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  1. Koo HC, Poh BK, Talib RA
    Nutrients, 2020 Sep 29;12(10).
    PMID: 33003299 DOI: 10.3390/nu12102972
    Diet composition is a key determinant of childhood obesity. While whole grains and micronutrients are known to decrease the risk of obesity, there are no interventions originating from Southeast Asia that emphasize whole grain as a strategy to improve overall quality of diet in combating childhood obesity. The GReat-Child Trial aimed to improve whole grain intake and quality of diet among overweight and obese children. It is a quasi-experimental intervention based on Social Cognitive Theory. It has a 12-week intervention and 6-month follow-up, consisting of three components that address environmental, personal, and behavioral factors. The intervention consists of: (1) six 30 min lessons on nutrition, using the Malaysian Food Pyramid to emphasize healthy eating, (2) daily deliveries of wholegrain foods to schools so that children can experience and accept wholegrain foods, and (3) diet counseling to parents to increase availability of wholegrain foods at home. Two primary schools with similar demographics in Kuala Lumpur were assigned as control (CG) and intervention (IG) groups. Inclusion criteria were: (1) children aged 9 to 11 years who were overweight/obese; (2) who did not consume whole grain foods; and (3) who had no serious co-morbidity problems. The entire trial was completed by 63 children (31 IG; 32 CG). Study outcomes were measured at baseline and at two time points post intervention (at the 3rd [T1] and 9th [T2] months). IG demonstrated significantly higher intakes of whole grain (mean difference = 9.94, 95%CI: 7.13, 12.75, p < 0.001), fiber (mean difference = 3.07, 95% CI: 1.40, 4.73, p = 0.001), calcium (mean difference = 130.27, 95%CI: 74.15, 186.39, p < 0.001), thiamin (mean difference = 58.71, 95%CI: 26.15, 91.28, p = 0.001), riboflavin (mean difference = 0.84, 95%CI: 0.37, 1.32, p = 0.001), niacin (mean difference = 0.35, 95%CI: 1.91, 5.16, p < 0.001), and vitamin C (mean difference = 58.71, 95%CI: 26.15, 91.28, p = 0.001) compared to CG in T1, after adjusting for covariates. However, T1 results were not sustained in T2 when intervention had been discontinued. The findings indicate that intervention emphasizing whole grains improved overall short-term but not long-term dietary intake among schoolchildren. We hope the present trial will lead to adoption of policies to increase whole grain consumption among Malaysian schoolchildren.
  2. Koo HC, Poh BK, Abd Talib R
    Nutrients, 2018 Jan 30;10(2).
    PMID: 29385769 DOI: 10.3390/nu10020156
    Background: The GReat-Child Trial was a quasi-experimental intervention that has emphasized whole grain as a strategy to manage childhood obesity. Methods: Two schools in Kuala Lumpur with similar demographic characteristics were assigned as intervention (IG) and control (CG). Eligibility criteria were overweight/obese children aged 9 to 11 years who had no serious co-morbidity. Children who reported consuming wholegrain foods in their 3-day diet-recall during screening were excluded. A total of 63 children (31 IG; 32 CG) completed the entire intervention program. The IG children underwent six 30-min nutrition education lessons and had school delivery of wholegrain food on a daily basis over a 12-week period. Parents of IG children attended 1-h individual diet counseling. Anthropometric outcomes including BMI-for-age z-score (BAZ), body fat percentage and waist circumference were measured at baseline [T0], post-intervention [T1] (3rd month) and follow-up [T2] (9th month). Results: IG showed significantly lower BAZ (weighted difference: -0.12; 95% CI: -0.21, -0.03; p = 0.009), body fat percentage (weighted difference: -2.6%; 95% CI: -3.7, -1.5; p < 0.001) and waist circumference (weighted difference: -2.4 cm; 95% CI: -3.8, -1.0; p = 0.001) compared to CG. IG reported significantly lower body fat percentage (weighted difference: -3.4%; 95% CI: 1.8, 5.0; p < 0.001) and waist circumference (weighted difference: -2.1 cm; 95% CI: -3.7, -0.5; p = 0.014) at T1 compared to T0. Conclusions: The GReat-Child Trial made a positive impact in managing childhood obesity. It can be incorporated into childhood obesity intervention programs that are being implemented by the policy makers.
  3. Koo HC, Hadirah Z, Airina A, Nurul Alifatul Amrina R, Faziela N
    Afr Health Sci, 2019 Jun;19(2):2243-2251.
    PMID: 31656510 DOI: 10.4314/ahs.v19i2.50
    BACKGROUND: Dietary composition is the cornerstone of weight management. This study aimed to investigate the effect of nutrient intakes on anthropometric profiles among university students.

