Association between academic stress during exam period, dietary behavior and bowel symptoms among medical students in Saudi Arabia

Background: The study evaluated the levels of academic stress in medical students and investigated its association with eating habits and bowel symptoms. Methods: Two hundred and ninety seven medical students participated in the study. Medical students from all five years of study were recruited using a stratified random sampling technique. A well-structured questionnaire containing three sections on stress levels, eating habits, and bowel symptoms was self-administered. Student t-test and ANOVA were used to quantify the association between variables. Results: The medical students showed high levels of stress accounting for low (2%), moderate (72%), and high-stress levels (26%) during exams. Men showed higher stress levels than women. The levels of stress were similar in distribution across all years of study. Poor dietary habits were noted among the medical students. Around 66% reported skipping breakfast, and 69% consumed frequent unhealthy snacks. Reduced consumption of fruits less than three times per week (61.5%) and drinking water less than 2 L per day (82.3%) was noted. Mean dietary scores worsened as the stress levels increased (p = 0.007). Similarly, higher PAC-SYM scores were associated with higher stress levels (p < 0.001). Women showed more severe constipation symptoms than men (8.83 ± 8.0 2; 5.68 ± 5.87; p < 0.001). Conclusions: Alarming levels of academic stress were noted during the exam period. There is an urgent need to frame multidisciplinary strategies involving behavior modification, nutrition education and a special focus on stress reduction programs for the medical students.


Introduction
Perception and coping mechanisms to challenging environmental stimuli differ from person to person.Response to stressful situations depends on the level of stress, in the case of mild stress, the response is helpful in terms of productivity while severe stress has been associated with significant and damaging health effects.Academic stress is associated with academic-related challenges and at times overburden which manifests as a negative response.It is defined as a student's psychological state resulting from continuous social and self-imposed pressure in a school environment that depletes the student's psychological reserves. 1The most common academic stressors include exams, presentations, projects, and academic overload, and the individual's stressors include, fear factors, interpersonal difficulties, parents' higher expectations, and limited coping responses. 2,3any research studies have demonstrated the increasingly common occurrence of academic stress among university students.The range can be as high as 84% in Pakistan University students 4 to a lower prevalence of 30% in Western nations like Canada. 5Evidence suggests medical students perceive higher academic-related stress and depression. 6An extensive systematic review evaluating 183 studies from 43 countries relating stress and depression among medical students reported an overall summary estimate prevalence of 27% depression and 11% suicidal ideation among medical students. 6However, the reported range of the prevalence estimates vary from 1.4% to 73.1%. 7Studies from Saudi Arabia have also found higher levels of academic stress of 63% among medical college students of which 25% were severe stress. 8he rigid, competitive, and exhaustive medical curricula in combination with time management and academic overload have generated immense pressure on medical students leading to stress and burnout, depression and anxiety, psychiatric disorders, and suicidal ideation. 9everal studies have associated stress with adverse health effects like cardiovascular disease, diabetes, mental illnesses, and sleeping and eating disorders. 10According to psychologists, behavioral response to stress by way of excess food intake or depleted eating is a coping mechanism that helps find solace and comfort. 11Eating disorders vary in presentation, either under-eating and skipping meals or overeating during a stressful environment. 12Overeating and excess consumption of unhealthy food, and high-calorie food under the influence of stressful stimuli are found to have a common occurrence among adolescents and young adults resulting in obesity and overweight while under-eating results in altered gastric function and changes in bowel habits. 13ecent research from Saudi Arabia showed a strong correlation between levels of stress and pattern of high-calorie consumption among medical students. 14Inconsistencies in food choices and eating behavior vary according to gender and largely depend on factors like the availability of food and individual level of perception.Although reports on prevalence of academic stress exist, studies investigating the impact of academic stress on food behavior and bowel habits among medical students are quite sparse in Saudi Arabia.Hence the present study is conducted to answer the research questionwhat is the level of academic stress of medical students during exam period and how is their eating behavior and bowel habits?Hence, the rationale behind the present study is to assess the levels of academic stress and its association with eating patterns and bowel symptoms during the exam period.

