Poor air quality, caused by pollutants such as particulate matter, nitrogen dioxide and ozone, is an important contributor to disease and premature mortality.
Although air quality in Belgium is generally improving, a considerable part of the population is still exposed to concentrations exceeding the World Health Organization Air Quality Guidelines (WHO AQGs) for all of the considered pollutants.
There are important regional differences, where exposure to particulate matter is highest in Flemish Region, while exposure to nitrogen dioxide is highest in the Brussels Capital Region and exposure to ozone is highest in the Walloon Region.
Internationally, air quality in Belgium is comparably poor, ranking below the EU-14 average for most of the considered pollutants.
Particulate matter (PM) refers to all of the fine microscopic particles suspended in the air. Generally, a distinction is made between PM with a diameter smaller than 10 micrometers (PM10) and with a diameter smaller than 2.5 micrometers (PM2.5). As PM2.5 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
PM can be emitted directly, but it can also be formed indirectly from precursors through chemical reactions. According to the most recent Belgian figures (2019), the most important direct source of PM2.5 is heating by households, where the use of wood disproportionally contributes to emissions. Other major sources of direct PM emissions are transport, where road traffic is most important, and heavy industry. The most important precursors of indirect PM are ammonia, nitrogen oxides, and sulphur dioxide. Ammonia is primarily emitted by the agricultural sector, especially by livestock. Sulphur dioxide, itself an air pollutant, originates mostly from heavy industry .
Exposure to particulate matter can lead to cardiovascular and respiratory diseases and lung cancer
The World Health Organization (WHO) guidelines recommend a maximum exposure of 5 µg m-3 mean concentration annually and 15 µg m-3 daily average for PM2.5, and 15 µg m-3 annually and 45 µg m-3 daily for PM10. The health effects of acute exposure to particulate matter include increased mortality due to cardiovascular and respiratory diseases and strokes , and for PM2.5 increased asthma attacks . Chronic exposure to PM is associated with ischemic heart disease, respiratory diseases, and lung cancer .
Particulate matter concentrations are higher in the Flemish Region compared to the Walloon Region
To detect spatial patterns in the occurrence of air pollutants, concentration levels can be mapped across the Belgian territory. The maps below visualise the 2020 yearly average PM2.5 and PM10 concentrations for each statistical sector, the smallest administrative unit in Belgium. The values are shown relative to the AQG for the pollutant, as an indication of the sector inhabitant’s exposure as compared to the WHO-advised value.
A clear north-south gradient is visible on the map of the AQG-relative concentration for PM2.5 in Belgium. Concentrations are generally high in the north of the Flemish Region, intermediate in central Belgium, including the Brussels Capital Region, and low in the Walloon Region, especially in the Ardennes. The same pattern appears for PM10, with the difference that relative pollution levels are generally lower compared to PM2.5. A possible explanation for this variation is that Flanders, being the more densely-populated region, has more PM sources (residential heating, transport, agriculture including intensive livestock) and fewer sinks (removal by vegetation) compared to Wallonia. While about half of the country has pollution levels above the annual WHO guideline value for PM10, more than two-thirds of the area has levels above the AGQ for PM2.5.
Relative concentration of PM2.5 per statistical sector in Belgium, 2020 Source: Own calculations based on air pollution data provided by IRCEL-CELINE 
Relative concentration of PM10 per statistical sector in Belgium, 2020 Source: Own calculations based on air pollution data provided by IRCEL-CELINE 
Population exposure to particulate matter is high but decreasing in Belgium
The Belgian regions can be compared in terms of exposure to PM2.5 and PM10, using the population-weighted concentration. This metric expresses the average pollutant concentration taking into account where people live, and as such is used as a measure for exposure. When considering the most recent figures for the year 2020, a similar pattern for both types of PM emerges: the exposure in the Brussels Region is comparable to the Belgian average, and exposure is substantially higher in the Flemish Region and lower in the Walloon Region. Two-thirds of the Belgian population is exposed to pollution levels exceeding the long-term WHO guideline value for PM10, and more than 90% of the people are exposed to levels above the AGQ for PM2.5.