    METHODS: This cross-sectional study was conducted among 411 students aged 18-29 years, purposive sampled from a selected private university in Klang Valley, Malaysia. Anthropometric profiles were measured. Nutrient intakes were assessed by 3-day 24-hour diet recalls.

    RESULTS: Respondents on average had adequate macronutrient intakes, however, total consumption of dietary fiber and micronutrients were fell short of recommended levels. Significant negative associations were found between body mass index (BMI) and all the macronutrients, calcium, thiamine, riboflavin and niacin. Body fat percentage was significantly associated with all the macronutrients, calcium, zinc, thiamine and niacin. Significant inverse associations were also found between waist circumference and carbohydrate, fiber, thiamine, riboflavin and niacin. Visceral fat showed significant inverse associations with carbohydrate, fat, fiber, thiamine, riboflavin and niacin. Further, after adjusting for sex, gender and race, BMI was associated with niacin (β=-0.161, p=0.027). Body fat percentage was also found significantly associated with niacin (β=-0.180, p=0.002) and riboflavin (β=-0.132, p=0.014).

    CONCLUSION: Micronutrients, especially B vitamins, are important in weight management among the young adults.

  4. Koo HC, Abdul Jalil SN, Ruzita AT
    Malays J Med Sci, 2015;22(1):32-9.
    PMID: 25892948
    BACKGROUND: Studies from the West have demonstrated that ready-to-eat cereals (RTECs) are a common form of breakfast and more likely to be consumed by children. This study aimed to investigate the breakfast eating pattern and RTECs consumption among schoolchildren in Kuala Lumpur.
    METHODS: In this cross-sectional study, a total of 382 schoolchildren, aged 10 and 11 years old, were recruited from seven randomly selected primary schools in Kuala Lumpur. Information on socio-demographics, breakfast eating patterns, and perceptions of RTECs and dietary intake (24-hour dietary recalls) were obtained.
    RESULTS: Among the respondents, only 22% of them consumed breakfast on a regular basis. The most commonly eaten food by children at breakfast was bread (27.2%), followed by biscuits (22.2%) and RTECs (20.5%). The majority of them (93%) reported that they consumed RTECs sometimes during the week. Chocolate RTECs (34.1%), corn flake RTECs (30.3%), and RTECs coated with honey (25.1%) were the most popular RTECs chosen by children. Respondents who consumed RTECs showed a significantly higher intake in calories, carbohydrate, vitamin A, vitamin B1, vitamin B2, vitamin B3, folate, vitamin C, calcium, iron, and fibre (P < 0.05), compared to those who skipped breakfast and those who had breakfast foods other than RTECs.
    CONCLUSION: The lower levels of breakfast consumption among schoolchildren in Kuala Lumpur need serious attention. RTEC is a nutritious food which is well accepted by a majority of the schoolchildren in Kuala Lumpur. Nutrition intervention should be conducted in the future to include a well-balanced breakfast with the utilisation of RTECs for schoolchildren.
    KEYWORDS: Malaysia; breakfast; calorie; cereals; children
  5. Ng CM, Kaur S, Koo HC, Mukhtar F
    J Hum Nutr Diet, 2022 Apr;35(2):350-362.
    PMID: 33938062 DOI: 10.1111/jhn.12911
    BACKGROUND: Emerging research has explored hands-on meal preparation as a strategy to improve children's nutrition-related outcomes. This scoping review was conducted to describe the extent of studies on children's involvement in hands-on meal preparation and the related psychosocial outcomes, actual nutrition behaviour/food consumption and weight status.

    METHODS: Scoping review methodology was used to select relevant studies, as well as extract and collate the data. Four databases (PubMed, Google Scholar, Science Direct and Cochrane Database of Systematic Reviews) were searched from the earliest available time up to December 2020. Observational studies, experimental studies and reviews that were conducted among children aged 5-12 years old and published from 2010 to 2020 were retrieved. Studies extracted involved children in hands-on healthy meal preparation activities and explored the associated nutrition outcomes.

    RESULTS: In total, 28 studies (5 observational studies, 21 experimental studies, 2 reviews) were included in the final review. Studies conducted demonstrated improvement in children's psychosocial outcomes and actual nutrition behaviour/food consumption after participating in hands-on meal preparation activities, despite differences in methodology, programme content and settings (countries/cultural origins). Limited studies assessed children's nutrients intake and weight status.

    CONCLUSIONS: The current review suggests that hands-on meal preparation comprises approach for instilling positive perceptions towards nutrition/healthy foods, potentially improving children's diet. Future studies should include the assessment of nutrient intake and weight status. The long-term sustainability of these nutrition outcomes should be explored.

