European Journal of Clinical Nutrition

https://doi.org/10.1038/s41430-020-00766-5

ARTICLE

Nutrition and Health (including climate and ecological aspects)

Urinary sodium and iodine concentrations among Belgian adults:

results from the first national Health Examination Survey
Stefanie Vandevijvere 1 Ann Ruttens2 Alain Wilmet3 Cédric Marien2 Pauline Hautekiet1 Joris Van Loco
● ● ● ● ●
2 ●

Rodrigo Moreno-Reyes4 Johan Van der Heyden1

●

Received: 11 March 2020 / Revised: 11 August 2020 / Accepted: 22 September 2020

© The Author(s), under exclusive licence to Springer Nature Limited 2020

Abstract
Background/objectives Iodine deficiency and excessive salt intakes have adverse health consequences. The objective was to
measure sodium and iodine concentrations in urine spot samples among a representative sample of Belgian adults and
compare those to World Health Organization (WHO) recommendations.
Subjects/methods Spot urine samples were collected in 2018 from participants of the Belgian Health Examination Survey.
Iodine and sodium concentrations were measured by inductively coupled plasma mass spectrometry and ion selective
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electrodes respectively. Tanaka and INTERSALT equations were used to predict 24-h urinary sodium excretion using
sodium and creatinine concentration in spot samples, sex, and measured height and weight.
Results Median urinary iodine concentration (UIC) among adults (n = 1092) was 93.6 μg/L, indicating mild iodine defi-
ciency according to WHO thresholds. Median UIC among participants who reported thyroid problems over the last year was
significantly higher than among those who did not report thyroid problems (104.1 μg/L versus UIC = 92.2 μg/L, p < 0.001).
There were no significant differences in median UIC between sexes, age groups, and regions. The average salt intake among
Belgian adults (n = 1120) was 8.3 ± 0.1 g/day using the Tanaka equation and 9.4 ± 0.1 g/day using the INTERSALT
equation. For both equations, <5% of the population met the recommended WHO upper salt intake level of 5 g/day.
Conclusions Iodine nutrition in the Belgian adult, nonpregnant population likely indicates mild iodine deficiency as the
median UIC was below the WHO threshold for iodine sufficiency. Salt intake was substantially higher than the WHO
recommendations. Further policy efforts are needed to optimize iodine and reduce salt intake in Belgium.

Introduction Generally, iodine deficiency in European countries is mild.

The number of iodine-deficient countries internationally has
decreased from 54 in 2003 to 47 in 2007 and 32 in 2011. Of
these 32 countries, 11 (34%) are in Europe, the largest
number from any continent [1]. In some countries, like the
UK, iodine deficiency has emerged as a public health issue
following several decades of apparent iodine sufficiency [2].
* Stefanie Vandevijvere
stefanie.vandevijvere@sciensano.be
1
Service of Lifestyle and Chronic Diseases, Sciensano,
Brussels, Belgium
2
Service of Trace Elements and Nanomaterials, Sciensano,
Brussels, Belgium
3
Hôpitaux Iris Sud, Ixelles, Brussels, Belgium
4
Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
The main consequences of mild iodine deficiency (MID) in
adults are a higher prevalence of thyroid nodules. MID in
children may prevent them from reaching their full intel-
lectual potential [3]. Universal salt iodization is considered
the most cost-effective and successful solution for pre-
venting and treating iodine deficiency. However, still few
European countries have mandatory salt iodization pro-
grammes, and legislation varies from country to country. As
of 2013, salt iodization is mandatory in 13 and not man-
datory in 21 European countries [4]. In April 2018, a con-
sortium of European scientists published the “Krakow
Declaration on Iodine” to call on policymakers to take
stronger measures to eliminate iodine deficiency in Europe
through mandatory iodization of table salt [5].
In the years 1985–1998, it was first noted that MID was a
public health problem among school-aged children in Bel-
gium [6]. In order to optimize the iodine status in Belgium,
a voluntary agreement was concluded in 2009 between the