The time series of the population-weighted concentration give an indication of whether exposure to PM2.5 and PM10 in the Belgian population is generally increasing or decreasing. The trends for both PM types are alike, and similar for all regions. Population-weighted concentrations peak in 2018, and then decrease to a minimum in 2020. The fall in concentration is less pronounced for Flanders compared to the other regions, and its value is – with one exception for PM2.5 – the highest compared to the rest of the country. Exposure in Brussels in 2017 was higher than average, with a decrease that puts it close to average by 2020. Exposure to PM is by far lower in the Walloon region.
The overall decrease in exposure is mainly the result of an overall reduction in PM concentrations (not shown). Based on the trends visible in the graphs for PM2.5 and PM10, air quality in Belgium is improving since 2017. This finding is consistent with the most recent air quality report published by IRCEL-CELINE (Belgian Interregional Environment Agency) which started measuring in 1997 and shows a decreasing trend in both PM concentrations and exposure .
Exposure to PM2.5, by region, 2017-2020 Source: Own calculations based on air pollution data provided by IRCEL-CELINE , and population data provided by Statbel .
Exposure to PM10, by region, 2017-2020 Source: Own calculations based on air pollution data provided by IRCEL-CELINE , and population data provided by Statbel .
Belgium has the fourth highest exposure to particulate matter compared to similar EU countries
Internationally, Belgium has the fourth highest population-weighted concentration for both PM2.5 and PM10, compared to the other EU-14 countries, well above the European average concentration .
PM2.5 population-weighted average concentration (µg m-3), 2019 Source: Own calculations based on air pollution exposure data provided by the European Environment Agency .
PM10 population-weighted average concentration (µg m-3), 2019 Source: Own calculations based on air pollution exposure data provided by the European Environment Agency .
Nitrogen oxides (NOx) including nitrogen dioxide (NO2) and nitrogen monoxide (NO) are formed and emitted together as a result of combustion, as occurs in car engines and power plants. NO is a colourless gas that is harmless at the concentrations present in the atmosphere, while ambient NO2 constitutes a serious health hazard.
Road traffic is by far the leading source of nitrogen dioxide emissions
Transport is the leading source of NOx emissions, where road traffic is by far the most important contributor, followed by shipping (both maritime and inland) and air traffic . The 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 with tall adjacent buildings . Other, less significant sources are industry and agriculture.
Exposure to nitrogen dioxide can lead to chronic respiratory diseases and infections
The WHO recommends a maximum average yearly exposure to NO2 of 10 µg m-3 and 25 µg m-3 daily. Long-term exposure to NO2 has been linked to mortality due to chronic obstructive pulmonary disease and acute lower respiratory infection .
Higher nitrogen dioxide concentrations in cities compared to the countryside
Considering the pollution map for NO2, concentrations are generally higher in the Flemish Region and the north of the Walloon Region, including the Sambre and Meuse basins, as compared to the Ardennes. Road traffic being the principal source of NOx, areas that include large cities and major highways are easily recognized on the map in red. The Brussels Capital Region, a highly urbanised area, exhibits major pollution, except for the forested part in the southeast. About 40% of Belgium’s territory has pollution values above the annual WHO guideline value for NO2.
Relative concentration of NO2 per statistical sector in Belgium, 2020 Source: Own calculations based on air pollution data provided by IRCEL-CELINE 
Population exposure to nitrogen dioxide is decreasing in Belgium
Applying the same population-weighted concentration metric as above, NO2 exposure is highest in the Brussels Region, followed by Flemish Region, and much lower in the Walloon Region which has fewer urban centers. In the whole of Belgium, 20% of the population is exposed to long-term NO2 levels above the WHO’s guideline value.
For all regions, concentrations have been steadily declining. Brussels is consistently the highest, but it has also seen the most significant fall in exposure, leading to convergence with the other regions. The declining trend in population-weighted concentration is similar for the other regions, although somewhat smaller for the Walloon region.