  6. Koo HC, Lim GP, Kaur S, Chan KQ, Chan KE, Chung C, et al.
    Children (Basel), 2021 Jul 02;8(7).
    PMID: 34356548 DOI: 10.3390/children8070569
    BACKGROUND: Optimal bone health is vital in children to prevent osteoporosis later in life, and body composition plays a crucial role in it. However, the literature reports contradictory results when considering the relationship between body composition and bone health in children. This study aimed to examine the bone health and its relationship with body composition in Malaysian schoolchildren.

    METHODS: In this cross sectional study, body composition data (weight, height, body fat percentage [% fat], fat mass, fat free mass, visceral fat, waist circumference [WC] and body mass index-for-age [BMI z-score]) and bone health data (Z-score and broadband ultrasound attenuation [BUA]) were collected from 415 schoolchildren aged 9-12 years, cluster sampled from randomly selected primary schools in Kuala Lumpur, Malaysia.

    RESULTS: Girls generally had significantly higher height, body fat percentage, fat mass, visceral fat and Z-score as compared to boys. A steady increase of the mean BUA value was observed with increasing age in both sexes. The mean BUA value of the present study across the population was significantly higher than that of schoolchildren from Nigeria (p < 0.001), Colombia (p < 0.001) and Spain (p = 0.002). Significant positive correlations were found between all the body composition variables and bone outcome variables across the population. Further, BUA was significantly correlated with weight (β = 0.172; p = 0.001), height (β = 0.299; p < 0.001), % fat (β = 0.131; p = 0.007), fat mass (β = 0.130; p = 0.007), fat free mass (β = 0.209; p < 0.001), visceral fat (β = 0.127, p = 0.008), WC (β = 0.165; p = 0.001) and BMI z-score (β = 0.162; p = 0.001), after controlling for sex, age and ethnicity. Similarly, after confounders adjusted, Z-score was significantly predicted by weight (β = 0.160; p = 0.001), height (β = 0.310; p < 0.001), % fat (β = 0.104; p = 0.032), fat mass (β = 0.107; p = 0.026), fat free mass (β = 0.218; p < 0.001), visceral fat (β = 0.107, p = 0.026), WC (β = 0.145; p = 0.002) and BMI z-score (β = 0.150; p = 0.002).

    CONCLUSIONS: Our findings have revealed that body composition variables were positive correlated with bone outcome variables, suggesting that adipose tissue acts to stimulate bone growth. Further clinical and molecular studies in the future is recommended to fully illustrate the complex interactions between adiposity and bone health.

  7. Ng CM, Satvinder K, Koo HC, Yap RWK, Mukhtar F
    Int J Vitam Nutr Res, 2021 Sep;91(5-6):522-530.
    PMID: 32463351 DOI: 10.1024/0300-9831/a000655
    Involving school-age children in the preparation of healthy meals is shown to be associated with positive eating behavior. Yet, it remains unclear whether this can extend to their nutritional status. The present study aimed to determine the association of school-age children's psychosocial factors (knowledge, attitude, practice, self-efficacy) towards healthy meal preparation with their nutritional status (BMI-for-age, waist circumference, body fat percentage). Stratified random sampling was used to select primary schools (n = 8) in Kuala Lumpur, Malaysia. Two hundred school children aged between 9-11 years old were involved. Psychosocial factors towards healthy meal preparation were assessed using validated questionnaire. Anthropometry measures were determined using standard protocol. Almost half (46 %) of the school-age children were obese/overweight, 39 % were abdominally obese and 40 % were overfat. Approximately half had poor knowledge (49 %), poor practice (45 %), good attitude (56 %) and good self-efficacy (47 %) towards healthy meal preparation. Significant positive correlations were observed between knowledge with attitude (r = 0.23, p 
  8. Ng CM, Kaur S, Koo HC, Mukhtar F, Yim HS
    J Nutr Educ Behav, 2022 Feb;54(2):100-108.
    PMID: 35148868 DOI: 10.1016/j.jneb.2021.04.006
    OBJECTIVE: To evaluate the effectiveness of a culinary nutrition education intervention on children's home food availability and psychosocial factors related to healthy meal preparation.

    DESIGN: Randomized-controlled trial.

    SETTING: Schools in Kuala Lumpur, Malaysia.

    PARTICIPANTS: Eighty-three school children aged 10-11 years and their parents.

    INTERVENTION: Twelve weeks of culinary nutrition education with 5 hands-on healthy meal preparation modules and a module with parents on home food availability (conducted every 2 weeks).