bakery sector and the Federal Minister of Public Health to
promote the use of iodized salt in bread (10–15 ppm). No
reliable data are available on the use of iodized salt by the
bakers in Belgium. Furthermore in Belgium iodized salt is
allowed to be used in processed food and feed stuff. A
representative national survey among school-aged children
in 2010–2011 showed that they were iodine sufficient
(median urinary iodine concentration (UIC) = 113.1 μg/l)
and that iodine status had significantly improved compared
to 10 years earlier (median UIC = 80 μg/l) [6, 7]. However,
women of child-bearing age were found to be still suffering
from MID with a median UIC of 84 μg/l [7]. Another study
in 2010–2011 showed that the prevalence of thyroid dis-
orders among Belgian pregnant women was high, affecting
one in six pregnant women [8, 9].
The median UIC during pregnancy (118.3 μg/l in the first
and 131.0 μg/l in the third trimester) indicated MID among
pregnant women in Belgium and some groups of women
(younger women, women not taking iodine-containing
supplements, women with low consumption of milk and
dairy drinks) were found at a significantly higher risk of
iodine deficiency [8]. The 2010 study among Belgian
children showed that 37% of Belgian households used
iodized salt [7]. A similar figure (38%) was found in the
most recent Belgian national food consumption survey [10].
A high intake of sodium is linked to a number of health
risks, including increased blood pressure (BP) and, as a
result, certain cardiovascular diseases and has been shown
to be among the three leading dietary risk factors for deaths
and disability-adjusted life years globally and in many
countries in the latest Global Burden of Disease Study 2017
[11]. A reduced intake of sodium and, consequently, a
reduction in BP is accompanied by several health benefits
[12]. The WHO recommends limiting sodium intake to 2 g
per day (equivalent to 5 g of salt per day). The Belgian
Superior Health Council (HGR) follows this recommenda-
tion [13, 14]. In 2009, it was found that salt intake among
Belgian adults aged 45–65 years was twice as high (on
average 10.5 g per day) as the WHO and HGR recom-
mendations. Only 4.0% of the study population had a salt
intake below the recommendation of 5 g per day [15]. The
latter study used 24-h urine samples, but had the limitation
that it was based on a convenience sample of the Belgian
adult population. The latest representative national food
consumption survey (2014/2015) estimated an average salt
intake of 5.9 g/day (excluding salt at the table or during
cooking) for adults aged 40–64 years old [10].
In response to the global NCD target set in 2012 to
reduce salt intake among the population by 30% by 2025
[16], a Convenant Balanced Diet was signed between sev-
eral food companies and associations and the Belgian
Ministry of Public Health to, among others, reduce sodium
in several food categories over the period 2021–2017 [17].
S. Vandevijvere et al.
As explained above, previous population surveys in
Belgium showed that iodine status is suboptimal among
several population groups and that salt intake is too high.
These surveys are, however, quite old, while recently,
policy actions to reduce sodium levels in food products
were taken. In public health programmes as well as mon-
itoring, it is important to consider both salt intake and iodine
status of the population as policy efforts to reduce salt
intake may influence iodine status and vice versa.
The aims of the present study were to measure sodium
