Food and Nutrition Future Directions for Timor-Leste

Kristina Nelson, BSc (Hons),1 Lily Stojanovska, MSc, PhD1

1
Centre for Chronic Disease Prevention and Management, College of Health and
Biomedicine, Victoria University, Vic, Australia

Address correspondence to: Professor Lily Stojanovska MSc. PhD. Centre for
Chronic Disease Prevention and Management, College of Health and Biomedicine,
Victoria University, St Albans Campus, PO Box 14428 Melbourne, VIC 8001,
Australia. Tel.: +03 9919 2737; Fax: +03 9919 2465. E-mail:
lily.stojanovska@vu.edu.au

Conflict of interest/financial disclosure: None

Key Words: Timor-Leste, dietary guidelines, nutrition

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INTRODUCTION
Dietary guidelines issued globally and nationally serve to guide nutrition direction in
supporting population health. Whilst nutrition guidelines worldwide share similarities
in terms of general recommendations, differences in life-stage as well as cultural and
ethnic specificities are necessary to ensure relevance across diverse populations.
Timor-Leste is a country that has undertaken various programmes aimed at
improving population health and nutrition, comprising interventions and guiding
principles to support improving population health outcomes.

This conference paper discusses key points presented at Future Directions for Food
in Timor-Leste on 11-12 July 2013 by Professor Stojanovska from Victoria University,
Australia. Specifically it will explore the importance of dietary guidelines in
population health, nutrition-related concerns across the lifespan, with particular
reference to the context of nutritional status of Timor-Leste, and the role of various
nutrition strategies and programmes in addressing the population health needs of its
people.

FOOD BASED DIETARY GUIDELINES

Dietary guidelines form part of nutritional frameworks of populations world-wide, and

are defined as sets of advisory statements that give dietary advice for the population
to promote overall nutritional well-being and relate to all diet-related conditions
(World Health Organisation et al. 1988). The World Health Organisation (WHO) in
conjunction with the Food and Agriculture Organisation (FAO) play a key role in
reviewing and disseminating nutrition research findings that underpin setting nutrient
requirements in supporting public health globally. To this end, countries can access
various WHO publications to help establish their national guidelines for dietary intake
(World Health Organisation 2014).

Dietary guidelines that are food based focus on whole foods to meet nutritional
needs, rather than individual nutrients. Importantly, it is recognised that both
traditional and modern dietary practices are considered in developing culturally
sensitive and practical food-based dietary guidelines specific to individual countries
(World Health Organisation et al. 1988).

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Features of food-based dietary guidelines as reported by WHO (World Health
Organisation et al. 1988) are:
1 Eat enough food to meet body needs and maintain healthy body weight
2. Eat a variety of foods
3. Eat clean and safe food
4. Eat whole grain cereals, legumes, roots and tubers
5. Eat plenty of vegetables and fruits regularly
6. Limit salt intake
7. Moderate sugar intake
8. Avoid or limit alcohol
9. Breast feed, as appropriate

The Asia-Pacific region comprises culturally diverse countries that and are in various
stages of health and nutrition status. Australia and Timor-Leste both inhabit this
region, yet exemplify diverse characteristics to each other, including cultural
influences and nutritional status. For instance, Australia faces challenges with
overweight and obesity and its related metabolic dysfunctional states such as type-2
diabetes, whereas undernutrition is a more significant concern in Timor-Leste.

National dietary guidelines in Australia are food-based, focussing on whole foods as

opposed to individual nutrients, and founded on a large body of scientific evidence
about dietary patterns, types and quantities of foods that are associated with
supporting good health outcomes and reducing the risk of several types of non-
communicable diseases, including obesity, heart disease and type-2 diabetes
(National Health and Medical Research Council (NHMRC) 2013). Additionally, the
Nutrient Reference Values for Australia and New Zealand is a companion document
issued by the National Health and Medical Research Council that quantitatively
describes specific nutrient requirements for different genders and life stages
(NHMRC 2006).

Conversely, Timor-Leste does not have country specific dietary guidelines, however
is implementing various nutrition strategies aimed at improving the health outcomes
of its population.

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TIMOR-LESTE NUTRITIONAL STATUS

Timor-Leste is facing serious nutrition challenges, particularly undernutrition and

malnutrition of under 5s and women of reproductive age (Noij 2011). Improved
nutrition outcomes are a Government priority, supported by several key partner
organisations: UNICEF, FAO, AusAid, WHO, EU and the Government of Spain
(UNICEF 2012).