    MAIN OUTCOME MEASURES: Psychosocial factors (knowledge, attitude, practice, and self-efficacy) related to healthy meal preparation and home food availability (fruits, vegetables, healthful foods, and less healthful foods) assessed via children and parents, respectively, using validated questionnaires at baseline, postintervention, and 3-month follow-up.

    ANALYSIS: Repeated measures ANOVA.

    RESULTS: Intervention group had a higher (P < 0.001) mean knowledge score (mean difference, 1.2), attitude (mean difference, 2.6), practice (mean difference, 4.4) and self-efficacy (mean difference, 3.9) of healthy meal preparation as compared with control group across 3-time points. Improvements were seen in the availability of fruits (mean difference, 3.0; P < 0.001), vegetables (mean difference, 2.4; P < 0.001), healthful foods (mean difference, 1.5; P < 0.001) and less healthful foods (mean difference, -0.9; P = 0.001), favoring the intervention group.

    CONCLUSION AND IMPLICATIONS: Culinary nutrition education had positive impact on children's psychosocial factors and home food availability, demonstrating the potential to improve children's nutrition.

  9. Koo HC, Tan LK, Lim GP, Kee CC, Omar MA
    PMID: 36833764 DOI: 10.3390/ijerph20043058
    This study aimed to report the prevalence of obesity, classified using Asian cut-off, and its relationships with undiagnosed diabetes mellitus, high blood pressure, and hypercholesteremia. We analyzed the nationally representative data from 14,025 Malaysian adults who participated in the NHMS 2015. The relationship between obesity and undiagnosed diabetes mellitus, high blood pressure, and hypercholesteremia was determined using multivariable logistic regressions, and lifestyle risk factors and sociodemographic characteristics were adjusted. The undiagnosed high blood pressure group showed the highest proportionate of overweight/obese (80.0%, 95% CI: 78.1-81.8) and central obesity (61.8%, 95% CI: 59.3-64.2). Inverse association was observed between underweight with undiagnosed high blood pressure (aOR: 0.40, 95% CI: 0.26-0.61) and hypercholesterolemia (aOR: 0.75, 95% CI: 0.59-0.95) groups. In contrast, positive relationships were shown between overweight/obese and risk of undiagnosed diabetes mellitus (aOR: 1.65, 95% CI: 1.31-2.07), high blood pressure (aOR: 3.08, 95% CI: 2.60-3.63), and hypercholesterolemia (aOR: 1.37, 95% CI: 1.22-1.53). Likewise, central obesity was positively associated with a risk of undiagnosed diabetes mellitus (aOR: 1.40, 95% CI: 1.17-1.67), high blood pressure (aOR: 2.83, 95% CI: 2.45-3.26), and hypercholesterolemia (aOR: 1.26, 95% CI: 1.12-1.42). Our findings indicated the importance of periodical health examinations to assess the risk of non-communicable diseases among the general and abdominal obese Malaysian adults.
  10. Ng CM, Satvinder K, Koo HC, Yap RWK, Mukhtar F
    Matern Child Nutr, 2020 Dec;16 Suppl 3(Suppl 3):e13054.
    PMID: 33347728 DOI: 10.1111/mcn.13054
    The involvement of children in healthy meal preparation activities has emerged as a potential strategy to promote healthy eating behaviour among children. However, there is a lack of understanding of children's internal (psychosocial factors) and external factors (home food availability) that may support the practice of preparing healthy meals. This study aimed to determine children's psychosocial factors of healthy meal preparation within themselves and their external environment of home food availability as predictors for the practice of healthy meal preparation. Public schools (n = 8) from all three zones (Bangsar-Pudu, Keramat and Sentul) in Kuala Lumpur, Malaysia, were selected through stratified random sampling. Two hundred children aged 9-11 and their parents participated. Children's psychosocial factors towards healthy meal preparation and their home food availability were assessed through children and parents, respectively, using validated questionnaires. Majority of the schoolchildren (86.5%) had poor practice of healthy meal preparation. Increased attitude (r = 0.344, P < 0.001) and self-efficacy (r = 0.501, P < 0.001) of healthy meal preparation and the availability of fruits (r = 0.304, P < 0.001), vegetables (r = 0.243, P < 0.001) and healthful ready-to-eat foods (r = 0.227, P = 0.001) at home were positively correlated with the practice of preparing healthy meals. After adjusting for age, sex and monthly household income, increased self-efficacy (P < 0.001), availability of fruits (P = 0.01) and lower availability of less healthful ready-to-eat food (P = 0.01) were associated with better healthy meal preparation practices. Outcomes revealed that positive self-efficacy of healthy meal preparation, home food availability of fruits and less healthful alternatives were associated with the practice of healthy meal preparation and thus should be targeted in future health-promotion strategy.
  11. Koo HC, Poh BK, Lee ST, Chong KH, Bragt MC, Abd Talib R, et al.
    Asia Pac J Public Health, 2016 07;28(5 Suppl):8S-20S.
    PMID: 27073200 DOI: 10.1177/1010539516641504