and iodine concentrations in urine spot samples among a
representative sample of Belgian adults as part of the first
Belgian Health Examination Survey (BELHES) and to
verify whether the Belgian adult population reached WHO
recommendations for salt and iodine intakes.
Materials and methods
Belgian Health examination survey (BELHES)
In 2018 the sixth Belgian Health Interview Survey (HIS)
was organized. Information on the health status, lifestyle,
health care use, and socio-demographic characteristics
was collected among a representative sample of 11,611
people residing in Belgium (total population =
11,482,178 in 2018). All Belgian provinces were inclu-
ded. Eligible HIS participants who were at least 18 years
of age were invited to participate also in a Health Exam-
ination Survey (HES) until a predefined number (n =
1100) was reached. As the fieldwork continued for a short
period after recruitment was stopped, finally 1184 people
participated.
Detailed information on the methodology of the
BELHES can be found elsewhere [18]. The BELHES was
approved by the Ethical Committee of the UZ Ghent
(registration number: B670201834895) and written
informed consent was obtained from participants.
Participants were visited at home by a trained nurse
during the period April to December 2018. Belgium was
divided into 27 geographical areas, each covered by one
nurse. The geographical areas were defined in such a way
that the nurse did not have to drive longer than 1 h to reach
the participant’s home. The HES included a short ques-
tionnaire, a physical examination, and the collection of a
blood and urine sample.
The physical examination consisted of the measurement of
height, weight, and blood pressure (BP). Body weight was
measured to the nearest 0.5 kg using a calibrated electronic
scale (type SECA 804). The body height was measured to the
nearest 0.1 cm with a portable stadiometer (type SECA 213)
following the Frankfort horizontal plane for the head position.
BP was measured with an electronic tensiometer (type Omron
Urinary sodium and iodine concentrations among Belgian adults: results from the first national Health. . .
M6) with the participant in sitting position. Three measure-
ments were done with an interval of 1 min.
A spot urine sample of minimum 50 ml was collected in a
polypropylene container. The participants had to be sober,
and the survey was carried out in the morning. In about 98%
of the cases the samples were taken before noon. After
collection, samples were brought to a collection point near
the nurses’ home, they were collected by the laboratory in
the afternoon, aliquoted in 10-ml tubes and stored at −80 °C
until analysis. Samples were analyzed the same day.
Through a unique identification code it was possible to
link the HES data with information from the same people
that is obtained in the HIS.
Laboratory analyses
Iodine concentrations in the urine samples were determined
by ICP-MS (Agilent 8800) [19] on mass 127I after 1/100
dilution in 0.5% TMAH, and using 130Te as an internal
standard and working in He gas mode. The certified refer-
ence material NIST 3668 (urine, level I, 142.7 ± 1.6 μg/L)
was added to the analytical series and showed a mean
trueness of 99.4%.
Sodium and creatinine concentrations in urine were ana-
lyzed on the cobas 8000 analyser (Roche Diagnostics GmbH,
Mannhein, Germany). Creatinine concentrations were analyzed
using a kinetic colorimetric assay based on the Jaffé method
(reagent: Creatinine Jaffé Gen.2 réf 064071370190, Roche