As reported in the Mid Term Evaluation Report Joint Programme of Promoting

Sustainable Food and Nutrition Security in Timor-Leste (Noij 2011):-
58% of children <5 years are short for their age (stunted)
19% of children <5 years are acutely malnourished
45% of children are low weight for their age (underweight)
27% of women of reproductive age (15-49 years old) are underweight, with
14% of women in this category giving birth before turning 18 years old

The reasons suggested for the undernutrition and malnutrition status include:
limited human resources in the nutrition sector (UNICEF 2012)
high food insecurity
knowledge deficit regarding feeding and caring for young children
high rates of respiratory infection, malaria and diarrhoea
poor accessibility to health and nutrition services (Noij 2011)

The Millennium Development Goal Fund (MDGF), the Children Food Security and
Nutrition Joint Programmes have been implemented to address these issues, as well
as establishing school feeding programmes, and food security and nutrition
surveillance systems (Noij 2011). The Government of Timor-Leste is developing a
national nutrition strategy, and in 2013 also prioritised a national nutrition survey
(UNICEF 2012).

The WHOs global database on the Implementation of Nutrition Action (GINA)

indicates that several nutrition programs are underway in Timor-Leste, including:-
Maternal, infant and young child nutrition (targeting infants up to 1-year and
promoting breastfeeding)
Vitamin and mineral nutrition programmes (targeting pregnant women,
particularly regarding folic acid supplementation)

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 School nutrition programmes (targeting school-aged children from
kindergarten to primary school to promote hygienic and clean cooking and
eating environments)
Obesity and dietary nutrition programmes for NCDs (targeting all population
groups via media coverage to promote healthy nutrition) (World Health
Organisation 2012).
A detailed list of various nutrition programmes and actions in each category being
undertaken in Timor-Leste can be accessed via the WHO GINA profile on Timor-
Leste
https://extranet.who.int/nutrition/gina/en/programmes/1590

LIFE-SPAN NUTRITION

Nutritional considerations for different age groups

Nutritional needs vary across the lifespan. Dietary guidelines support meeting
nutritional needs at different life stages, however it must be stressed that the
recommendations are made for healthy populations, and need to be taken into
context beyond reference individuals that they are based on. For instance, energy
intake recommendations are for healthy weight maintenance, do not account for
undernutrition or overnutrition. Therefore energy intake would need to be adjusted to
account for increased or decreased needs from recommendations (FAO Human
Energy Requirements http://www.fao.org/docrep/007/y5686e/y5686e00.htm).
The following pages are not intended to be prescriptive, and care needs to be taken
when considering individual needs. They should be read in conjunction with other
key health documents such as issued by the FAO and WHO, as well as consultation
with appropriate nutrition professionals.

Pregnancy
Good nutrition is important in pregnancy for maternal and foetal growth and
developmental requirements. The consequences of nutritional deficiencies during
pregnancy can have adverse outcomes, particularly for the baby (Table 1). The
following paragraphs highlight several nutrients of significance during pregnancy.

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Table 1: Adverse effects of nutritional deficiencies on foetus
Nutrient Effect
Energy Low infant birth weight
Protein Reduced head circumference
Folate Miscarriage, neural tube defect
Vitamin D Low infant birth weight
Calcium Decreased infant bone density
Iron Low infant birth weight, anaemia
Iodine Infants brain development cretinism
Zinc Congenital malformations
(Stojanovska 2013)

Energy
Healthy women that are well-nourished are recommended to gain an average of
12kg in pregnancy (Food and Agriculture Organisation of the United Nations (FAO)
et al. 2004), however adjustments in weight gain are required depending on pre-
pregnancy BMI and ethnicity (National Health and Medical Research Council
(NHMRC) 2013). The weight gain recommendations accounts for weight of the
foetus, placenta and amniotic fluid associated with the baby, and increased growth of
a womans uterus and breasts, as well as increases in blood, extracellular fluid, and
stored fat (Food and Agriculture Organisation of the United Nations (FAO) et al.
2004). Accordingly, energy needs in the first trimester increase by 00.35 mJ/day,
1.2-1.4mJ/day in the second trimester, and 1.9- 2.0 mJ/day in the third trimester
(Food and Agriculture Organisation of the United Nations (FAO) et al. 2004; NHMRC
2006). Special consideration needs to be applied to different levels of physical
activity, in undernourished women, women with overweight or obesity, and
adolescent pregnancies (Food and Agriculture Organisation of the United Nations
(FAO) et al. 2004).

