences

In men, while the prevalence was significantly higher in Flanders in 2008, the difference between regions has narrowed and is no more significant. Between 2013 and 2018, a declining trend is observed in all three regions.

In women, in Flanders and Wallonia, the percentages remain stable around 4%; while Brussels witnesses a decrease but had still a higher prevalence than the other regions.

Socio-economic disparities

There is no clear socio-economic gradient in the prevalence of weekly risky single occasion drinking.

International comparison

The prevalence of weekly risky single occasion drinking is higher in Belgium than the EU-15 average, for both men (11,5% vs 8,4%) and women (3.9% vs 2.6%).

5. Problematic alcohol consumption

Belgium

Problematic alcohol use is defined based on answers to a specific 4-item questionnaire (CAGE) and is predictive of alcohol dependence. The prevalence of problematic alcohol consumption in the last 12 months was 7% in Belgium in 2018. It was higher in men (9.5%) than in women (4.7%). The prevalence of problematic alcohol consumption was the highest in the younger age group (9.8%) followed by the age group 25-44 and 45-54 (8.8%). The prevalence was similar in men and women in the age group 55-64.

Regional differences

The prevalence of problematic alcohol consumption in the past 12 months was the highest in Wallonia for men and in Brussels for women.

6. Total alcohol consumption per capita

According to the WHO estimations for 2019, the total consumption in Belgium was 10.8 liters of pure alcohol per capita (15+), which was lower than the EU-15 average (11.1 liters). The World Health Organization (WHO) European Region has the highest level (9.5 l) of alcohol consumption in the world (5.8 l).

7. Read more

View the metadata for this indicator

HISIA: Interactive Analysis of the Belgian Health Interview Survey

Definitions

EU-15

The EU-15 corresponds to all countries that belonged to the European Union between 1995 and 2004: Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, the Netherlands, Portugal, Spain, Sweden, and the United Kingdom. We compare the Belgian health status to that of the EU-15 rather than the one of EU-28 because this historical construction has more socio-economic similarity than EU28.

Hazardous alcohol consumption

Hazardous alcohol consumption, or alcohol overconsumption is defined as a consumption of pure alcohol exceeding 30 g for men and 20 g for women daily; it is equivalent to 21 and 14 standard drinks (of 10 g pure alcohol content) per week respectively.

Weekly risky single occasion drinking (WRSOD)

Weekly risky single occasion drinking is defined as consumption of at least 6 standard drinks (of 10 g pure alcohol content) on the same occasion, at least once a week.

Problematic alcohol consumption

Problematic alcohol consumption is defined as 2 positive answers out of the 4 questions of the CAGE instrument and is predictive of alcohol dependence.

CAGE instrument

The CAGE instrument is a widely used screening test for problem drinking and potential alcohol problems. The questionnaire contains four ‘yes-no’ questions and two positive answers are considered as a warning signal for potential problematic use of alcohol:
1. Have you ever felt the need to cut down on your drinking?
2. Have you ever been criticized concerning your drinking?
3. Have you ever felt guilty about drinking?
4. Have you ever felt the need to take a drink first thing in the morning (eye-opener) to steady your nerves or to get rid of a hangover?

Total alcohol consumption per capita

The total alcohol per capita consumption is the recorded 3-years average and the unrecorded alcohol consumption per capita in the population aged 15 and over, expressed in liters of pure alcohol a year. Recorded alcohol consumption refers to official statistics (production, import, export, and sales or taxation data. Unrecorded consumption refers to alcohol which is not taxed and is outside the usual system of governmental control. This can be estimated thanks to specific survey questions. https://www.who.int/data/gho/indicator-metadata-registry/imr-details/465

References

1. Health Interview Survey, Sciensano, 1997-2018. https://www.sciensano.be/en/projects/health-interview-survey
2. Eurostat. http://ec.europa.eu/eurostat/fr/data/database
3. World Health Organization, GISAH, 2019. http://apps.who.int/gho/data/node.gisah.A1036?lang=en&showonly=GISAH

Please cite this page as: Sciensano. Determinants of Health: Alcohol use, Health Status Report, 25 June 2020, Brussels, Belgium, https://www.healthybelgium.be/en/health-status/determinants-of-health/alcohol-use 

