AbstractBackground: It is well documented that stress and anxiety can lead to over eating and obesity. The objective of the study was to explore the possible effect of academic examination stress on development of overweight/obesity in medical students.Materials and Methods: A cross-sectional study was conducted which included 150 first year medical students  of 2013 batch . Perceived Stress scale questionnaire was given and assessed prior to and during the examination. BMI was calculated prior and after examinations for students with height and weight data.Results: Moderate amount of perceived Stress was prevalent among the students, more in the overweight BMI category of students and both Perceived Stress scores and BMI among medical students increased after exam and was found to be statistically significant.Conclusion: The positive correlation between PSS and B.M.I demonstrated that stress increases the development of overweight/Obesity.

Key words: Perceived Stress Scale(PSS). Obesity. Body Mass Index(BMI)


Stress is defined as body’s nonspecific response to any demand placed upon it whether it is caused by, or results in pleasant or unpleasant conditions.1Medical education is one of the stressful and an emotionally demanding training in which academic stress is one of the major stressor.2

A decline in physical & mental health among medical students has been associated with academic stress-perceived events such as exams, elevated workload or cognitive tasks. 3

There is strong evidence from both human and animal studies that stress can alter eating behaviour and food intake. 4-7

Previous research exploring association between academic examination stress and eating habits in students appears to be inconsistent. Some studies suggest that some are nonresponders to stress 8,some decrease their food intake and some increase their foodintake9-12which can lead to obesity.

The high prevalence of obesity is a major public health problem because of the association of obesity with chronic health conditions such as,Hypertension, Hyperlipidemia,Coronary heart disease, Type 2 diabetes & cerebrovascular accidents. 13

Hence the purpose of the current study was to investigate the possible effect of academic examination stress on development of overweight/obesity in medical students.


Materials and methods:

Study design: This is cross – sectional study at Bangalore Medical College &Research Institute, Karnataka, India, in a period of 2013-2014.

Study subjects: Out of 250 students of the year 2013 batch, 150 were selected as per inclusion and exclusion criteria.100 was males and 50 were females.

Data collection:one hundred and fifty medical students participated in this study All  were told of the objective of the study and then called to participate in it. The data regarding stress levels and obesity were collected both in the pre-examination (one month before the examination) and later in the post-examination period (same day after the examination).  Students with H/O psychiatric illness, medical illness on medication, was excluded from the study .Informed consent were taken. Strict confidentiality was assured to all participants.




Parameters which were studied

Perceived stress scale questionnaire: -10 item perceived stress scale, previously validated and utilized by several successful investigators researching student’s stress levels, was employed. The Perceived Stress Scale is a 10-item self-report questionnaire that measures the persons’ evaluation of the stressfulness of the situations in the past one month of their lives. The Perceived Stress Scale is the only empirically established index of general stress appraisal.
In the present study, the students were explained about the PSS scale questionnaire in detail and were told to tick the appropriate numbers.

Later, the total score was assessed. For each question, they had to choose from the following alternatives:
0 – never , 1 – almost never , 2 – sometimes , 3 – fairly often and 4 – very often
Assessing the PSS score:
The PSS score was determined by the following method: First, by reversing the scores for questions 4, 5, 7 and 8. On these 4 questions, the scores could change from: 0 = 4, 1 = 3, 2 = 2, 3 = 1, 4 = 0. Then, the scores were added up for each item to get the total.

The total score was represented as the stress score:
The individual scores on the PSS could range from 0 to 40, which were grouped into 3 groups.  Scores ranging from 0-13 groped under low stress. Scores ranging from 14-26 grouped under moderate stress. Scores ranging from 27-40 grouped under high perceived stress.

The conventional anthropometric methods were included for the measurement of obesity/overweight, like- weight comparison (with the weight taken prior and after the time of medical examination), B.M.I. (Quetelet Index, WHO criteria). After B.M.I calculation the medical students were classified under various group of (1) underweight(< 18.5), (2) normal weight(18.50-24.99), (3) overweight(25.0-29.9), and (4) obese(30.0-34.9).

Conditions as per the WHO recommendations for adult Europids, 1998.


Statistics: The statistical analysis was done by using the Student’s unpaired ‘t’ test.

Statistical software: The Statistical software namely SAS 9.2, SPSS 15.0, Stata 10.1, MedCalc 9.0.1 ,Systat 12.0 and R environment ver.2.11.1 were used for the analysis of the data and Microsoft word and Excel have been used to generate graphs, tables etc.




