Abstract
Background
Medical students are affected both psychologically and physically due to the change in environment for most from home to the hostel and the extensive undergraduate curriculum. This study was undertaken to assess psychological distress and measure surrogate markers of the physical health risk score in a medical college in South India.
Methods
The study group included three batches of medical students, from first to third year. Along with anthropometric measurements and a questionnaire on personal history, the Indian Diabetic Risk Score (IDRS), and the Kessler’s psychological distress scale based on K10 questions were applied and assessed for each participant.
Results
There were gender differences in the association of IDRS with physical activity, Body Mass Index (BMI), Waist Hip Ratio (WHR), and sleep. More than one-third of medical students had various psychological distress grades (40%) and were at risk of developing diabetes (36.7%). There was a significant difference in the K10 scores (p = 0.000) among the three groups, with the first-year students showing maximum psychological distress.
Conclusions
A large number of medical students undergo psychological distress and also are at risk for developing Diabetes Mellitus. Long-term cohort studies are needed to assess the effect of such stress on medical students.
Keywords: Psychological stress, Diabetes, Medical students, Questionnaires, Risk
Introduction
Joining the undergraduate medical education program in India is a big transition for students, not only in the study environment but also in terms of the volume of the curriculum, time allocated for completion of the course, expectations from family and self and the responsibility of patient care.1 Due to academic pressures, our students have reduced physical activity, sleep disturbances, and precipitation of psychosomatic manifestations, especially in those who cannot cope. All these accumulated over time affects our students both physically and psychologically. Diabetes mellitus (DM) is a significant health problem among Indians, and several recent reports reveal an increasing incidence among the youth.2 This study was undertaken to assess psychological distress and to measure surrogate markers of physical health risk scores among medical students.
Material and methods
This cross-sectional study was conducted in a medical college in South India. The approval from the Institutional Ethics Committee and written consent from students who volunteered to participate were obtained. The study group included three consecutive batches of medical students, from first to third year, who were not having any immediate exams. The fourth and final year students were not included as they had their final university exams in the upcoming months.
The semi-structured questionnaire included information like age, gender, average study, and sleep duration on a regular day when they had no assignment submission or exam scheduled.
The Indian Diabetic Risk Score (IDRS) is a low cost and validated screening tool that is calculated using age, physical activity, waist circumference, and family history of DM and identifies individuals at risk of developing Type 2 DM.3 The IDRS was totalled, and anthropometric measures were taken using standard guidelines, and the Body Mass Index (BMI), Waist Hip Ratio (WHR), were calculated applying standard formulae. IDRS of 30–59 and ≥ 60 were considered moderate and high risk, respectively, for developing DM.4 Kessler’s psychological distress scale based on K10 questions was used to assess psychological distress.5 This is a 10-question screening scale of psychological distress, which can be easily applied and has a role in community screening which is used across the world, even by the World Health Organization. There are 10 questions with a score between 1 and 5, thereby giving us a final minimum score of 10 and a maximum score of 50. Low and high scores indicate less and more psychological distress respectively: The classification of scores are as follows 10–19 = likely to be well, 20–24, 25–29, and 30–50 were likely to have mild, moderate or severe psychological distress, respectively.
Results
A total of 300 students were included in the study comprising 100 students from each batch. The data of all three batches of medical students were tested for normality using the Kolmogorov Smirnov test in SPSS 19.0v. The data for age, K10 scores, BMI, and IDRS, were normally distributed, thus represented as mean and standard deviation (SD) (Table 1). On comparing the groups using one-way ANOVA, there was a significant difference in age (p = 0.000) with an increasing trend with seniority, as expected. The psychological score from the K10 questionnaire showed a significant difference within the groups (p = 0.000), but the Bonferroni Post Hoc test showed a difference between the first and second year batches when compared to the third year students. The latter batch had a lower K10 score than the former two batches (p = 0.001, 0.000). Although the BMI was within normal limits, it was not different within the groups; the IDRS score was between 30 and 59, showing moderate risk in all three batches. It was highest in the third year batch, which was statistically different from the second year (p = 0.011) batch but not the first year (p = 0.09) batch with an overall p of 0.01. The medians and interquartile ranges (IQR) were compared using the Kruskal Wallis test for the data that were not normally distributed. There was a statistically significant difference in WHR (p = 0.000), duration of physical activity (p = 0.000) and sleep (p = 0.012). Although there was a significant rise in abdominal obesity, physical activity, and sleep with senior male students, there was no significant increase in the BMI in the third year students.
Table 1.