Last Updated: 03 July 2024

1. Key messages

2. Background

Overweight and obesity are defined as an excessive accumulation of body fat, which favors the development of chronic diseases (diabetes type 2, cardiovascular diseases, cancers). The body mass index (BMI), calculated as the weight divided by the square of the height, is a simple tool allowing to classify the weight status into broad categories: underweight, normal weight, overweight, and obesity. In adults, obesity is defined as having a BMI ≥ 30. A person is considered overweight if they have a BMI ≥ 25, a definition including overweight-non obese as well as obese people. It is to be noted that the same term (overweight) is sometimes used to designate overweight-non obese people (BMI between 25 and 29.9). To avoid any confusion, in this report, it will be always specified if overweight percentages include obesity or not. In children and adolescents, the cut-offs of the BMI categories are age and sex-specific, the cut-offs recommended by the International Obesity Task Force (IOTF) [1] are used.

The BMI categories can be assessed either from self-reported information about weight and height, such as that collected in the Health Interview Survey (HIS) [2] and the Health Behavior in School-aged Children survey (HBSC) [3,4], or from measured information such as that collected by the Health Examination Survey (HES) [5] and the Food Consumption Survey (FCS). The HES is a subsample of the HIS; for 1184 participants in the HIS a second visit was realized by a nurse who performed physical measurements and collected biological samples. Self-reported data usually lead to some underestimation of the true overweight/obesity prevalence. People are not exactly aware of their exact height and weight and tend to overestimate their height and underestimate their weight.

We first present results for the adult (18+) population. The prevalence of self-reported overweight and obesity are based on the HIS 1997 to 2018 data, and that of measured weight status on the HES 2018. Results for adolescents are based on the HBSC surveys conducted in the Flemish and the French Community. We computed a Belgian average based on the results by community. For socio-economic disparities and international comparisons, data are used from the most recent international reports published by the World Health Organization.

More information about the cost of overweight and obesity can be found in a dedicated factsheet.

More information about the projected prevalence of overweight and obesity in the future can be found in a dedicated factsheet.

3. Overweight and obesity in adults

Situation in 2018

Belgium

According to the HIS, based on self-reported height and weight, the prevalence of overweight (including obesity) was 49% and the prevalence of obesity was 16% in 2018. More men (55%) than women (43%) were overweight (incl. obesity), and more men (17%) were obese than women (15%) (the latter is however not significant).

According to the HES, the prevalence of overweight (including obesity) (55%) and obesity (21%) based on measured height and weight were higher than those based on self-reported data. The difference between self-reported and measured rates was higher among women.

The measured prevalence of overweight (incl. obesity) was higher among men (59%) than among women (52%), as was the case for the self-reported prevalence. The measured prevalence of obesity was higher among women (23%) than among men (20%), but this difference was not statistically significant.

The prevalence of self-reported overweight (incl. obesity) increased with age until the age group of 65-74 years where it reached a peak in both men (68%) and women (56%); it then decreased among people aged 75 and older, in both sexes. This increase starts earlier in men (25-34 years) than in women (35-44 years).

Self-reported obesity follows the same age pattern as overweight and reached its highest level in 65-74-year-olds, in both men (26%) and women (20%).

Regional differences

The prevalence of both overweight and obesity was higher in Wallonia than in the other regions in all HIS waves and in both sexes.

Trends

At the Belgian level, the prevalence of overweight (incl. obesity) has continuously increased when considering both sexes together. From 2013, the prevalence remained stable among men but continued to increase among women. The prevalence of obesity also slowly and continuously increased over all HIS waves, with a stronger increase between 2013 and 2018.

Regional differences

At regional level, the prevalence of overweight and obesity has always been higher in Wallonia than in the other regions. Among men, the trends of obesity and overweight were similar, and similar to the ones described for Belgium; among women, a stabilization of overweight and obesity was observed in Flanders.

Socio-economic differences

Overweight, and even more obesity, are associated with the educational level. The lowest educated group (61%) had a prevalence of overweight (incl. obesity) 1.5 times higher than the most educated group (41%). There were two times more people obese among the less educated (23%) compared to the most educated (12%).