Study description and sampling technique
A cross-sectional study design was used involving subjects selected from all five years of undergraduate study at the College of Medicine in Riyadh, Saudi Arabia.Data collection was done between September and November 2021.A stratified random sampling technique was used based on the academic year of study and gender.The number of students on roll was extracted from each year of study and stratified based on gender.The total sample for each year of study was based on the population proportion size and the gender was balanced proportionally.
Undergraduate medical students who reported any existing psychological disorders, bowel obstruction, inflammatory bowel diseases, chronic conditions, or any ongoing infection were excluded from the study.

Sample size estimation
Considering a 53.2% prevalence of stress from a previous study 15 a confidence level of 95%, a 5% margin of error, and a population size of 1315 students, the minimal sample size required was estimated to be 297.

Data collection
The period of distribution of the questionnaire ranged from two weeks prior to and a maximum of three days after the examinations.The link for the questionnaire was sent through emails.Data were collected using an electronic-based self-administered questionnaire using Google forms.Study variables were age, gender, academic year, and stress level, while the outcome variables included eating habits and constipation symptoms The questionnaire consisted of the consent form and four main sections, (i) socio-economic characteristics of participants.(ii) the stress level of the participants was assessed using the academic stress scale (ASS) 14 containing 16 statements rated on a 5-point Likert scale, from the lowest (Strongly Disagree "0", Disagree "1", Neutral "2", Agree "3" and Strongly Agree "4").The total score for all the questions was added to get the final score ranging from 0 to 64, with categories -low, moderate, or high-stress groups.(iii) Eating habits of participants were assessed using an eating habits questionnaire adopted from a previous study. 16Healthy and unhealthy items were awarded a score of 1 or 0 respectively, obtaining a minimum = 0 and maximum total score = 8, with additional 2 self-assessment questions.(iv) presence of constipation was assessed using PAC-SYM which is a self-reported questionnaire consisting of 11 symptoms divided into three domains: abdominal, rectal, and stool, with responses rated according to the severity of the symptom (No "0", Mild "1", Moderate "2", Severe "3" and Very Severe "4"), the score ranges from 0 to 44 with a low score indicating fewer symptoms and lower severity. 17

Data analysis
Data were analyzed using SPSS 28.0 version (IBM Inc., Chicago, USA) statistical software.Descriptive statistics (frequencies, percentages, mean and standard deviation) was used to describe the categorical and quantitative variables.The univariate analysis included a student's t-test for independent samples, one-way analysis of variance was used for quantitative outcome variables to compare the mean values in relation to the categorical study variables which have more than two options.A p-value of ≤0.05 and 95% confidence intervals were used to report the statistical significance and precision of the results.

Ethical considerations
Ethics approval was obtained from the Institutional Review Board of the University Hospital with reference No. 21/0637/IRB.Informed consent was obtained from each participant, and the confidentiality of information and privacy of the participants were maintained throughout the study.

Socio-demographic details
The study received responses from 425 participants, of which only 299 (70.4%) were included in the final analysis.The distribution of socio-demographic characteristics of the study participants is presented in Table 1.The proportion of males was higher (62.5%).The sample was almost equally distributed across the five academic years.The majority (76%) of the study population reported an income of greater than 10000 SR per month.The distribution of stress scores was computed and the majority of the study population reported moderate stress (71.9%) and 26% showed severe stress.

Eating behavior mean scores
Eating behavior of the participants is displayed in Table 2. Most of the study population (66%) reported to not having breakfast daily, 82.3% consumed less water than the recommended 2 L per day and 64.2% considered their eating habits to be unhealthy.Frequent consumption of snacks like chips and chocolates was found in 69% of the respondents.Three times or more frequent consumption of vegetables and fruits was 60% and 38.5% respectively.Worsened eating habits were reported during the exam period by 58% of the students and 64.2% agreed their diet was unhealthy.
Furthermore, the distribution of mean values of eating habits scores across the stress levels is shown in Table 3.A significant association was found between lower mean scores and higher levels of stress (p = 0.007).In addition, the distribution of scores across gender and years of study was also done.Females scored higher than males in eating scores (3.59 ± 1.64; 3.30 ± 2.03; p = 0.623).The distribution of total mean eating scores across the five years of study was similar and did not show any significant effect (3.26 ± 1.91; 3.49 ± 1.91; 3.42 ± 1.90; 2.93 ± 2.03; 3.70 ± 1.57 for year one to five respectively).