Protein
To support periods of increased growth, protein intake for adult pregnant women is
recommended to increase during the second and third trimesters. The RDI for
protein for non-pregnant females aged 19-70 years is 46 g/day (0.75g/kg/day), and
this increases during pregnancy to an RDI of approximately 60g/day
(1g/kgday)(NHMRC 2006). Increased protein is recommended in terms of food rather
than supplements (World Health Organisation et al. 2007). In terms of whole food

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recommendations during pregnancy, the Australian Dietary Guidelines recommends
consumption of protein-rich, nutrient dense foods such as lean red meat and poultry,
fish, eggs, legumes, nuts and seeds at a target of 3.5 serves/day (~500-600 kJ), and
dairy foods/dairy equivalents at 2.5 serves/day (~500-600 kJ), with avoidance of raw
eggs and unpasteurised dairy products and soft, semi-soft and surface-ripened
cheese as these products carry risk of bacterial infections (National Health and
Medical Research Council (NHMRC) 2013).

Folate
Folate is a mineral found in plant foods, mainly cereals, vegetables and legumes,
and to a lesser extent fruit and fortified orange juice. Folate is required for DNA
synthesis, so requirements are increased during times of rapid cell turnover such as
pregnancy (NHMRC 2006). The RDI for folate, as dietary folate equivalents, is 400
g/day for adult women 19-70 years old, and this increases to 600 g/day during
pregnancy, however higher levels are required in the month prior to conception and
during the first trimester to prevent neural tube defects, with an upper level of intake
of 1000g/day for folic acid during pregnancy (NHMRC 2006).

Iron
Iron is an important mineral that plays a key role in delivering oxygen to tissues, and
is derived primarily from red meat, poultry and fish, with smaller and less bioavailable
quantities found in plant foods such as wholegrains (NHMRC 2006). The RDI for
iron for female adults is 18mg/day, whereas this increases in pregnancy to 27
mg/day (NHMRC 2006), which is nearly double.

Calcium
Calcium is another important mineral, with key functions in supporting skeletal,
cardiac and neuromuscular function. Main sources of calcium in foods include dairy
foods, with smaller quantities found in fortified soy-drinks and cereal products, tinned
fish with bones, legumes and some nut varieties (NHMRC 2006). The RDI for adult
women 19-50 years old is 1000 mg, however this is the same in pregnancy (NHMRC
2006) and can be met by the recommended 2.5 serves of dairy products/day
(National Health and Medical Research Council (NHMRC) 2013).

Phosphorus
Phosphorus is an abundant mineral in the body stored largely in bone, and has many
functions including being required for DNA and RNA, acid-base balance, and energy

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transport (NHMRC 2006). It is found in a wide range of foods and the RDIs for adult
women aged 19-70 years, including pregnant women is 1000mg/day (NHMRC
2006).

Table 2: Daily RDI of water soluble vitamins: pregnant and non-pregnant

women (19-70 years old)

Water Soluble vitamins Non Pregnant Pregnant Woman

Woman

Thiamin 1.1 mg 1.4 mg

Riboflavin 1.1 mg 1.4 mg

Niacin 14 mg 18 mg

Pyridoxin 1.3 mg 1.9 mg

Folate (as dietary folate equivalents) 400 g 600 g

Vitamin B12 2.4 g 2.6 g

Vitamin C 45 mg 60 mg

(NHMRC 2006)

Children and Adolescents

Energy needs of children and adolescents vary widely with age, gender, weight,
height and physical activity levels.

Infant nutrition
Infant nutrition, between birth and 1 year, is crucial as it is the period of rapid growth
rate, with the amount of nutrition needed per unit of body weight greater than at any
other age (Stojanovska 2013). Nutrition deficits at this time can impair growth and
development. As infants are unable to digest starch until approximately 3 months of
age, and proteins until approximately 6 months of age, the risk of the baby
developing an allergy may increase if solid foods are introduced before 4-6 months of

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age. Accordingly, breast milk is considered the most appropriate food at this age as
it supplies the infants nutritional and fluid requirements. Fluid requirements may
increase however in hot weather, diarrhoea or vomiting and may necessitate
supplemental water to prevent dehydration. Breast milk provides all nutrients, except
vitamin D and fluoride, for infants needs for the first 4-6 months of life, as well as
many protective factors such as immunoglobulins (Stojanovska 2013).

In cases of undernutrition, failure to thrive (FTT) can occur that is characterised by

stunting and impaired cognition, decreased growth rate (weight, length), social and
developmental delays, abnormal behaviours and distorted caretaker-infant
interactions. Additionally, iron deficiency can also occur with undernutrition, and is
associated with anorexia, irritability, lack of interest in surroundings, and impaired
growth and development (Stojanovska 2013).

Other nutrition-related concerns associated with infancy include Nursing Bottle Tooth
Decay: tooth decay that affects incisors and upper first molars, that can occur with
prolonged, inappropriate bottle feeding with sugar-containing liquids such as fruit
juice, sweetened drinks, milk and formula (Stojanovska 2013).