International comparison

The prevalence of overweight (incl. obesity) was lower in Belgium than the EU-15 average, both in men (54.4% versus 57.6%) and in women (43.5% versus 44,8%).

4. Overweight and obesity in adolescents

Situation in 2018

In 2018, the prevalence of overweight (incl. obesity) in adolescents was around 15%, calculated as the average of the estimates in the French and Flemish HBSC 2018. It was higher among boys (15.5%) than among girls (14.5%) and tended to increase with age (the statistical significance is unknown). The lowest prevalence (around 13%) was observed among the younger girls (11-14 years) while the highest prevalence (around 16%) was observed among boys aged 15-16 years and girls aged 17-18 years.

The prevalence of obesity in adolescents was 4.0% among boys and 3.6% among girls and was relatively similar across age groups.

Trends and differences between Communities

In 2018, overweight (incl. obesity) prevalence among 15-year-old adolescents was slightly higher in the French than in the Flemish Community. This was especially pronounced among boys, with an overweight prevalence of 19% in the French Community and 13% in the Flemish Community (the statistical significance is unknown). Overweight prevalence among girls was more similar in both Communities.

The overweight prevalence increased between 2006 and 2014 in each Community and for both sexes. Between 2014 and 2018, among boys, the prevalence decreased in the Flemish Community while it continued to increase in the French Community. Among girls, the overweight prevalence increased in a same way in both Communities.

Trends in obesity prevalence are not available at the moment.

Socio-economic differences

According to the HBSC report, being overweight (incl.obesity) is associated with low family affluence for both sexes. In the Flemish Community, boys and girls from the lowest socio-economic group were 1.8 more likely to be overweight than boys and girls from the higher socio-economic group. In the French Community, boys and girls from the lowest socio-economic group were respectively 2 times and 3 times more likely to be overweight than boys and girls from the higher socio-economic group. Low- and high-affluence groups represent the lowest 20% and the highest 20% in each Community.

International comparison

Based on the results for 2018, Belgium ranks quite favorably among the EU-15 countries with an overweight prevalence of 16.1% compared to 20.7% for the EU-15 average among boys. The prevalence of overweight is similar to the EU-15 average among girls (14.3% in Belgium, 14.5% for EU-15).

5. Read more

View the metadata for this indicator

HISIA: Interactive Analysis of the Belgian Health Interview Survey

Health-Behaviour in School-aged Children (HBSC) survey - French Community

Health-Behaviour in School-aged Children (HBSC) survey - Flemish Community

Definitions

Body mass index (BMI)

The body mass index (BMI) is a measure of a person’s weight relative to their height that is reasonably well related to body fat. It is calculated as a person’s weight (in kilograms) divided by the square of his/her height (in meters).

BMI categories

In adults:
• Underweight: is defined as a BMI lower than 18.5.
• Normal weight: is defined as a BMI range of 18.5-24.9.
• Overweight: is defined as a BMI between 25.0 and 29.9. We often referred to overweight including obesity i.e. with a BMI ≥ 25.
• Obesity: is defined as a BMI ≥ 30.
In children and adolescents, the cut-off points to define BMI categories are age and sex-specific.

EU-15

The EU-15 corresponds to all countries that belonged to the European Union between 1995 and 2004: Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, the Netherlands, Portugal, Spain, Sweden, and the United Kingdom. We compare the Belgian health status to that of the EU-15 because these countries have a similar socio-economic situation.