General characteristics of the three batches of MBBS students.
| First Year | Second Year | Third Year | p | |||
|---|---|---|---|---|---|---|
| AGE | Mean (SD) | 18.73 (0.763) | 19.11 (0.723) | 20.91 (0.954) | One way ANOVA | 0 |
| K 10 | 19.56 (6.697) | 20.02 (4.761) | 16.73 (4.4) | 0 | ||
| BMI | 22.18 (3.52) | 21.8 (4.1) | 21.3 (3.1) | 0.233 | ||
| IDRS | 32.9 (9.244) | 31.9 (8.61) | 35.8 (10.2) | 0.01 | ||
| WHR | Median (IQR) | 0.78 (0.76–0.81) | 0.79 (0.76–0.82) | 0.83 (0.78–0.87) | Kruskal Wallis Test | 0 |
| Physical activity | 0 (0,1) | 0 (0,0) | 0.5 (0,1) | 0 | ||
| Sleep | 6 (5,6.5) | 6 (6,7) | 7 (6,8) | 0.012 | ||
Table 2 depicts the differences in correlation with psychological and physical stress among the female and male students in all batches. Among the girls, the positive correlation of BMI with IDRS (p < 0.01) and the negative correlation of BMI with sleep (p < 0.01) was statistically significant, but the same pattern in the boys was not significant. Sleep and BMI correlated positively with WHR in the boys (p < 0.01). Girls had a statistically significant negative correlation (p = 0.05) of physical activity with psychological stress, but the positive correlation among boys was not statistically significant.
Table 2.
Gender-wise correlation (Spearman’s rho, r) with physical and psychological risk factors.
| F (197) |
M (103) |
|||||
|---|---|---|---|---|---|---|
| IDRS | Sleep | Physical activity | IDRS | Sleep | Physical activity | |
| BMI | 0.187b | –.224b | 0 | 0.149 | −0.023 | 0.106 |
| WHR | 0.178a | 0.124 | −0.022 | 0.467b | 0.301b | 0.123 |
| K 10 | 0.021 | −0.07 | –.143a | 0.082 | −0.191 | 0.174 |
| IDRS | 0.121 | 0.028 | 0.164 | 0.309b | ||
| Sleep | 0.121 | 0.109 | 0.164 | 0.119 | ||
Correlation is significant at the 0.05 level (2-tailed).
Correlation is significant at the 0.01 level (2-tailed).
According to the IDRS of ≤30, 31–59, and ≥ 60, study participants were subgrouped into low (n = 190, 63.3%), moderate (n = 105, 35%) and high (n = 5, 1.7%) risk categories respectively (Fig. 1b). For estimating the risk association of physical and psychological parameters, the data was converted to binomial as no risk or at risk with an IDRS cut-off of 30. Table 3 shows a significant difference in the two groups in age, BMI, WHR, IDRS, physical activity, and sleep, which increased in the group at risk. Although the K10 increased in the latter group, it was not statistically significant.
Fig. 1.
Risk scores among medical students.
Table 3.
The general characteristics of the two groups categorized by the IDRS.
| No risk | At risk | pa | |
|---|---|---|---|
| Age | 19.44 (1.18) | 19.83 (1.34) | 0.02 |
| K10 | 18.52 (5) | 19.2 (6.3) | 0.66 |
| BMI | 21.2 (3.2) | 22.7 (40 | 0.00 |
| WHR | 0.8 (0.07) | 0.84 (0.1) | 0.00 |
| Physical Activity | 0.4 (0.77) | 0.6 (1) | 0.05 |
| IDRS | 27.4 (4.4) | 44.2 (5.8) | 0.00 |
| Sleep | 6.4 (1.1) | 6.8 (1.4) | 0.01 |
Comparison of two groups was done by Mann–Whitney U test.
In our study group (Fig. 1a), 40% of students had psychological distress. Fifteen (5%) students had a K10 score of 30 and more, who were referred to specialists for management, while our mentor cell members counselled those with scores between 20 and 29.
Discussion
In our study, 60% were well psychologically, and 63.3% were well physically. This reveals that more than one-third of our medical students had different grades of psychological distress (40%) and were at risk of developing diabetes (36.7%). In a meta-analysis conducted for medical students in India, the pooled anxiety was 34.5% from four studies, and stress was 51.3% from 28 studies.1 The factors contributing to the stress and psychological distress among our medical students has been attributed to the curriculum, examination frequency, fear of failure, and lack of recreation.6 K10 scores were highest among the first year students, probably because of the shift from home to hostel/new city, vastness of the syllabus, expectations from self and parents or society at large and the apprehension of poor performance. Some studies have shown increased stress in females,6,7 but the same was not seen in our study (table not shown).
The IDRS score in our study was 35% moderate, and 1.7% at high risk, similar to that reported by Singh et al,2 Bhatia et al,8 and Gopalakrishnan et al9 Higher moderate IDRS risk of 40% in medical students10 and the general population have been reported from 46 to 74.7%.11,12 For girl students, BMI and WHR to the risk of diabetes were significant compared to physical activity. However, in boys, there was a contradictory finding, BMI correlated negatively, WHR and physical activity positively with IDRS. Although there was no significant rise in BMI, the increase in abdominal obesity contributed to the diabetes risk in the boys. Therefore, there should be a negative calorie balance for bodyweight reduction: to burn more calories than consumed, and physical activity must be included.13 The gender differences in the association of risk factors to BMI, sleep, and IDRS can be explained by the variances in their respective hormones’ actions.