Bowel habits and PAC-SYM scores
A comparison of mean values of PAC-SYM scores across the stress levels of study participants is illustrated in Table 4.A significant association was found between higher stress levels and the severity of constipation symptoms (p < 0.001).
Gender differences in the mean values of PAC-SYM scores are shown in Table 5. Females were found to show increased severity of constipation symptoms for moderate and higher stress levels ((p = 0.047 and p = 0.002 respectively; overall significance is p < 0.001).Furthermore, the overall distribution of PAC-SYM scores according to the years of the study showed a significant difference in constipation symptoms and severity (p = 0.024).Fourth-year medical students appeared to have the highest score (9.17 ± 7.43), the second year had the least score (5.06 ± 5.39) while the first, third, and fifth-year students showed similar scores (6.49 ± 7.57, 6.82 ± 6.59, 6.86 ± 7.14).Table 6 illustrates the linear correlation analysis with academic stress scores.Both bowel habits and eating habits showed significant correlation with increasing levels of stress (p < 0.001).In addition, Fig. 1 shows the linear relation between the bowel symptoms and stress scores.Higher PAC-SYM scores were seen with increasing stress scores.

Prevalence of stress
Academic stress levels vary during different times of graduate studies and the highest concentration of stress is evident during the exam period.The present study, therefore, investigated the association of exam stress among medical students with eating patterns and bowel habits.A large proportion of 72% and 26% of the medical students were either moderately or severely stressed during the exam period.There was a predilection towards the male gender.These findings are consistent with other studies that showed high-stress rates among medical students from India (91.1%),9][20][21] These enormous high rates are a cause of serious concern.Regional literature is also in line with our findings.A recent study among medical students from the Western region of Saudi Arabia reported 85.5% prevalence of stress and 25% severe stress. 22Previous research in 2011 from the same center as the present study had reported 63% total prevalence of stress, and 25% severe stress. 8However, there was a difference in gender association between the two studies, the former showing male preponderance while the latter associated females with higher stress levels.][25] However, from a general psychological perspective, women have been more often reported to have perceived higher loads of stress, with culture, environment, and work status as contributing factors. 26Our finding of male students having higher stress may be related to several reasons like anxiety about future careers, competitive atmosphere, differences in levels of perception, and coping.
The stress levels appear to have similar distribution across the years of study, except in the third year, that had higher levels of stressed participants while the fifth-year students showed lower stress levels, although non-significant.This trend is supported by other studies that demonstrate the third year as a major stressor, followed by marked lower levels in the fifth year. 21,27An explanation to support this finding is based on the academic curriculum design and work overload with the initiation of clinics in addition in the third year.Moreover, by the time, the students reach the final year of study, the adaption mechanism, coping strategies, and experience over the years of study would have gotten them helped to reduce the stressors.On the other hand, some reports are in stark contradiction to these findings that project a progressive rise in stress levels over the years of study and reach the highest level in clinical training. 28

Stress and eating behavior
The stress-related adverse changes in the diet behavior of medical students is another important finding of the study.Deliberate skipping of breakfast reported by 66% of students is appalling.Moreover, consumption of an unhealthy diet was predominant in the form of frequent snacking of fried food and, lesser consumption of fruits and water.Furthermore, only 39.5% consumed three meals a day and 58% reported further deterioration of eating behavior during exams.An inverse relation was evident between increasing levels of stress and poor eating habits score (p = 0.007).These findings demand urgent attention.The negative effects of stress on food behavior are well known.The two entities have a synergistic effect on each other leading to repercussions on the overall health and academic performance of the students.
Established evidence from other studies is in robust support of our findings.Skipping meals and unhealthy diet consumption has been commonly reported in university students that is more pronounced during stressors like exams. 29Medical studies are highly demanding with extensive commitments and dedication to be executed within a shorter period of time.Hence, future physicians develop the risk of facing a profound impact on their health that necessitates the installation of remedial measures at an early phase of graduate studies.