    A large body of epidemiological data has demonstrated that diet quality follows a sociodemographic gradient. Little is known, however, about food group intake patterns among Malaysian children. This study aimed to assess consumption pattern of 7 food groups, including cereals/grains, legumes, fruits, vegetables, fish, meat/poultry, and milk/dairy products, among children 7 to 12 years of age. A total of 1773 children who participated in SEANUTS Malaysia and who completed the Food Frequency Questionnaire were included in this study. A greater proportion of children aged 10 to 12 years have an inadequate intake of cereals/grains, meat/poultry, legumes, and milk/dairy products compared with children 7 to 9 years old. With the exception of meat/poultry, food consumption of Malaysian children did not meet Malaysian Dietary Guidelines recommendations for the other 6 food groups, irrespective of sociodemographic backgrounds. Efforts are needed to promote healthy and balanced dietary habits, particularly for foods that fall short of recommended intake level.
  12. Chong GY, Kaur S, Ruzita AT, Wilfred Mok KH, Tan HY, Loy SL, et al.
    Chronobiol Int, 2024 Jun;41(6):904-923.
    PMID: 38832541 DOI: 10.1080/07420528.2024.2360742
    Chrononutrition, an emerging body of evidence on the relationship between biological rhythms and metabolism, has been established to be associated with glycemic responses. However, the available evidence is inconsistent, due to protocol variations. Therefore, this review aims to summarize the findings on chrononutrition characteristics and their association with glycemic responses among adults. Systematic searches were conducted across six databases (PubMed, EBSCO Host, ProQuest Central, MEDLINE & Ovid, Scopus and Web of Science) to identify all relevant studies published from January 2012. Two reviewers independently screened the abstracts and full-text articles based on the inclusion and exclusion criteria. Details about population characteristics, study methods and key findings were extracted following the PRISMA-ScR guideline. The quality of selected studies was evaluated using the mixed methods appraisal tool. The searchers identified 49 studies eligible for analysis. The results showed that meal timing, particularly night-time eating and snacking were associated with glycemic responses. Regarding meal regularity, skipping breakfast may affect glycemic responses, but no clear conclusion was drawn about its effect on insulin. The association between meal frequency and glycemic responses was inconclusive. Night fasting duration and restricted eating window are potentially associated with glycemic responses. The current review extensively investigates the association between chrononutrition factors and glycemic responses in adults. However, more prospective cohort and interventional studies are needed to better understand this causal-effect relationship.
  13. Chong GY, Kaur S, Talib RA, Loy SL, Tan HY, Mok KHW, et al.
    PLoS One, 2025;20(2):e0313931.
    PMID: 39951411 DOI: 10.1371/journal.pone.0313931
    Chrononutrition, which examines the relationship between circadian rhythms and nutrition, has been associated with glycemic outcomes in adults. However, published data on delayed meal timing, increased meal frequency and frequent breakfast skipping have shown inconsistent glycemic outcomes due to variations in methodologies and populations studied. This review presents the scoping review protocol designed to map the evidence on the association between chrononutrition factors and glycemic outcomes in adults. The methodology framework from Arksey and O'Malley will be adapted for this scoping review. Relevant publications will be searched on databases including PubMed, EBSCO Host, ProQuest Central, MEDLINE & Ovid, Scopus and Web of Science. This review focuses on original articles published from January 2014 to 2024, involving participants aged 18 years and older, published in English, and encompassing experimental and observational studies. A comprehensive keyword search strategy will be developed to identify relevant articles. Two reviewers will independently screen the abstracts and titles to determine the eligibility. Subsequently, the full text of potentially eligible articles will be reviewed by additional independent reviewer for final inclusion, with full text screening being verified by two reviewers, and interrater reliability will be conducted. Data from the included articles will be extracted, collated and charted to summarize the relevant methods, outcomes and key findings. This Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist will be used to guide the development of protocol. This scoping review represents a novel approach to summarize the association between chrononutrition factors and glycemic outcomes among adults. We anticipate the findings of the review will provide stakeholder with crucial evidence-based information for development of effective intervention to manage glycemic outcome in adults. This protocol has been prospectively registered in the Open Science Framework (https://doi.org/10.17605/OSF.IO/PA9BU).
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