Diagnostics GmbH, Mannheim, Germany). Sodium con-
centrations were determined by using ion-selective electrodes
(ISE Indirect Gen.2) (Sodium electrode réf. 10825468 001,
Roche Diagnostics GmbH, Mannheim, Germany).
Data analyses
Out of 1184 BELHES participants, 1166 provided a urine
sample. For 1132 participants, sodium and creatinine could
be analyzed. Thereafter, for 1106 participants there was still
sufficient urine volume to analyze iodine.
Iodine
Out of the 1106 participants for whom iodine and creatinine
were analyzed in their urine sample, pregnant women (N =
7) and participants with extremely high iodine concentra-
tions (N = 7), indicating acute or chronic iodine over-
exposure, were excluded. For the two highest
concentrations (UIC > 10000 μg/L), the questionnaire
reported use of amiodarone/cordarone medication in the
24 h prior to urine sampling, which can therefore be con-
firmed as the cause of the extreme concentrations observed.
For the other participants (UIC > 4000 μg/L), no known
cause could be identified. In total, 1092 (92%) BELHES
participants were included in the final sample.
Median UIC was calculated for the total adult non-
pregnant population and by sex, age group (18–39 years,
40–64 years, 65 years and over), region (Flanders, Wallo-
nia, Brussels), and for adults with/without reported thyroid
problems during the last 12 months. The median UIC was
compared to established WHO thresholds, which consider a
median UIC between 100 and 199 μg/L as adequate iodine
nutrition [20]. A median UIC below 50 μg/L is considered
moderate iodine deficiency (severe iodine deficiency when
median UIC is below 20 μg/L), while a median UIC higher
than 300 μg/L is considered excessive iodine nutrition [20].
While surveys among school-aged children are recom-
mended to assess iodine nutrition at the population level, the
thresholds can be used for nonpregnant non-lactating adults
[20].
Sodium
Out of the 1132 participants for whom sodium and creati-
nine were analyzed in their urine sample, participants
without information on measured weight and/or height
(N = 5) and pregnant women (N = 7) were excluded. In
total, 1120 (95.0%) BELHES participants were included in
the final sample. Various equations exist to estimate 24-h
sodium excretion from spot urine samples [21–24]. The
Mage equation was not used because it was mainly devel-
oped for specific ethnicities [24]. The Kawasaki equation
was also excluded because it has previously been found to
markedly overestimate mean population salt intake com-
pared with 24-h samples [25]. In this study, we used the
INTERSALT [21] and Tanaka equations [22] to predict 24-
h urinary sodium excretion from spot urine samples in
Belgian adults using sodium and creatinine concentration in
spot samples, sex, height, and weight (Table 1).
Salt consumption data were expressed in grams of salt
(sodium chloride) per day using the following conversions: 1-
mmol Na = 1 mEq Na = 23-mg Na, and 1 g Na =
2.54-g Na Cl.
BP was categorized into four different levels based on the
mean reading over the last two out of three measurements:
normal (systolic BP < 120 mm Hg and diastolic BP < 80 mm
Hg), elevated (systolic BP 120–129 mm Hg and diastolic BP <
80 mm Hg), high stage 1 (systolic BP 130–139 mm Hg or
diastolic 80–89 mm Hg), and high stage 2 (systolic BP ≥
140 mm Hg or diastolic BP ≥ 90 mm Hg) [26, 27].
Statistical analyses
Analysis was conducted in SAS 9.4 (SAS Institute Inc.,
Cary, NC, USA). For all analyses survey strata (province),
 S. Vandevijvere et al.

