Nutrition knowledge, attitude, and practice in relation to health-related quality of life among urban-poor children in Malaysia: the mediating role of lifestyle factors.
Cheah J, Chin Y, et al. • Health and quality of life outcomes • 2026
Nutrition knowledge influences health-related quality of life among urban-poor children primarily through indirect behavioural pathways—including nutrition attitude, nutrition practice, fast-food intake, supper intake, and physical activity—rather than through a direct pathway.
Key Findings
Results
Nutrition attitude significantly mediated the relationship between nutrition knowledge and nutrition practice in urban-poor children.
The indirect effect estimate was b = 0.034 (95% CI: 0.019, 0.054).
This indicates that improvements in nutrition knowledge translate into better nutrition practice largely through improved attitudes.
Sample consisted of 408 children with a mean age of 9.7 years recruited from ten urban-poor flats in Kuala Lumpur, Malaysia.
A cluster sampling design was used with cross-sectional methodology.
Results
Nutrition knowledge showed no significant direct effect on health-related quality of life (HRQoL) but had significant indirect effects through multiple behavioural pathways.
Indirect effects were statistically significant (p < 0.05).
Behavioural pathways included nutrition attitude, nutrition practice, fast-food intake, supper intake, and physical activity.
Serial mediation analysis was conducted through path analysis to evaluate these inter-relationships.
The absence of a direct pathway suggests knowledge alone is insufficient to improve HRQoL without behavioural translation.
Results
The final serial mediation model explained 32.1% of the variance in HRQoL among urban-poor children.
The model incorporated nutrition KAP, eating behaviours, physical activity, and body composition as variables.
HRQoL was measured using the Pediatric Quality of Life Inventory™ (PedsQL™) 4.0.
Body composition was assessed using InBody 270s bioelectrical impedance analysis.
Physical activity was measured using the Physical Activity Questionnaire for Older Children (PAQ-C).
Results
Fast-food intake, supper intake, and physical activity each served as mediating lifestyle behaviours in the pathway from nutrition KAP to HRQoL.
These lifestyle factors were identified as significant indirect pathway components in the serial mediation analysis.
Eating behaviours were measured using the Eating Behaviours Questionnaire (EBQ).
The findings indicate that specific dietary behaviours (fast-food and supper consumption) and activity levels are key modifiable links between nutrition knowledge and quality of life.
This pathway structure suggests HRQoL is influenced 'primarily through modifiable lifestyle-related behaviours rather than through a direct pathway.'
Background
Children living in urban-poor communities were identified as particularly vulnerable to poor HRQoL due to multiple socioeconomic and environmental disadvantages.
Identified risk factors include socioeconomic disadvantage, food insecurity, constrained food environments, and limited access to health-promoting resources.
Participants were recruited from ten urban-poor flats in Kuala Lumpur, Malaysia using cluster sampling.
The study noted that behavioural pathways through which nutrition KAP affects HRQoL had remained 'insufficiently understood' prior to this work.
408 children participated, with a mean age of 9.7 years.
What This Means
This research suggests that simply teaching children about nutrition is not enough to improve their overall health and well-being. Among 408 children living in low-income urban housing in Kuala Lumpur, Malaysia, researchers found that nutrition knowledge only improved quality of life when it led to better attitudes about food, which in turn shaped actual eating and activity behaviors. Key behaviors in this chain included how often children ate fast food or late-night snacks, and how physically active they were. The model linking all these factors together explained about one-third of the differences in children's reported quality of life.
This research suggests that effective programs for children in low-income urban communities need to go beyond simply providing nutrition information. Because the path from knowledge to better well-being runs through attitudes and daily habits, interventions should actively work to shift children's beliefs and feelings about food, help build healthier routines, reduce habits like frequent fast-food and late-night eating, and encourage physical activity. Addressing only knowledge without targeting these behavioral steps is unlikely to meaningfully improve children's health-related quality of life.
The study also highlights that children in urban-poor settings face a combination of challenges—including food insecurity and limited access to healthy options—that make them especially vulnerable. The findings point to the importance of designing community-based programs that acknowledge these barriers and support sustainable behavior change rather than focusing solely on education.
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Cheah J, Chin Y, Abu Saad H, Lim P, Chan Y, Mohd Shariff Z. (2026). Nutrition knowledge, attitude, and practice in relation to health-related quality of life among urban-poor children in Malaysia: the mediating role of lifestyle factors.. Health and quality of life outcomes. https://doi.org/10.1186/s12955-026-02564-2