The overall decrease in exposure is mainly the result of an overall reduction in NO2 concentrations (not shown). As with PM, these observations correspond to a finding in the most recent air quality report published by IRCEL-CELINE. Data collection starting in 1997 confirm this decreasing trend in NO2 concentrations .
Exposure to NO2, by region, 2017-2020 Source: Own calculations based on air pollution data provided by IRCEL-CELINE , and population data provided by Statbel .
Belgium has the fifth highest exposure to nitrogen dioxide compared to similar EU countries
Internationally, Belgium has the fifth highest population-weighted concentration for NO2 compared to the other EU-14 countries, well above the average European concentration .
NO2 population-weighted average concentration (µg m-3), 2019 Source: Own calculations based on air pollution exposure data provided by the European Environment Agency .
Ozone (O3) is a highly reactive gas, which makes it harmful to both humans and ecosystems. Although its presence in the stratosphere, tens of kilometers high up in the atmosphere, protects lifeforms against the most damaging solar radiation, ozone in the lower troposphere poses a serious health hazard.
There is more ozone in summer, especially on sunny days
O3 is not emitted directly but formed in the atmosphere by chemical reactions under the influence of sunlight. O3 is formed from so-called precursors, including nitrogen oxides, methane, and volatile organic compounds. As a consequence, 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. In the atmosphere, a chemical equilibrium exists between O3 and NO on the one hand, and O2 (oxygen) and NO2 on the other. The most significant consequence of this is that NO, such as emitted by road traffic, breaks down ozone to form NO2.
Ozone peaks cause respiratory problems and premature mortality
Because of its seasonal and diurnal character, the WHO guidelines for O3 are based on daily maximum 8-hour mean concentration, and only peak season values are taken into account. The daily AQG is 100 µg m-3, the annual limit is 60 µg m-3 for the 8-hour maximum values averaged over the peak ozone season. The acute effects include mortality in adults, days with mildly reduced activity, hospitalizations for respiratory problems, adult use of bronchodilators, days with cough, and lower respiratory problems in children. There is still great uncertainty concerning the effects of chronic O3 exposure. Some studies find a weak relationship between long-term exposure to O3 and all-cause and respiratory mortality .
The countryside has higher ozone concentrations compared to cities
Considering 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 the ozone formed locally by chemical reactions. The result is that urban centers and highways, confronted with busy traffic, experience lower concentrations compared to the countryside, making exposure to ozone primarily a rural problem.
Relative concentration of O3 per statistical sector in Belgium, 2020 Source: Own calculations based on air pollution data provided by IRCEL-CELINE 
Exposure to ozone has been stable over the last few years
In terms of population-weighted concentration of O3 in 2020, exposure in the Flemish Region is comparable to the Belgian average, while it is slightly higher in the Walloon Region and substantially lower in the Brussels Region. In Belgium, the entire population is exposed to O3 concentrations above the annual WHO AQG.
There is no clear trend in terms of concentrations over the last few years. However, considering the longer measurement series in IRCEL-CELINE’s air quality report, a slightly increasing trend in O3 concentrations and exposure is observable over the previous three decades . This is in contrast to the other considered air pollutants, which show a steady decline.
Exposure to O3, by region, 2017-2020 Source: Own calculations based on air pollution data provided by IRCEL-CELINE , and population data provided by Statbel .
Belgium has the sixth lowest exposure to ozone compared to similar EU countries
The European comparison of ozone exposure is not based on average concentration, as is the case for the AQGs, 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 .
SOMO35population-weighted average concentration (µg days m-3), 2019 Source: Own calculations based on air pollution exposure data provided by the European Environment Agency .
Poor air quality constitutes the single biggest environmental health risk, responsible for millions of premature deaths and healthy life years lost worldwide. Exposure to air pollution has been associated with respiratory disease, cardiovascular disorders, and lung cancer. It disproportionally affects vulnerable groups, including young children, the elderly, and people with lung diseases and asthma. Examples of ambient air pollutants include particulate matter, nitrogen dioxide, and ozone .