Table 1 Equations to estimate

Tanaka equation, 2002
24-h sodium excretion (mmol/
day) from spot urine samples   0:392
21:98
SNa
SCr
10
½ð2:04
ageÞ þ ð14:89
wtÞ þ ð16:14
htÞ  2244:45
used in this study.
INTERSALT without potassium equation, 2013

Males f23:51 þ ½0:45
SNa  ½3:09
SCr þ ½4:16
BMI þ ½0:22
ageg
Females f3:74 þ ½0:33
SNa  ½2:44
SCr þ ½2:42
BMI þ ½2:34
age  ½0:03
age2 g
SNa in mmol/L; SCr in mmol/L for the INTERSALT equation, in mg/dL for the Tanaka equation; age in
years; weights in kilograms; height in centimeters; BMI in kg/m2.
SNa spot sodium, SCr spot creatinine, ht height, wt weight, BMI body mass index.

clusters (households) and sampling weights were taken into
account.
Median UIC among different population groups were
compared using Wilcoxon rank sum test or Kruskal Wallis
test. Mean salt intakes among different population groups
were compared using t-tests or ANOVA. Linear regression
was conducted to compare salt intakes among different BP
levels adjusting for age, sex, and region.
Results
Iodine excretion among adults in Belgium
The study sample included about 50% of women, 31% of
18–39 year olds, and 23% of participants older than 65
years. About half of the participants were higher educated
(i.e., had a diploma of tertiary studies). More than half of
participants were overweight (BMI ≥ 25 and <30 kg/m²) or
obese (BMI ≥ 30 kg/m²), and 8.6% of participants reported
thyroid problems during the last 12 months (Table 2).
Median creatinine levels were 141.3 (IQR = 98.2–199.8)
mg/dl; 165.2 (IQR = 115.7–214.5) mg/dl for men and 121.6
(IQR = 84.6–175.7) mg/dl for women (data not shown).
Overall, median UIC among Belgian adults was 93.6 μg/
L. About 12.1% of Belgian adults had a UIC below 50 μg/L,
while 2.2% of adults had a UIC above 300 μg/L (Table 3).
When expressing the iodine concentrations in μg/g creati-
nine, the median UIC was 60.8 ± 1.9 μg/g creatinine for
men and 73.1 ± 2.4 μg/g creatinine for women (data not
shown).
There were no significant differences in median UIC
between sexes, age groups, and regions in Belgium, but
males had higher median UIC than females, and the
youngest age group (18–39 years) had higher median UIC
than the other age groups (Table 3). The median UIC
among participants who reported thyroid problems during
the last 12 months (median UIC = 104.1 μg/L) was sig-
nificantly higher (p < 0.001) than the median UIC among
those who did not report thyroid problems (median UIC =
92.2 μg/L)(Table 3).
Sodium excretion among adults in Belgium
The study sample included about 50% of women, 31% of
18–39 year olds, and 24% of participants older than 65
years. About half of the participants were higher educated.
More than half of participants were overweight or obese and
22% of participants reported using medicines for high BP.
About 45% of participants suffered from high BP while
45% of participants had normal BP (Table 2).
The average population salt intake was 8.3 ± 0.1 g
per day using the Tanaka equation and 9.4 ± 0.1 g per day
using the INTERSALT equation. For both equations, <5%
of the population met the recommended salt intake level of
<5 g per day. Salt intakes were significantly higher for
males than females, in particular for the INTERSALT
equation (Table 4). Compared to people with stage 2
hypertension, salt intake was significantly lower among
people with normal BP (−0.92 ± 0.24 g/day for Tanaka p <
0.001; −0.55 ± 0.18 g/day for INTERSALT; p = 0.002)
corrected for age, sex, and region. Compared to people with
stage 2 hypertension, salt intakes were also lower for people
with elevated BP (−0.51 ± 0.30 g/day for Tanaka; −0.35 ±
0.24 g/day for INTERSALT) and people with stage 1
hypertension (−0.42 ± 0.23 g/day for Tanaka; −0.16 ±
0.18 g/day for INTERSALT), but these differences were not
significant (data not shown).
Discussion
This study, based on a representative sample of Belgian
adults, showed that the median UIC (94 μg/L) was below
the WHO threshold for population iodine sufficiency
(100 μg/L) [20], likely indicating MID, while population
salt intake was substantially higher than the WHO recom-
mendation of 5 g/day.
Iodine status among nonpregnant adult women sig-
nificantly improved in Belgium over the last decade.
A previous national survey conducted among school-aged
children and their mothers in 2010–2011 indicated iodine
sufficiency among children (median UIC = 113 μg/L), but
Urinary sodium and iodine concentrations among Belgian adults: results from the first national Health. . .