References

1. International Obesity Task Force. https://www.worldobesity.org/about/about-obesity/obesity-classification
2. Health Interview Survey, Sciensano, 2018.  https://www.sciensano.be/en/projects/health-interview-survey
3. HBSC French Community, ULB, 2018. http://sipes.ulb.ac.be/
4. HBSC Flemish Community, UGent, 2018. http://www.jongeren-en-gezondheid.ugent.be/
5. Health Examination Survey, Sciensano, 2018.https://www.sciensano.be/en/projects/health-examination-survey
6. Eurostat. http://ec.europa.eu/eurostat/fr/data/database
7. Inchley J et al. eds. Growing up unequal: gender and socioeconomic differences in young people's health and well-being. Health Behaviour in School-aged Children (HBSC) study: international report from the 2013/2014 survey. Copenhagen, WHO Regional Office for Europe, 2016 (Health Policy for Children and Adolescents, No. 7). http://www.euro.who.int/__data/assets/pdf_file/0003/303438/HSBC-No.7-Growing-up-unequal-Full-Report.pdf?ua=1
8. Currie C et al. eds. Social determinants of health and well-being among young people. Health Behaviour in School-aged Children (HBSC) study: international report from the 2009/2010 survey. Copenhagen, WHO Regional Office for Europe, 2012 (Health Policy for Children and Adolescents, No. 6). http://www.euro.who.int/__data/assets/pdf_file/0003/163857/Social-determinants-of-health-and-well-being-among-young-people.pdf?ua=1
9. Currie C, Nic Gabhainn S, Godeau E, Roberts C, Smith R, Currie D, Pickett W, Richter M, Morgan A & Barnekow V (eds.) (2008). Inequalities in young people's health: HBSC international report from the 2005/06 Survey. Health Policy for Children and Adolescents, No. 5, WHO Regional Office for Europe, Copenhagen, Denmark. http://www.euro.who.int/__data/assets/pdf_file/0005/53852/E91416.pdf?ua=1
10. Inchley J, Currie D, Budisavljevic S, Torsheim T, Jastad A, Cosma A. Spotlight on adolescent health and well-being. Findings from the 2017/2018 Health Behaviour in School-aged Children (HBSC) survey in Europe and Canada. International report. Volume 2. Key data [Internet]. Copenhagen: WHO Regional Office for Europe; 2020 [cited 2020 Jun 15]. Available from: https://www.euro.who.int/en/health-topics/Life-stages/child-and-adolescent-health/health-behaviour-in-school-aged-children-hbsc/publications/2020/spotlight-on-adolescent-health-and-well-being.-findings-from-the-20172018-health-behaviour-in-school-aged-children-hbsc-survey-in-europe-and-canada.-international-report.-volume-2.-key-data
11. OECD Health at a Glance 2020. https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-europe-2020_82129230-en

Please cite this page as: Sciensano. Determinants of Health: Weight status, Health Status Report, 01 July 2020, Brussels, Belgium, https://www.healthybelgium.be/en/health-status/determinants-of-health/weight-status 

Last Updated: 03 July 2024

1. Key messages

2. Background

Lack of physical activity is one of the leading risk factors in terms of both morbidity and mortality for a series of chronic conditions, including cardiovascular diseases, cancer, and diabetes. Moreover, regular physical activity, when reaching a certain threshold, can have significant benefits for health. The World Health Organization (WHO) [1] recommends that adults aged 18-64 perform at least 150 minutes of moderate-intensity physical activity throughout the week. They further recommend that children and teenagers aged 5-17 perform at least 60 minutes of moderate- to vigorous-intensity physical activity per day.

To date there is no consensus on the method for estimating levels of physical activity based on self-reported surveys: the use of different instruments and cut-off points for classifying the levels of activity make international comparisons difficult. In the 2001 to 2013 waves of the Belgian Health Interview Survey (HIS), physical activity was measured with the short version of the International Physical Activity Questionnaire (IPAQ). Since 2018, the EHIS-PAQ questionnaire is used as recommended by the European Health Interview Survey (EHIS) whereby time trend analysis is no longer possible, but international comparability is enhanced.

In this report, we evaluate physical activity among adults based on the share of adults meeting the WHO recommendations to do at least 150 minutes of at least moderate-intensity aerobic physical activity throughout the week, based on the self-reported data from the Belgian Health Interview Survey (HIS).

Physical activity among adolescents is evaluated based on the share of adolescents aged 11-18 who meet the WHO recommendations to perform at least 60 minutes of moderate- to vigorous-intensity physical activity per day, based on self-reported data from the Health Behavior in School-aged Children (HBSC) survey.