To improve air quality and public health, the WHO publishes the Air Quality Guidelines (AQGs), which are a set of recommended limit values for specific air pollutants. The AQGs 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 guidelines, 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 .
The air pollutants addressed in this report are particulate matter with aerodynamic diameters <2.5 µm and <10 µm (PM2.5 and PM10), nitrogen dioxide (NO2), and ozone (O3). Air quality assessment is based on pollutant data provided by IRCEL-CELINE, in the form of high-resolution maps depicting yearly average concentration for the years 2017 to 2020. The pollution maps are the result of high-resolution models, calibrated against actual measurements but still subject to a degree of uncertainty . Exposure to air pollution is approached using the population-weighted average concentration, with population data provided by Statbel .
Concentration, sources, and sinks
Air quality can be quantified by the concentration of known air pollutants. Air pollution 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 sources (direct or indirect) and sinks, which are factors or processes that emit or remove the pollutant, respectively. Emissions and removals are commonly expressed as rates, for instance as kilogram per hour or tonne per year.
Population-weighted average concentration
The population-weighted average concentration is used as an indication of population exposure to air pollution. It is used to aggregate concentration values into a larger region. Instead of calculating a simple ‘spatial average’ concentration of the area, the population at each location is taken into account as the weight for the corresponding concentration level. As it incorporates information on air quality as well as where people live, it can serve as a measure of exposure to air pollutants.
Orellano, P., Reynoso, J., Quaranta, N., Bardach, A., & Ciapponi, A. (2020). 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. https://doi.org/10.1016/j.envint.2020.105876
Orellano, P., Quaranta, N., Reynoso, J., Balbi, B., & Vasquez, J. (2017). Effect of outdoor air pollution on asthma exacerbations in children and adults: Systematic review and multilevel meta-analysis. https://doi.org/10.1371/journal.pone.0174050
One third of the population aged 15 years and over (33%) has a low level of health literacy, meaning they do not have sufficient skills to make decisions about their health.
Low levels of health literacy are more prevalent among women (35%) than men (32%), and in Brussels and Wallonia (38% and 36%, resp.) than in Flanders (29%).
People in poor health, older people, and lower educated people have a lower level of health literacy; in other words, people who have higher needs for healthcare and health promotion, are those who benefit the least from such interventions.
Attention is therefore needed to detect people with low health literacy and adapt the communication; it is however also important to improve the health literacy levels in the population.
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” . 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 . 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 . 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 .
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.
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).
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.
Prevalence of poor health literacy level among the population aged 15 years and over, by educational level, Belgium, 2018 Source: Own calculations based on Health Interview Survey, Sciensano 
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.
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. . 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 . 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.
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.
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.
Nutbeam D. Defining and measuring health literacy: what can we learn from literacy studies? Int J Public Health. 2009;54(5):303–5.
Van den Broucke S. Health literacy: a critical concept for public health. Arch Public Health. 2014;72(1):10.
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.
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.
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.
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.
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.
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.
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.
15% of the population were daily smokers in 2018 in Belgium, lower than the EU-15 average. This proportion is higher in men (18%) than in women (12%) and higher in Wallonia (18%) than in Brussels (16%) and Flanders (13%).
The prevalence of daily smoking has decreased by 40% between 1997 and 2018.
4.1% of the population were regular users of e-cigarettes in 2018 in Belgium, higher than the EU-15 average.
Socio-economic disparities are large in smoking behavior: the proportion of daily smokers and electronic cigarette users is 2.4 times smaller in the higher versus the lower educated people.
Among adolescents aged 11-18, 17% have at least tried tobacco and 3.8% are daily smokers.
Daily smoking has significantly decreased among adolescents between 2006 and 2018.
In 2018, more adolescents have tried e-cigarettes than conventional cigarettes.
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 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.
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.
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%).
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.
Prevalence of electronic cigarettes or similar electronic devices use, by country (EU-15), 2017 Source: Eurobarometer 458 
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.
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.
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.
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.
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 . 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 .
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.
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 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.
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 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.
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
European countries have the highest level of alcohol consumption in the world. The average consumption of pure alcohol in Belgium is 12 liters per capita per year, which is above the mean European consumption. This makes Belgium one of the countries with a high disease burden related to alcohol.