Table 2 Characteristics of adult participants in the urinary iodine (n = survey included mothers from school-aged children selected
1092) and sodium concentration (n = 1120) study.
through sampling of schools, and data on age of those
Characteristic Iodine (N = 1092) Sodium (1120) mothers were not available. In addition, analysis at both
N (weighted%) N (weighted%)
moments was done in different laboratories using a different
Gender method (spectrophotometric detection based on a modifica-
Male 528 (50.4) 538 (49.7) tion of the Sandell–Kolthoff reaction in 2010–2011 versus
Female 564 (49.6) 582 (50.3) ICP-MS following dilution with TMAH in 2018). A previous
Age
study [19], however, showed no significant difference
18–39 years 287 (31.1) 295 (30.9)
40–64 years 572 (45.8) 579 (44.8)
between both methods, with the ICP-MS method producing
65 years and over 233 (23.1) 246 (24.4) slightly lower concentration results for UIC < 250 μg/L.
Region For males there are no previous data available as pre-
Flanders 516 (60.6) 531 (60.5) vious surveys in Belgium focused on school-aged children
Brussels 260 (10.7) 263 (10.5) and pregnant women. A significant improvement in iodine
Walloon Region 316 (28.7) 326 (29.0) intake in Belgium was, however, also noted through the
Education level household
results from the national food consumption surveys (2004
No diploma/primary 50 (4.3) 53 (4.5)
versus 2014/15) in all age groups, including males and
Lower secondary 105 (11.1) 108 (11.0)
Higher secondary 332 (32.1) 341 (31.9)
children. The most important source of iodine intakes was
Higher education 586 (51.2) 598 (51.2) cereals and cereal products, representing about half of the
Missing 19 (1.4) 20 (1.4) usual iodine intake. Iodine intakes (excluding iodized salt
Smoked in the last 24 h added during cooking or consumption) were significantly
Yes 121 (9.8) 121 (9.4) higher among males than females (164 μg/day versus
No 967 (89.9) 994 (90.1) 125 μg/day) [10]. Usual iodine intake was lower among
Missing 4 (0.4) 5 (0.5)
lower than higher educated individuals, but the intake
Used medicines in the last 24 h
Yes 569 (52.6) 585 (53.1)
among men was found to be sufficient, regardless of the
No 518 (46.8) 530 (46.4) education level [10]. Only 36% of the Belgian population
Missing 5 (0.5) 5 (0.5) reported using iodized salt in 2014. People with a university
BMI category education were more likely (44%) to use iodized salt than
Underweight 28 (2.5) 24 (2.1) individuals with a lower, secondary education or no
Normal weight 441 (41.5) 458 (42.2) diploma (32%) and people with a post-secondary non-
Overweight 384 (34.1) 394 (34.0)
university education (35%). The percentage of people who
Obese 239 (21.9) 244 (21.8)
Used medicines for high blood pressure
use iodized salt was also higher in Wallonia (42%) than in
Yes 233 (21.1) 243 (21.9) Flanders (34%) [10].
No 854 (78.4) 872 (77.5) In the present study, there was a small but significantly
Missing 5 (0.5) 5 (0.5) higher UIC among persons who reported thyroid disorders.
Thyroid problems in the last 12 months This may be due to these persons taking thyroid hormone
Yes 90 (8.6) 93 (8.9) replacement therapy, which may slightly increase urinary
No 1002 (91.4) 1027 (91.1)
iodine excretion.
Blood pressure levela
Average salt intakes among adults in Belgium are too high
Normal 482 (45.2) 496 (45.3)
Elevated 102 (9.8) 102 (9.5)
compared to the WHO recommendation. Although both
High stage 1 300 (26.0) 305 (25.4) equations used give fairly different results (i.e., about a gram
High stage 2 208 (18.9) 217 (19.8) of difference on average), it is likely that average salt intake of
Mean systolic blood pressure 121.2 (0.7) 121.4 (0.8) the population decreased somewhat over the last decade. A
Mean diastolic blood pressure 76.8 (0.4) 76.8 (0.4) previous study in Belgium among adults, using 24-h urine
a
Normal (systolic BP < 120 mm Hg and diastolic BP < 80 mm Hg), collections but including a convenience sample of 123 and
elevated (systolic BP 120–129 mm Hg and diastolic BP < 80 mm Hg), 157 adult participants (45–65 years) found that average intake
high stage 1 (systolic BP 130–139 mm Hg or diastolic 80–89 mm Hg), of salt in Flanders (n = 114) was 10.9 g/day, whereas in the
and high stage 2 (systolic BP ≥ 140 mm Hg or diastolic BP ≥
90 mm Hg). Walloon region (n = 135) it was 10.0 g/day [15].
In both regions, sodium intake in men was higher than in
women [15], similar as in the present study. Results from
the Belgian food consumption surveys also found a sig-
MID among their mothers (median UIC = 84.4 μg/L or nificant decrease of salt intake (excluding salt at the table
66.0 μg/g creatinine) [7]. The methodology of this survey and and during cooking) from 7 g per day in 2004 to 6 g per day
the previous survey was, however, different as the previous in 2014–2015 including all age groups [10].
 S. Vandevijvere et al.