Child nutrition
Children aged between 3 and 5 years require adequate amounts of protein, calcium
and phosphorus to support normal bone growth, and of concern to many parents is
the limitation of milk intake, rejection of meat and vegetables, and excessive intake of
sweets. Nutrients most likely to be lacking are iron and vitamin C (Stojanovska
2013).

The energy requirements of children vary considerably with their age, gender and
physical activity levels. Boys aged 3, 10 and 18 engaging in light to moderate
physical activity levels require approximately 5-6, 8-9 and 13-14 mJ/day respectively,
whereas girls of same age and activity require slightly less energy, approximately
5.5, 8 and 10 mJ/day (Food and Agriculture Organisation of the United Nations
(FAO) et al. 2004; NHMRC 2006).

Similarly, protein requirements also vary. The RDI for children aged 1-3 years is
14g/day (1.08g/kg) and aged 4-8 years is 20g/day (0.91g/kg) (NHMRC 2006).

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Carbohydrate intake is recommended for children and adults to comprise 45-65% of
dietary energy intake (NHMRC 2006). Recommended after the age of 2 y, children
should consume at least 20%-30% of energy from fat. Saturated fat intake should be
limited to less than 10% of energy (Stojanovska 2013).

The AI for dietary fibre for children 1-3 years is 14g/day, 4-8 years 18g/day, boys 9-
13 years 24 g/day and girls 9-13 years 20g/day, boys 14-18 yrs 28g/day and girls 14-
18 yrs 22g/day. The AI set for adult dietary fibre intake is 25g/day for women, and in
pregnancy 28g/day, and 30g/day for men (NHMRC 2006).

For adolescent children (aged 12-18 years), this is a period of rapid physical,
emotional, social and sexual maturation, therefore nutritional needs increase for
energy, protein, calcium and iron. Growth begins at different times in different
individual and different gender (10-11y for girls) and (13-14y for boys). The increase
in nutritional requirements is dependent on the timing and duration of the growth
spurt. Boys have higher calorie needs than girls and girls have greater requirements
for iron (Stojanovska 2013). Nutrients most likely to be inadequate amounts: iron,
calcium (low intake of dairy products), Vit B2, Vit A (among low socioeconomic
groups) (Stojanovska 2013).

Adults
Dietary recommendations in Australia as an example of Western diet comprise one
third grain (cereal) foods (mostly wholegrain and/or high fibre), one third vegetables,
and then the balance comprising high protein foods (lean meats, poultry, eggs, tofu,
fish, nuts, seeds, legumes), dairy and dairy equivalent foods, fruit, with water as the
main drink, small amounts of fats and oils (National Health and Medical Research
Council (NHMRC) 2013). Compared with the diet of Timor-Leste, most foods
consumed are grains (92%), with dietary intake comprising corn, rice, cassava,
sweet potato, peanuts, soy, taro, fruits (bananas), fish and some red meat
(Stojanovska 2013).

Elderly
Challenges presented in nutrition for elderly people are derived from changes in
physiological, psychological and functional abilities, particularly decrease in energy
expenditure.
RDA recommend decrease 10% in calories intake for people aged 51-75 yr
RDA recommend decrease 20-25% in calories intake for people aged 75 yr.

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RDA for iron in women decrease from 18mg (23-50yr) to 10 mg (51 yr).
Physical activity decreases
Loss of muscle mass
Nutrition absorption decreases
Digestive disorders
Frequent dehydration (Stojanovska 2013).

Important nutrition considerations are risks of iron deficiency due to iron availability
and iron absorption. Iron deficiency in elderly may be related to decreased meat
intake, haemorrhoids, ulcers and renal disease (Stojanovska 2013).

Additionally, elderly nutritional considerations include risk of calcium deficiency, that

can lead to osteoporosis and bone fractures (Ca intake decrease, Ca absorption
decrease). The RDI for women aged >51 years old is 1,300 mg/day and for men is
1,000 mg/day, increased to 1,300 mg/day over 70 years (NHMRC 2006).

Other considerations for nutrition in elderly include:

Consume foods high in fibre
Avoid excessive salt intake
To drink plenty of water daily
Chop or grind hard-to-chew foods.
Softer, protein-rich foods can be substituted for meat (Stojanovska 2013).

CONCLUSIONS

Food based dietary guidelines provide useful parameters for modelling health advice
for individuals and populations, however need to be tailored to meet the ethnic and
cultural needs of particular nations as well as specific dietary needs across the
lifespan. The nutritional challenges for Timor-Leste have been recognised and
prioritised, and receiving support from the Government of Timor-Leste with
partnerships from several key organisations in improving nutritional health outcomes
of its population.

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