Micronutrients and cognitive functions among urban school-going children and adolescents: A cross-sectional multicentric study from India

PLOS ONE RESEARCH ARTICLE Micronutrients and cognitive functions among urban school-going children and adolescents: A cross-sectional multicentric study from India Shweta Singh1, Shally Awasthi ID2*, Divas Kumar2, Seema Rani Sarraf1, Anuj Kumar Pandey2, Girdhar G. Agarwal3, Avivar Awasthi4, Anish T. S.5, Joseph L. Mathew6, Sonali Kar7, Suma Nair ID8, Chythra R. Rao ID8, Harsh Pande2, B. N. Mahanta9, Bhavneet Bharti6, C. M. Singh10, Kuldeep Singh ID11, Mushtaq A. Bhat12, Somashekar A. R.13, Rajiv Awasthi14, Abbas Ali Mahdi15 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 OPEN ACCESS Citation: Singh S, Awasthi S, Kumar D, Sarraf SR, Pandey AK, Agarwal GG, et al. (2023) Micronutrients and cognitive functions among urban school-going children and adolescents: A cross-sectional multicentric study from India. PLoS ONE 18(2): e0281247. https://doi.org/10.1371/ journal.pone.0281247 Editor: Hesham M. Al-Mekhlafi, Jazan University, SAUDI ARABIA Received: March 31, 2022 Accepted: January 18, 2023 Published: February 2, 2023 Copyright: © 2023 Singh et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper. Funding: This work was supported by a grant from Hindustan Unilever Limited (Grant Number: 212332). Funding supports all study related expenses including manuscripts processing fees. Funding source was not involved in study design, implementation, collection and interpretation of data and in writing of the manuscript. 1 Department of Psychiatry, King George’s Medical University, Lucknow, Uttar Pradesh, India, 2 Department of Pediatrics, King George’s Medical University, Lucknow, Uttar Pradesh, India, 3 Department of Statistics, University of Lucknow, Lucknow, Uttar Pradesh, India, 4 Department of Endocrinology, Medical College, Kolkata, India, 5 Department of Community Medicine, Government Medical College, Thiruvananthapuram, Kerela, India, 6 Department of Pediatric Medicine, Post Graduate Institute of Medical Sciences, Chandigarh, India, 7 Department of Community Medicine, Kalinga Institute of Medical Sciences, Bhubaneswar, Orissa, India, 8 Department of Community Medicine, Kasturba Medical College, Manipal, Karnataka, India, 9 Department of Medicine, Assam Medical College, Dibrugarh, Assam, India, 10 Department of Community & Family Medicine, All India Institute of Medical Sciences, Patna, Bihar, India, 11 Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India, 12 Department of Pediatrics, Sher-iKashmir Institute of Medical Sciences, Srinagar, Jammu & Kashmir, India, 13 Department of Pediatrics, M. S. Ramaiah Institute of Medical Sciences, Bangalore, Karnataka, India, 14 Prarthana Diabetic Care Centre, Lucknow, Uttar Pradesh, India, 15 Department of Biochemistry, King George’s Medical University, Lucknow, Uttar Pradesh, India * Abstract Background Micronutrient deficiency (MD) is associated with deficits in cognitive functioning of children. However, no comprehensive multicentric study has been conducted in India to explore the role of multiple MD in cognition of children and adolescents. The present study aimed to explore association of MD with level of general intelligence and specific cognitive functions, in urban school-going children and adolescents across ten cities of India. Method Cross-sectional multicentric study, enrolled participants aged 6–16 years. Blood samples were collected for biochemical analysis of calcium, iron, zinc, selenium, folate, vitamin A, D and B12. Colored Progressive Matrices / Standard Progressive Matrices (CPM/SPM), Coding, Digit Span and Arithmetic tests were used for the assessment of cognitive functions of participants. Height and weight measures were collected along with socio-economic status. Results From April-2019 to February-2020, 2428 participants were recruited from 60 schools. No MD was found in 7.0% (134/1918), any one MD in 23.8% (457/1918) and � 2 MD in 69.2% PLOS ONE | https://doi.org/10.1371/journal.pone.0281247 February 2, 2023 1 / 14 PLOS ONE Competing interests: The authors declare that they have no competing interests. Micronutrients and cognitive function of school going children in India (1327/1918) participants. In presence of � 2 MD, adjusted odds ratio (OR) for borderline or dull normal in CPM/SPM was 1.63, (95% CI: 1.05–2.52), coding was 1.66 (95% CI: 1.02– 2.71), digit span was 1.55 (95% CI: 1.06–2.25) and arithmetic was 1.72 (95% CI: 1.17– 2.53), controlling for gender, socioeconomic status and anthropometric indicators. Conclusion Since � 2 MD were found in more than 2/3rd of participants and was associated with impairment in cognitive function, attempts must be made to ameliorate them on priority in school going children in India. Trial registration number CTRI/2019/02/017783. Introduction Micronutrients are vital components of diet that are required for a wide range of physiological and cognitive functions. Being integral to various metabolic pathways in the brain, the deficiency of a micronutrient can potentially impact the development and functioning of the nervous system adversely. Due to this, every year, millions of children are affected not only from physiological challenges (stunted growth, weakened immunity and physical diseases) but also cognitive and intellectual deficits [1–4]. Studies demonstrate that deficiency of micronutrients is associated with children’s impaired cognitive development and poor classroom performance [5–7]. Various micronutrients and hemoglobin have a major role in physical and cognitive development. Poor cognitive development, loss of concentration and even lower intelligence has been reported with deficiencies of iron [8], vitamin B12 [9, 10] and folate [11, 12]. Impaired behavior and cognition have also been reported with deficiency of zinc [13] and vitamin D [14]. Studies conducted in India, among school aged children and adolescents, reported widespread deficiency of micronutrients [7, 15–19]. However, no comprehensive multicentric study has been conducted in India to assess the impact of various crucial micronutrient deficiencies on general intelligence as well as specific cognitive functions in children and adolescents. The present study set out to explore association of micronutrient deficiency with level of general intelligence, and specific cognitive functions, i.e. attention, concentration, visuomotor coordination and working memory, in urban school-going children and adolescents aged 6 to 16 years across ten cities of India. The primary objective was to assess the association of no micronutrient deficiency, any one or �2 micronutrient deficiencies with cognitive performance as determined by Colored Progressive Matrices (CPM) / Standard Progressive Matric (...truncated)