Table 3 Distribution of urinary iodine concentration (UIC) (μg/L) among Belgian adults (n = 1092)—Belgian Health Examination Survey
(BELHES) 2019.
Population N Median (SE) P25 (SE) P75 (SE) min max % (SE) < 100 μg/L % (SE) < 50 μg/L % (SE) > 300 μg/L

All 1092 93.6 (2.3) 67.5 (2.1) 132.8 (4.0) 8.3 1121.6 56.0 (2.0) 12.1 (1.1) 2.2 (0.5)
Gender
Male 528 94.2 (3.3) 70.3 (2.5) 132.8 (8.4) 13.5 1121.6 54.8 (2.9) 10.1 (1.5) 1.8 (0.6)
Female 564 91.7 (2.9) 62.3 (2.7) 133.7 (4.3) 8.3 1042.7 57.3 (2.6) 14.2 (1.6) 2.5 (0.7)
Age
18–39 years 287 98.0 (5.6) 67.7 (4.1) 136.5 (9.3) 8.3 1121.6 52.4 (4.2) 8.8 (1.8) 1.3 (0.6)
40–64 years 572 91.0 (2.5) 65.3 (2.7) 126.0 (4.4) 13.7 1042.7 57.8 (2.6) 13.6 (1.7) 2.3 (0.7)
65 years and older 233 93.4 (4.3) 68.4 (3.8) 137.9 (11.3) 20.8 1082.4 57.3 (4.0) 13.8 (2.3) 3.1 (1.2)
Region
Flanders 516 93.5 (3.0) 67.6 (2.9) 127.6 (5.1) 13.7 1121.6 56.7 (2.8) 9.7 (1.4) 1.5 (0.5)
Brussels 260 91.3 (5.4) 62.9 (4.2) 134.4 (7.6) 8.3 1028.8 56.5 (3.5) 16.9 (2.7) 4.1 (1.7)
Wallonia 316 93.8 (4.2) 69.3 (4.0) 139.7 (10.4) 13.5 1042.7 54.5 (3.6) 15.5 (2.3) 2.9 (1.0)
Reported thyroid problems
Yes 90 104.1 (10.9)a 85.6 (5.2) 168.6 (18.7) 14.1 1042.7 42.8 (7.0) 5.9 (2.7) 3.0 (1.8)
No 1002 92.2 (2.1) 65.9 (2.1) 129.8 (4.1) 8.3 1121.6 57.3 (2.1) 12.7 (1.2) 2.1 (0.5)
SE standard error.
a
Statistically significantly different from participants who did not report thyroid problems (p < 0.001).

Table 4 Mean salt excretion per

Population N Tanaka equation INTERSALT without K equation
24 h (g/day) as calculated using
several equations. Mean (SE) salt % <5 g Mean (SE) salt intake % <5 g
intake (g/day) per day (g/day) per day

All 1120 8.3 (0.1) 4.5 (0.8) 9.4 (0.1) 2.5 (0.7)
t, i
Gender*
Male 538 8.6 (0.1) 2.9 (0.8) 11.2 (0.1) 0.0
Female 582 8.0 (0.1) 6.1 (1.3) 7.6 (0.1) 5.0 (1.3)
Age*i
18–39 years 295 8.1 (0.2) 3.7 (1.2) 9.5 (0.1) 0.0
40–64 years 579 8.4 (0.1) 4.7 (1.2) 9.7 (0.1) 0.0
65 years and over 246 8.3 (0.2) 5.0 (1.7) 8.5 (0.2) 10.4 (2.6)
Region*t
Flanders 531 8.5 (0.1) 2.3 (0.6) 9.4 (0.1) 2.3 (0.9)
Brussels 263 7.7 (0.1) 6.4 (1.5) 9.1 (0.1) 3.4 (1.6)
Walloon Region 326 8.1 (0.2) 8.5 (2.1) 9.4 (0.2) 2.6 (1.4)
BP level*t, i
Normal 492 7.9 (0.1) 6.0 (1.3) 9.0 (0.1) 1.0 (0.5)
Elevated 109 8.4 (0.2) 2.4 (1.5) 9.9 (0.3) 0.9 (0.9)
High BP 1 301 8.5 (0.1) 3.2 (1.3) 9.8 (0.2) 2.5 (1.3)
High BP 2 218 8.8 (0.2) 3.6 (1.5) 9.4 (0.2) 6.7 (2.7)
SE standard error, BP blood pressure.
*
t < 0.001.
*
i < 0.01.