3. Physical activity in adults

Situation in 2018

Belgium

In Belgium in 2018, 30% of the population aged 18 years and over did at least 150 minutes of at least moderate aerobic physical activity per week. More men (36%) than women (25%) met the recommendations. The prevalence was the highest in the youngest age group (47%) and the lowest in the highest age group (12%).

Regional differences

More people were meeting the physical activity recommendations in Flanders (43% in men and 34% in women) than in Brussels (29% and 18%, respectively) and Wallonia (27% and 15%, respectively).

Socio-economic disparities

After age standardization, people with tertiary education were more likely to meet the recommendations (38%) than people with an upper secondary education (26%), a lower secondary education (22%), and primary education (12%).

4. Physical activity in adolescents

Situation in 2018

Belgium

In Belgium in 2018, more boys (20%) than girls (13%) between 11 and 18 yearsold met the WHO recommendations to perform at least 60 minutes of moderate- to vigorous-intensity physical activity per day. A decrease is observed with ageing, with young adolescents (aged 11-12 years old) more likely to be sufficiently physically active than older adolescents.

Regional differences

More adolescents in the Flemish Community (21% of boys and 14% of girls) met the WHO recommendations than in the French Community (18% of boys and 11% of girls).

Trends

In the Flemish Community, the proportion of boys meeting the WHO recommendations increased between 2014 and 2018, while in the French Community, it decreased. These opposite evolutions led to a stable Belgian average.

In the Flemish Community, the proportion of girls meeting the WHO recommendations increased between 2014 and 2018, while in the French Community, it remained stable. Both evolutions combined led to an increasing Belgian average.

Socio-economic disparities

According to the HBSC report, spending at least 60 minutes a day on physical activity was generally associated with high family affluence. In the Flemish Community, boys and girls from the highest socio-economic group were respectively 2 times and 1.7 times more likely to meet the recommendations than boys and girls from the lowest socio-economic group. In the French Community, a socio-economic (SE) gradient was only observed in girls, with girls from the higher socio-economic group being 1.6 times more likely to meet the recommendations than girls from the lowest socio-economic group.

Some regional differences were also observed by SE group: boys from the low family affluence group were 1.5 times more likely to meet the recommendation in the French community than in the Flemish Community, while on the contrary, boys from high family affluence were 1.3 times more likely to meet the recommendation in the Flemish than in the French community. Among girls, a same low versus high gradient was observed in both communities.

International comparison

The HBSC international report 2018 reveals that for all countries considered, the proportion of young people meeting the physical activity recommendation is quite weak, ranging from 7% to 24% in boys, and from 4% to 14% in girls. Keeping in mind the fact that the situation is worrying everywhere, Belgium ranks not too bad among the EU-15 countries. With 18.0% of 15-year-olds Belgian boys (ranking 6th) and 10.5% of the Belgian girls (ranking 4th) meeting the recommendations, Belgium compares favorably to the respective 16.1% male and 8.3% female EU-15 average.

5. Read more

View the metadata for this indicator

HISIA: Interactive Analysis of the Belgian Health Interview Survey

Health-Behaviour in School-aged Children (HBSC) survey - French Community

Health-Behaviour in School-aged Children (HBSC) survey - Flemish Community

Definitions

Age-adjusted proportion

Since lifestyle factors are strongly influenced by age, comparisons among regions and educational levels need to be standardized by age to have a similar age structure. 

EHIS-PAQ questionnaire 

The EHIS-PAQ is a domain-specific physical activity questionnaire compounded of eight questions. It takes into account physical activity related to work, going from and to places, and sport. The EHIS-PAQ was tested in different regions and cultural settings in Europe. It allows estimating the health-enhancing physical activity recommendation defined by the WHO.

Performing at least 150 minutes of at least moderate aerobic physical activity throughout the week

To calculate this indicator in the HIS, three questions were asked to the participants to assess the time they spend bicycling to get to and from places and the time they spend on sport leisure activities.

Performing at least 60 minutes of moderate- to vigorous-intensity physical activity per day

To calculate this indicator in the HBSC, the participants were asked how many days over the past week they had been physically active for a total of at least 60 minutes.