Table 1 Comparison of  PSS according to BMI category

BMI(kg/m2) Before examination After examination P value
  • <18.5
21.97±3.36 23.77±4.67 <0.001**
  • 18.5-23
20.98±4.31 21.54±6.01 0.082+
  • 23-25
22.57±3.32 22.86±6.54 0.791
  • >25
21.78±5.87 23.67±6.5 0.027*

+ Suggestive significance (P value: 0.05<P<0.10),

* Moderately significant  ( P value:0.01<P £ 0.05)

** Strongly significant   (P value : P£0.01)

From table 1 shows that the  PSS scores increased from 21.97±3.36 to 23.77±4.67 after examination  in underweight BMI group which was statistically strongly significant (P value: <0.001**).

In normal weight BMI  group also PSS Scores increased from 20.98±4.31 to 21.54±6.01 after examination  which was statistically suggestive of significance (P value: 0.082+).

In overweight BMI group also PSS Scores increased from 22.57±3.32 to 22.86±6.54 after examination  which was not statistically significant (P value: 0.791).

In obese BMI group PSS scores increased from 21.78±5.87 to 23.67±6.5 after examination  which was statistically suggestive of moderate significance (P value: 0.027*).

Table 2   BMI and PSS before exams

BMI 1(Before exam) 



PSS 1 SCORE(Before exam)( Mean±SD)
UNDERWEIGHT(n=29) 12(1) 22 ±2.65(27) 28(1)
NORMAL(n=112) 12(1) 20.42 ±3.26(100) 29.27±2.37(11)
OVERWEIGHT(n=8) 19.33±2.73(6) 31±4.243(2)
OBESE(n=1) 18(1)

Table 3: BMI and PSS immediately after exams

BMI 2(After Exam) PSS 2 SCORE(After exam)(Mean±SD)
UNDERWEIGHT(n=22) 13(1) 22.72±3.2(18) 30.75± 5.5(4)
NORMAL(n=115) 12.2±.79(10) 20.86 ±3.5(81) 29.96 ±3.26(24)
OVERWEIGHT(n=12) 8(1) 20.25  ±3.3(8) 34.5±3.5(2)
OBESE(n=1) 20(1)


Table 2 and table 3 shows that there is decrease in  number of students in       under weight BMI  category ( 29 to 22) and  increase in  number of students in normal (112 to 115) and overweight(8 to 12) BMI  categories. This suggests that weight gain has occurred in students though not to  significant extent.

From table 2 and table 3 we can also observe that among different PSS groups number of students have increased  in mild stress PSS group (2 to 12) and high stress PSS group (14 to 30) PSS groups after examination where as decreased in moderate stress PSS group(134  to 100). This suggests that is increase in number of students with stress in each group.

From table 2 and table 3 also shows that PSS scores have also increased in each groups in mild (12 to 13), moderate (22 ±2.65 to 22.72±3.2), high(28 to 30.75± 5.5)  in underweight category students.

Mild( 20.86 ±3.5 to 20.86 ±3.5) moderate (20.42 ±3.26  to 20.86 ±3.5 ), high (  29.27±2.37 to 29.96 ±3.26) in normal weight category students.

Mild(0- 8), moderate(19.33±2.73 to 20.25  ±3.3), high(31±4.243 to 34.5±3.5) in overweights category students. This also suggests that severity of stress has also increased in all BMI categories of students


Medical college is a challenging environment that requires students to deal effectively with stress borne out of the medical education environment, as well as their personal lives

Stress is defined as nonspecific response of the body under pressure 14 which can lead to favourable results is classified as eustress and unfavourable results like depression or anxiety termed as distress. 15


Previous research had revealed that the academic examinations increased stress level in medical students and may have very different psychological and immunological consequences .16   Our study observed that the perceived stress levels were high and significantly increased after exam. Also B.M.I levels increased significantly after the examination.

Our results suggest that BMI & stress levels were increased in response to the academic stress (examination) which can lead to overeating/weight gain/obesity. Our results are well in agreement with the previous studies where students experience stress during academic examination resulting in increased food intake and B.M.I. (8, 17, 18)




There is strong evidence from both human and animal studies that stress can alter eating behaviour food intake.