In 2018, 7.4% of men and 4.3% of women (15 years and over) reported a hazardous consumption of alcohol (defined as more than 21 or more than 14 drinks per week for men and women, respectively). This prevalence has decreased over time.
Around one in ten young people in the age group 15-24 years reported a weekly episode of "risky single occasion drinking" (consumption of at least 6 glasses of alcohol at a single occasion), and also one in ten young people met the criteria for "problematic alcohol consumption" (as defined by the CAGE instrument) in the past 12 months.
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:
Hazardous alcohol consumption: weekly consumption exceeding 21 drinks containing the equivalent of 10 g of pure alcohol in men and 14 drinks in women;
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+.
In 2018, the highest rate was observed in Brussels both for men and women, while the prevalence was lower in Flanders.
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.
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.
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%).
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.
At Belgian level, after age-adjustment, the prevalence of WRSOD decreased in men (-18%) and remained stable in women between 2013 and 2018.
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.
Prevalence of weekly risky single occasion drinking in men aged 15 or older by country of residence, Europe, 2019 or latest year Source: Eurostat 
Prevalence of weekly Risky Single Occasion Drinking in women aged 15 or older by country of residence, Europe, 2019 or latest year Source: Eurostat 
5.Problematic alcohol consumption
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.
Prevalence of problematic alcohol consumption in the last 12 months in the population aged 15 years and over by age group and sex, Belgium, 2018 Source: Health Interview Survey, Sciensano 
The prevalence of problematic alcohol consumption in the past 12 months was the highest in Wallonia for men and in Brussels for women.
Prevalence of problematic alcohol consumption in the last 12 months in the population aged 15 years and over by region and sex, Belgium, 2018 Source: Own calculation based on Health Interview Survey, Sciensano 
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).
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.
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
Weight excess is an important problem in Belgium like in most industrialized countries.
In 2018, nearly half of the adult population aged 18+ (49%) was overweight (BMI ≥ 25) and 16% was obese (BMI ≥ 30) based on self-reported height and weight from the Belgian health interview survey.
Objective height and weight measurements (from the Belgian health examination survey) reveal even higher figures, with as much as 55% of the adult population being overweight and 21% being obese.
The overweight and obesity prevalences are higher in Wallonia than in the other regions.
After a regular increase from 1997, the prevalence of overweight remained stable in men between 2013 and 2018, but increased slightly in women. The prevalence of obesity increased in men but remained stable in women between 2013 and 2018.
Overweight as well as obesity is strongly related to the socio-economic status with a much higher prevalence among people with a lower educational level.
In 2018, among adolescents, the prevalence of overweight (including obesity) was 15.5% in boys and 14.5% in girls.
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)  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)  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)  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 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
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%).
The prevalence of both overweight and obesity was higher in Wallonia than in the other regions in all HIS waves and in both sexes.
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.
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.
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%).
Age-adjusted prevalence of overweight and obesity among people aged 18 and over, by level of education, Belgium, 2018 Source: Own calculations based on Health Interview Survey, Sciensano 
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%).
Prevalence of overweight (incl. obesity) among men aged 18 and over, by country of residence (EU-15), 2019 Source: Eurostat 
Prevalence of overweight (incl. obesity) among women aged 18 and over, by country of residence (EU-15), 2019 Source: Eurostat 
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.
Prevalence of overweight and obesity among adolescent boys, by age group, Belgium, 2018 Source: Own calculations, unweighted Belgian average based on the HBSC [3,4] (IOTF cut-off )
Prevalence of overweight and obesity among adolescent girls, by age group, Belgium, 2018 Source: Own calculations, unweighted Belgian average based on the HBSC [3,4] (IOTF cut-off )
Trends anddifferences 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.
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.
Age-adjusted prevalence of overweight (incl. obesity) among adolescents, by sex, Community, and family affluence status, Belgium, 2018 Source: HBSC international report 
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).