Stress level and severity of bowel symptoms
The significant association of higher PAC-SYM scores with increasing stress levels (p < 0.001) is another important finding of this study.Stress has a direct effect on gastric function.Besides, poor dietary habits manifest a detrimental impact on gastric health and bowel function.The study found a PAC-SYM mean score of 10.4 ± 8.1 among highly stressed students indicating a high degree and severity of constipation symptoms.These findings are suggestive of a significant association between perceived stress and gastrointestinal symptoms.
Another important finding is the female preponderance in constipation symptoms.Females showed significantly higher mean PAC-SYM scores proportional to the level of stress suggesting that women under stress are more prone to develop constipation symptoms than men.Women displaying high stress obtained a mean score of 13.3 ± 9.3 for constipation symptoms with reference to men who scored 7.6 ± 5.8 (p = 0.002).It is worth mentioning that despite having better eating scores than the men; more women appear to suffer from constipation symptoms.
1][32] Lee et al. examined the association between perceived stress and gastrointestinal function in nursing students and found that the students under high stress were at 3.5 times more risk of developing gastrointestinal symptoms. 30Elizabeth et al. demonstrated a positive correlation between irritable bowel syndrome and academic stress in medical students in Mexico. 33All these studies have enumerated exam periods, academic overload, and time management as major stressors.

Limitations
The study contains many limitations.First, the causality cannot be determined since the design of the study does not permit the accomplishment of the cause-effect relationship.Next, the sample size could not adequately meet the generalizability requirements.In addition, single-center studies are not comprehensive and hence cannot be generalized to entire population.The data collection followed the selfadministration method that limits the precision and accuracy in addition to the possibility of recall bias.However, the study provides important findings correlating to stress, eating habits, and bowel symptoms among the medical student community that is sparse in the region of Saudi Arabia.

Conclusion
In conclusion, high levels of stress prevailed among the medical students.The study found varied gender differences in stress levels, eating habits, and bowel symptoms.Men perceived more stress than women did.Women showed better eating habits but had worse constipation symptoms.Year of study did not play a significant role in stress and its negative effects; the distribution was similar in all the years.Dietary habits detrimental to future health like skipping breakfast, frequent snacking, lesser consumption of fruits and water, and eating fewer meals a day were widely prevalent among the future physicians.The stress levels showed a direct effect on poor eating habits and higher constipation symptoms in women.
These findings strongly favor the urgent need to evolve student mental health wellness and counseling programs.Moreover, innovations in the translation of knowledge into practice must be a priority of focus since medical students are already well aware of the negative effects of psychological stress.
In-depth studies that are both qualitative and longitudinal are highly recommended to understand the causality, risk factors, and negative effects of stress on medical students.Comparative studies with western nations are also recommended to determine the effect of medical curricula and social, cultural, and environmental factors.

Table 1
Distribution of sociodemographic characteristics for the study participants (n = 299).
a SR= Saudi Riyal.

Table 2
Distribution of study participants responses towards their Eating habits (n = 299).

Table 3
Comparison of mean values of eating habits scores a across the stress levels of study participants (n = 299).

Table 4
Comparison of mean values of PAC-SYM a scores across the stress levels of study participants (n = 299).
a Patient Assessment of Constipation-Symptoms, lower score indicates fewer symptoms and lower severity.S. Alduraywish et al.

Table 5
Comparison of mean values of PAC-SYM scores between males and females across the stress levels of study participants (n = 299).

Table 6
Linear correlation analysis with academic stress scores.
Fig. 1.Distribution of PAC-SYM scores across mild, moderate and severe stress levels.S. Alduraywish et al.