In our study we observed that stress is  more  in underweight(23.77±4.67)  and obese (23.67±6.5) BMI category  students(table 1). Examination Stress causes variations in eating behaviour. Some decrease their food intake, some increase their foodintake 9-12which can lead to obesity  as shown by various studies. It is also suggested that some are nonresponders to stress 19,20.


In some Previous studies it was observed that stress-perceived events such as exam-stress,

elevated workloads and cognitive tasks are what result in increases in energy intake.(8,21,22,23). According to the results of a recent study, female medical students exhibited behavioural shifts like an increased consumption of food when stressed, coupled with an increased frequency of emotional eating and sedentary lifestyle leading to overweight/obesity 18. It is observed that people cope up with negative emotions generated by stressful events by engaging in emotional eating. 24


Adolescents report that stress is associated with a shift towards unhealthy eating practices 25

Perceived stress and binge eating frequency three times greater than reported by individuals with low negative stress26Stress induced eating studies have found that a preference for high energy dense food in response to stress, specifically women preferred sweets. 27

Prolonged sleep deprivation increases both food intake and energy consumption, as also a hormone imbalance is observed, leading to weight gain. 28


The immediate response to different stressors is the brain’s evaluation of the threat carried out by the amygdala, hippocampus and pre- frontal cortex .This activates the sympathetic-adrenal- medullary (SAM) axis which releases catecholamines  such as epinephrine.

A more long-term response to stress is mediated by the hypothalamic- pituitary-adrenal (HPA) axis which releases glucocorticoids mainly cortisol29.

 Animal and human studies have demonstrated that cortisol injections are associated with increased appetite, cravings for sugar, and weight gain 12.

Epel et al. demonstrated that premenopausal women who secreted more cortisol during and after novel laboratory stressors chose to consume more foods high in sugar and fat which leads to obesity. 30


High levels of cortisol cause fat stores and excess circulating fat to be relocated and deposited deep in the abdomen, which can develop into or enhance obesity. In addition, hypertension (high blood pressure), hyperlipidemia (elevated lipids), and hyperglycemia (elevated glucose) have been linked to elevated cortisol levels 31,32. Individuals with visceral obesity are at a greater risk for developing cardiovascular disease, type II diabetes mellitus, and cerebrovascular disease.

Stress and anxiety lead to release of naturally occurring opiate B– endorphin,which increases food intake, but also reduces the perception of pain and anxiety associated with stress. Their is increasing evidence to support that some people are prone to eating sweet,fatty,high energy foods during stress which may result in obesity. 33,34,35



In contrary to our results some previous studies observed that professional course environments precipitate high levels of stress, anxiety and depression that may contribute to poor eating habits 36,37,38. Anxiety and depression have been linked to changes in appetite, with a decline in healthy food choices and eating habits.39

It has also been observed in some previous studies that academic examinations are stressful but no significant change was observed in weight of medical students. 19,20


Overweight children scored significantly lower on the psychosocial health score compared to children of normal weight in a Cleveland, Ohio community-based sample.40



A positive correlation between perceived stress scale scores and Body Mass Index showed

Showed that there is a significant effect of academic examination stress on

overeating/weight gain/obesity.

Programs like regular stress assessment and counselling, conducting monthly tests, mock examinations can reduce the impact of academic examination stressor on physical and mental health of medical students.

An effective inclusion and implementation of regular exercise, sports and cultural activities and stress management program like meditation, yoga in the medical curriculum may be a key to reducing and or preventing stress-induced psychological distress and overweight/obesity. We  also  suggest that the examinations which causes mild to moderate stress that will condition the students and the efficacy of the General Adaptation Syndrome will be improved in such subjects.

Acknowledgement: All the first year medical students of 2013 batch who participated in this study.

Source of funding:  Self

Conflict of interest: NIL

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First Author –Dr. Shashikala K.T,                      

 Assistant professor of Physiology,

             Bangalore Medical College & Research Institute


Second Author –Dr. Srinivasulu Naidu.S,                      

 Professor of Physiology,

             Bangalore Medical College & Research Institute





Corresponding Author –

Dr. Shashikala K.T,                      

 Assistant professor of Physiology,

 Bangalore Medical College & Research Institute


Mobile 9611121123,



Using the 12-item General Health Questionnaire (GHQ-12) to assess the Psychological Health of Indian Medical College Students. Shashikala k.t, Mayadevi d.k., Srinivasulu naidu s.