Such alarming prevalence of diabetes risk, especially among budding doctors, leaves us questioning our health delivery and medical education system. Why have we not been able to prevent and reduce risk factors for non-communicable diseases among medical students? The answer lies in the policymakers and students’ concerted effort in believing and implementing change in dietary habits, physical activities, proper sleep, and taking appropriate measures to destress like incorporating prayer, meditation, hobbies, and exercise in daily routine. With the new improvised Competency-Based Medical Education (CBME) being followed recently in India, the focus should also be given to inculcating healthy habits, maintaining BMI, WHR, taking measures to relieve the pressure of examinations and stress among the young doctors during their training. Considering the difference in metabolomic profile and risk among Indians, we recommend preventive actions to safeguard our future health guardians.
The limitation of our study was that the study was conducted only among students of one college. The collation of data from other medical colleges will give a broader picture and help us understand the risks involved in mental health and DM. We suggest more extensive studies identifying the problems causing such stress among medical students and evaluating the remedial measures undertaken by the mentoring cell.
Conclusion
Medical students undergo psychological stress and are at risk for developing diabetes in future. Cohort studies with a long term follow up will help determine whether the risk during college days is relieved or compounded when they are in their working environment.
Ethics approval
This study was conducted with the approval of the Institute Ethics Committee.
Consent to participate
Each consenting student filled in the questionnaire and participated in anthropometric measurements.
Disclosure of competing interest
The authors have none to declare.
Acknowledgment
We thank our students for their consent to participate and their cooperation during data collection.
References
- 1.Sarkar S., Gupta R., Menon V. A systematic review of depression, anxiety, and stress among medical students in India. J Mental Health Hum Behav. 2017;22:88–96. doi: 10.4103/jmhhb.jmhhb_20_17. [DOI] [Google Scholar]
- 2.Singh M., Mangla V., Pangtey R., Garg S. Risk assessment of diabetes using the Indian diabetes risk score: a study on young medical students from Northern India. Indian J Endocr Metab. 2019;23(1):86. doi: 10.4103/ijem.IJEM_623_18. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Adhikari P., Pathak R., Kotian S. Validation of the MDRF-Indian diabetes risk score (IDRS) in another south Indian population through the boloor diabetes study (BDS) J Assoc Phys India. 2010 Jul;58:434–436. PMID: 21121209. [PubMed] [Google Scholar]
- 4.Mohan V., Deepa R., Deepa M., Somannavar S., Datta M. A simplified Indian Diabetes Risk Score for screening for undiagnosed diabetic subjects. J Assoc Phys India. 2005 Sep;53:759–763. PMID: 16334618. [PubMed] [Google Scholar]
- 5.Kessler R.C., Andrews G., Colpe L.J., et al. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med. 2002 Aug;32(6):959–976. doi: 10.1017/s0033291702006074. [DOI] [PubMed] [Google Scholar]
- 6.Anuradha R., Dutta R., Raja J.D., Sivaprakasam P., Patil A.B. Stress and stressors among medical undergraduate students: a cross-sectional study in a private medical college in Tamil nadu. Indian J Community Med. 2017 Dec;42(4):222–225. doi: 10.4103/ijcm.IJCM_287_16. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Shah M., Hasan S., Malik S., Sreeramareddy C.T. Perceived stress, sources and severity of stress among medical undergraduates in a Pakistani medical school. BMC Med Educ. 2010 Jan 15;10:2. doi: 10.1186/1472-6920-10-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Bhatia T., Oka M., Dharamdasani V., Bhattaccharjee S., Fortwengel G., Limaye V. Type 2 diabetes mellitus: risk evaluation and advice in undergraduate students in Mumbai. Int J Pharmaceutical Sci Invention. 2014;3(4):37–40. [Google Scholar]
- 9.Gopalakrishnan S., Rama R., Muthulakshmi M. Assessing the risk of developing type 2 diabetes mellitus among medical students in Chennai using Indian diabetes risk score. Int J Community Med Public Health. 2017;4:2366–2372. https://www.ijcmph.com/index.php/ijcmph/article/view/1399 [Google Scholar]
- 10.Vardhan A., Prabha M.R.A., Shashidhar M.K., Shankar N., Gupta S., Tripathy A. Value of Indian diabetes risk score among medical students and its correlation with fasting plasma glucose, blood pressure and lipid profile. J Clin Diagn Res. 2012 Nov;6(9):1528–1530. doi: 10.7860/JCDR/2012/4264.2550. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Gupta S.K., Singh Z., Purty A.J., Vishwanathan M. Diabetes prevalence and its risk factors in urban Pondicherry. Int J Diabetes Dev Ctries. 2009 Oct;29(4):166–169. doi: 10.4103/0973-3930.57348. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Chowdhary R., Mukherjee A., Saibendu L. A study on distribution and determinants of Indian diabetic risk score (IDRS) among rural population of West Bengal. Natl J Med Res. 2012;2(3):282–286. [Google Scholar]
- 13.Gupta S., Ray T., Saha I. Overweight, obesity and influence of stress on body weight among undergraduate medical students. Indian J Community Med. 2009;34(3):255. doi: 10.4103/0970-0218.55296. [DOI] [PMC free article] [PubMed] [Google Scholar]