References

1. Global recommendations on physical activity for health. Genève: WHO; 2010. https://www.who.int/dietphysicalactivity/global-PA-recs-2010.pdf
2. Health Interview Survey, Sciensano, 2001-2018. https://www.sciensano.be/en/projects/health-interview-survey
3. HBSC French Community, ULB, 2018. http://sipes.ulb.ac.be/
4. HBSC Flemish Community, UGent, 2018. http://www.jongeren-en-gezondheid.ugent.be/
5. Spotlight on adolescent health and well-being. Findings from the 2017/2018 Health Behaviour in School-aged Children (HBSC) survey in Europe and Canada. International report., WHO Regional Office for Europe, 2020. https://www.euro.who.int/en/health-topics/Life-stages/child-and-adolescent-health/health-behaviour-in-school-aged-children-hbsc/publications/2020/spotlight-on-adolescent-health-and-well-being.-findings-from-the-20172018-health-behaviour-in-school-aged-children-hbsc-survey-in-europe-and-canada.-international-report.-volume-2.-key-data

Please cite this page as: Sciensano. Determinants of Health: Physical activity, Health Status Report, 30 July 2021, Brussels, Belgium, https://www.healthybelgium.be/en/health-status/determinants-of-health/physical-activity 

Last Updated: 03 July 2024

1. Key messages

2. Background

Dietary quality is an important factor in health and disease burden. A healthy diet helps protect against non-communicable diseases (NCDs) including diabetes, cancer, heart disease and stroke [1]. Recommendations for each food groups have been established at international [2] and national [3,4] levels.

In Belgium, information on dietary consumption patterns are available from two national Food Consumption Surveys (FCS), conducted in 2004 and 2014 [5–7]. More data about the nutritional habits are available from the Belgian Health Interview Survey (HIS) in 2001, 2004, 2013, 2018 [8]. Data from the FCS are obtained from 24h dietary recalls, while the HIS uses self-reported usual food habits questions, which are more prone to biases linked to recollection and adequate estimation of quantities.

In this report, we present consumption patterns from the FCS and two additional indicators from the HIS:

• The consumption patterns for 9 food groups (vegetables, nuts and seeds, milk, fruits, eggs, fish, red meats, sugar sweetened beverages, processed meats) are compared against international recommendations in 2004 and 2014 [2].
• The proportion of the population aged 6 years and over that consumes the daily recommended amount of fruits and vegetables (at least 5 portions). Fruit and vegetables are low-energy density foods and are important sources of dietary fibre, vitamins and minerals. A high consumption of fruit and vegetables has been significantly associated with a decrease in the risk of coronary heart disease, stroke and obesity [9]. The WHO recommends a daily consumption of 400 grams of fruit and vegetables (i.e. 5 portions) [10].
• The proportion of the population that drinks sugary drinks (no "diet") daily and those that drink at least 1 litre of sugary drinks (no "diet") daily. A high intake of free sugars, particularly in the form of sugar-sweetened beverages, is associated with poor dietary habits, unhealthy weight gains, risk of dental carries and other NCDs [1,9]. The WHO strongly recommends restricting the intake of free sugars to less than 10% of the total energy consumption, throughout the life course [11]. With respect to this guideline the consumption of sugar-sweetened beverages should be avoided.

3. Overall consumption patterns

Overall, the Belgian diet is characterized by excessive consumption of red meat, processed meat and sugar sweetened beverages and by insufficient consumption of fruits, vegetables, nuts and seeds, milk, eggs and fish. Overall, these patterns have only slightly improved between 2004 and 2014. For red meat consumption, however, an improvement was observed, with the proportion of excessive consumptions dropping from 59% to 36%.

4. Consumption of fruits and vegetables

Situation in 2018

Belgium

In 2018, 12.7% of the population aged 6 years and over consumed the daily recommended amount of fruit and vegetables (at least 5 portions). More women (15.6%) than men (9.8%) consumed the recommended amount. Children and young adults were less likely to meet the recommendations than middle-aged and older adults.

Regional differences

In men as in women, after age standardization, more people were meeting the recommendations on daily fruit and vegetable consumption in Brussels (13.3% in men and 19.2% in women) and Wallonia (12.5% and 18.0%) than in Flanders (8.7% and 14.7%).