Since 2012, the Covenant Balanced Diets [17] may have the Nutriscore front-of-pack nutrition label was adopted for
encouraged the food industry in Belgium to reduce sodium Belgium, which may further stimulate food manufacturers
levels in their food products to some extent. More recently, to reduce sodium levels in certain product categories. These
Urinary sodium and iodine concentrations among Belgian adults: results from the first national Health. . .
are voluntary initiatives, however, and in view of the cur-
rent results, mandatory targets for sodium in processed food
products are recommended.
Strengths of the study include that the results are based
on a representative sample of Belgian adults, measured
weight and height data, and the linkage of the HES with the
HIS. Limitations include the use of spot urine samples,
especially for determining salt intakes, the lack of data for
urinary potassium excretion, the lack of reliable data on use
of iodized salt by the bakers in Belgium, the lack of data on
urine volume over 24 h, and the lack of data on iodine
nutrition for school-aged children.
It is recommended to use 24-h urine samples to estimate
salt intakes in future surveys. As previously reported
[25, 28], equations estimating 24-h sodium excretion based
on spot urine samples tend to overestimate excretion at low
intakes and underestimate excretion at high intakes. Due to
this, estimating intake in a population by these equations
can lead to over- or underestimation of salt intake.
The large difference in salt intakes between men and
women using the INTERSALT equation in this study has
also been found in a recent study in Norway. The same
study found that mean daily sodium excretion estimated by
the INTERSALT formula was 4% higher in men and 1%
lower in women than that measured by 24-h urine [29].
While thresholds for evaluating population iodine nutri-
tion can be used among adults, WHO recommends popu-
lation surveys among school-aged children [20]. The
thresholds are based on the assumption of 1-L urine
excretion per 24 h among children and 1.5 L per 24-h
among adults. We did not collect data on urine/drinking
volume in this study to verify this assumption. However,
based on the data from the latest national food consumption
survey 2014/15, the average fluid intake among Belgium
adults was ~1533 ml/day for the group 18–39 years old
(including on average 1194-ml/day water and non-sugary
drinks, 209-ml/day sugary drinks and 130-ml/day milk) and
1619 ml/day for the group 40–64 years old (including on
average 1404-ml/day water and non-sugary drinks, 88-ml/
day sugary drinks and 127-ml/day milk) [10]. Since the last
survey on iodine status among children in Belgium is
already more than 10 years old, a new children’s survey on
iodine status would be recommended.
Furthermore, the limited sample size did not allow to
explore socio-demographic and regional differences in salt
intake and iodine concentrations. While the sample dis-
tribution by age group and gender resembled well the one of
the Belgian general population (except for a slight under-
representation of people in the age groups 18–24 years and
75 years and over), a specific concern of the study sample
was the underrepresentation of low educated people.
Unfortunately, educational attainment could not be taken
into account to calculate the survey weights, because this
information was not available in the Belgian National
Register.
Conclusion
In conclusion, iodine nutrition in the adult, nonpregnant
population improved over 10 years but the median UIC was
still below the WHO threshold for iodine sufficiency likely
indicating MID.
Population salt intake was substantially higher than the
WHO recommendations. Further policy efforts are nee-
ded to optimize iodine and reduce salt intake in Belgium.
In view of the differences in salt intakes estimated using
different equations, 24-h urine collections are recom-
mended for future assessments. Since this study focused
on adults only, it is recommended to collect urine sam-
ples from a representative sample of school-aged children
and pregnant women in Belgium to verify their iodine
nutrition.
Acknowledgements The authors would like to thank Frédéric Van
Steen for his skillful technical assistance for iodine analysis. The
authors thank all individuals who participated in the BELHES2018.
Funding The BELHES2018 was funded by the National Institute for
Health and Disability Insurance (RIZIV/INAMI).
Author contributions SV performed the statistical analyses and wrote
the paper. AR, AW, CM, and JVL performed the laboratory analyses.
PH organized the fieldwork of the BELHES2018. RM-R helped with
interpretation of the iodine nutrition results. JVH coordinated the
BELHES2018. All authors critically commented on and approved the
final version of the manuscript.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Publisher’s note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
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