Prevalence of overweight (including obesity) among 15-year-old boys, by country of residence (EU-15), 2018 Source: OECD Health at a glance 
Prevalence of overweight (including obesity) among 15-year-old girls, by country of residence (EU-15), 2018 Source: OECD Health at a glance 
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).
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.
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.
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
In 2018, less than one third (30%) of the adult population (18 years and older) met the WHO recommendations of doing at least 150 minutes of moderate-intensity aerobic physical activity throughout the week. More men (36%) comply than women (25%). Residents of Flanders (37%) and people with tertiary education (38%) were more likely to meet the recommendations.
Among children aged 11 to 18 years, one boy out of five (20%) and one girl out of eight (13%), met the WHO recommendations of performing 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.
Proportion of the population aged 18 years and over who do at least 150 minutes per week of at least moderate-intensity aerobic physical activity by age and sex, Belgium, 2018 Source: Health Interview Survey, Sciensano 
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).
Proportion of the population aged 18 years and over who do at least 150 minutes per week of at least moderate-intensity aerobic physical activity by sex and region, Belgium, 2018 Source: Own calculation based on Health Interview Survey, Sciensano 
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%).
Age-adjusted proportion of the population aged 18 years and over who do at least 150 minutes per week of at least moderate-intensity aerobic physical activity by educational level, Belgium, 2018 Source: Own calculation based on Health Interview Survey, Sciensano 
Proportion of adolescents 11-18 years old who perform at least 60 minutes of moderate- to vigorous-intensity physical activity per day, by age and sex, Belgium, 2018 Source: Own calculation, unweighted Belgian average based on HBSC French Community  and HBSC Flemish Community 
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).
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.
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.
Proportion of adolescents aged 11-18 years old spending at least 60 minutes on moderate – to vigorous-intensity physical activity daily, by sex, communities, and family affluence group, Belgium, 2018 Source: HBSC International report 
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.
Proportion of boys aged 15 years old spending at least 60 minutes on moderate – to vigorous-intensity physical activity daily, by country of residence (EU-15), 2018 Source: HBSC International report 
Proportion of girls aged 15 years old spending at least 60 minutes on moderate – to vigorous-intensity physical activity daily, by country of residence (EU-15), 2018 Source: HBSC International report 
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.
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.
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. Over time, these patterns have only slightly improved.
In 2018, only 12.7% of the population aged 6 years and over consumed the daily recommended amount of fruit and vegetables (at least 5 portions).
In 2018, 20.4% of the population drank sugary drinks on a daily basis; 4.1% even drank a litre or more daily.
Women, older people, people with a tertiary education and people living in Brussels had better nutritional habits.
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 . Recommendations for each food groups have been established at international  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 . 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 .
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 . The WHO recommends a daily consumption of 400 grams of fruit and vegetables (i.e. 5 portions) .
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 . 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%.
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.
Proportion of the population aged 6 years and over that eats daily the recommended amount of fruits and vegetables (at least 5 portions), by age and sex, Belgium, 2018 Source: Health Interview Survey, Sciensano 
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%).
Age-adjusted prevalence of the population aged 6 years and over that eats daily the recommended amount of fruits and vegetables (at least 5 portions), by sex and region, Belgium, 2018 Source: Own calculations based on Health Interview Survey, Sciensano 
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.
Age-adjusted prevalence of the population aged 6 years and over that eats daily the recommended amount of fruits and vegetables (at least 5 portions), by educational level, Belgium, 2018 Source: Own calculations based on Health Interview Survey, Sciensano 
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%).
Prevalence of men aged 15 years and over that eats daily the recommended amount of fruits and vegetables (at least 5 portions), by country of residence EU-15, 2019 Source: Eurostat 
Prevalence of women aged 15 years and over that eats daily the recommended amount of fruits and vegetables (at least 5 portions), by country of residence EU-15, 2019 Source: Eurostat 
5.Consumption of sugary drinks
Situation in 2018
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.
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.
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.
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.
Vanhauwaert E. De actieve voedingsdriehoek: een praktische voedings- en beweeggids. Brussel; 2012.
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.
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.