Socio-economic disparities

The socio-economic position has a strong influence on the probability of meeting the recommendations concerning the consumption of fruits and vegetables (at least 5 portions). People with a tertiary education (18.0%) were 2.9 times more likely to meet the recommendations than those from the lowest education group (6.3%). People with a secondary education (9.2% to 9.9.%) were also nearly twice less likely to meet the recommendations than people with a tertiary education.

International comparison

The consumption of at least 5 portions of fruits and vegetables daily was lower in Belgium compared to the EU-15 average in 2019, for both men (11.8% vs 13.6%) and women (18.2% vs 19.9%).

5. Consumption of sugary drinks

Situation in 2018

Belgium

In 2018, 20.4% of the population drank sugary drinks on a daily basis; 4.1% of the population even drank at least 1 litre or more per day. More men (24.9%) than women (16%) drank sugary drinks daily. The prevalence of daily consumption was higher amongst those aged 15-24 and 25-34 (29.2% and 28.6%, respectively) and decreased in older age groups.

Regional differences

The prevalence of the population that consumes sugary drinks daily is 16.3% in Brussels, 20.1% in Flanders, and 22.9% in Wallonia.

Trends

Belgium

There were less people drinking sugary drinks in 2018 (20.4%) than in 2013 (25.5%). This trends was observed both in men (decreasing from 30.2% in 2013 to 24.9% in 2018) and women (from 21.1% to 16%).

Regional differences

After adjustment for age, the same decreasing trend was observed in the three regions.

Socio-economic disparities

Based on age-adjusted prevalence, people with a tertiary education were less likely to consume sugary drinks daily compared to people with a lower educational level.

6. Read more

View the metadata for this indicator

FCS: Food consumption survey

HISIA: Interactive Analysis of the Belgian Health Interview Survey

Definitions

Age-adjusted prevalence

Since lifestyle factors are strongly influenced by age, comparisons among regions and educational levels need to be standardized by age to have a similar age structure.

References

1. Amine EK, Baba NH, Belhadj M, Deurenberg-Yap M, Djazayery A, Forrestre T, et al. Diet, nutrition and the prevention of chronic diseases. World Health Organization; 2003.
2. GBD 2017 Risk Factor Collaborators. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018.
3. Vanhauwaert E. De actieve voedingsdriehoek: een praktische voedings- en beweeggids. Brussel; 2012.
4. Lebacq T, Oost C. Recommandations alimentaires. In: Tafforeau J, editor. 2016.
5. De Ridder K, Bel S, Brocatus L, Lebacq T, Ost C, Teppers E. La consommation alimentaire. Résumé des principaux résultats. In: Teppers E, Tafforeau J, editors. Bruxelles: WIV-ISP; 2016.
6. Debacker N, Cox B, Temme L, Huybrechts I, Van Oyen H. De Belgische voedselconsumptiepeiling 2004: voedingsgewoonten van de Belgische bevolking ouder dan 15 jaar. Wetenschappelijk Instituut Volksgezondheid; 2007.
7. Sciensano. Website of the Belgian National Food Consumption survey 2014. https://fcs.wiv-isp.be/SitePages/Home.aspx.
8. Drieskens S, Charafeddine R, Gisle L. Enquête de santé 2018: Habitudes nutritionnelles [Internet]. Bruxelles, Belgique: Sciensano. Available from: https://www.sciensano.be/en/projects/health-interview-survey
9. EFSA Panel on Dietetic Products, Nutrition, and Allergies (NDA). Scientific opinion on principles for deriving and applying dietary reference values. 2010.
10. World Health Organization. Diet, nutrition, and the prevention of chronic diseases. Report of a WHO Study Group. Geneva: World Health Organization;1990.
11. World Health Organization. Guideline: sugars intake for adults and children. Geneva: World Health Organization; 2015.
12. Eurostat. http://ec.europa.eu/eurostat/fr/data/database

Please cite this page as: Sciensano. Determinants of Health: Nutritional habits, Health Status Report, 31 July 2020, Brussels, Belgium, https://www.healthybelgium.be/en/health-status/determinants-of-health/nutritional-habits