Association between coffee consumption and psychological stress with gastroesophageal reflux disease among Indonesian medical students

Abstract

Objective

Medical students are experiencing gastroesophageal reflux disease (GERD) due to academic demands, dietary factors, such as coffee consumption and psychological stress. This study examined the relationships among coffee consumption, psychological stress, and GERD among medical students. A cross-sectional simple random sampling study was conducted among 200 students at the Faculty of Medicine, Syarif Hidayatullah State Islamic University Jakarta.

Results

The study found that a significant portion of students consumed coffee (53%), and experienced psychological issues, including anxiety (42%), depression (28%), and psychological stress (28%). GERD was found in over a quarter of student (27%). GERD was significantly associated with drinking high coffee consumption of more than 3 cups daily, long-term consumption of more than 4 years, instant coffee intake, depression, anxiety, and psychological stress (p < 0.05; 95% CI). However, in multivariate analysis only psychological stress remained the strongest risk factor significantly associated with GERD (OR 3.968; 95% CI 1.59–5.90). The study concludes that psychological stress is the strongest factor linked to GERD, more than anxiety, depression, or coffee habits. Reducing stress and limiting coffee may help lower GERD risk among students.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-026-07655-3.

Introduction

GERD is the reflux of gastric contents causing heartburn, epigastric pain, dysphagia, regurgitation, chest discomfort, respiratory symptoms, and affects approximately 20% of the global population [1]. Based on epidemiological data in Indonesia, the prevalence of GERD among dyspepsia patients subjected to endoscopic procedures was 32.4% while the prevalence of GERD among Indonesian physician was 27.4% [2]. A study conducted by Sharma et al. reported that the incidence of this disease among medical students was 58.8% and frequent coffee consumption was a significant risk factor [3]. In Southeast Asia, Singapore reported an incidence of GERD at 10.5%, with an increasing trend over the years. Some of the factors triggering GERD include diet, coffee, alcohol consumption, smoking, obesity, age above 50, and psychological stress, including depression and anxiety [4]. 

Coffee consumption is recognized as a trigger for GERD and can weaken the tonus of the lower esophageal sphincter (LES), facilitating gastric acid reflux and irritating the esophageal mucosa because of its caffeine content [3, 5]. However, some investigations, including those by Atta et al., have identified no significant relationship between coffee consumption and GERD [6]. Several studies have shown a strong relationship between psychological conditions and gastrointestinal function. Psychological factors, such as depression and anxiety can increase the risk of reflux symptoms by altering esophageal motility, increasing gastric acid secretion, and reducing acid clearance in the esophagus [3]. A study conducted by Choi et al. showed that the levels of anxiety and depression were significantly higher in individuals with GERD, specifically non-erosive reflux disease (NERD) than in the control group [7].

Medical students are particularly vulnerable to stress and unhealthy lifestyle behaviors due to demanding schedules, mental strain, irregular eating patterns, and frequent coffee intake. Baklola et al. reported that 17.1% of Egyptian medical students experienced GERD, with stress identified as a significant predictor [8]. Such combined factors contribute to the heightened prevalence of GERD in student populations. Accordingly, this study aimed to examine the association between depression, anxiety, psychological stress, and coffee consumption and the occurrence of GERD among medical students at the Faculty of Medicine, Syarif Hidayatullah State Islamic University, Indonesia.

Materials and methods

Study design and participant

This study employed an observational analytic design with a quantitative, cross-sectional methods. The population consisted of preclinical and clinical students at the Faculty of Medicine, Syarif Hidayatullah State Islamic University, Indonesia.

The samples were selected according to inclusion and exclusion criteria. Inclusion criteria comprised medical students who provided informed consent. In contrast, exclusion criteria included a prior GERD diagnosis based on gastroscopy, a history of gastrointestinal bleeding, unexplained weight loss exceeding 10%, the presence of an abdominal mass, or alcohol consumption.

This study included 200 medical students from Syarif Hidayatullah State Islamic University. Sampling was conducted using simple random sampling based on the full faculty student registry list, and all selected students completed questionnaire.

Variable definition and assessments

Data collection was conducted using a four-part Google Form questionnaire. The first section collected demographic information, and GERD symptoms were measured using the GERD-Q, as described in the National Guideline for Gastroesophageal Reflux Disease (GERD) Management in Indonesia (2022). The GERD-Q is widely used in clinical and research settings in Indonesia. This tool has demonstrated good diagnostic accuracy, with a sensitivity of 78.6% and specificity of 92.9%, and the Indonesian validation reported a Cronbach’s alpha of 0.834, indicating strong internal reliability. The GERD-Q consists of six items with a total possible score ranging from 0 to 18, and a score of ≥ 8 indicates a high likelihood of GERD [9].  Depression, anxiety, and stress levels were assessed using the DASS-42, originally developed by Lovibond & Lovibond (1995) [10] and later validated in Indonesian by Damanik E.D. (2011) [11], showing high internal consistency (Cronbach’s Alpha = 0.9053). The Depression Anxiety Stress Scales (DASS-42) is a self-report instrument comprising 42 items that evaluate three negative emotional states: depression, anxiety, and stress. Each of these three scales consists of 14 items, which are further grouped into subscales of 2 to 5 items sharing similar content.The depression scale is designed to assess a range of depressive symptoms, including dysphoria, hopelessness, devaluation of life, self-deprecation, lack of interest or involvement, anhedonia, and inertia.The anxiety scale evaluates symptoms related to autonomic arousal, skeletal muscle effects, situational anxiety, and the subjective experience of anxious affect.The stress scale is sensitive to levels of chronic, non-specific arousal. It measures difficulty relaxing, nervous arousal, and tendencies to be easily upset or agitated, irritable or over-reactive, and impatient. Respondents are asked to use 4-point severity/frequency scales to rate the extent to which they have experienced each state over the past week. Established cut-offs were applied, with scores of ≥ 10 for depression, scores of ≥ 8 for anxiety, and scores of ≥ 15 for psychological stress. For analysis, severity categories were classified into two groups: normal versus presence of symptoms [1].

Coffee consumption was evaluated through a modified questionnaire adapted from Czarniecka et al. (2021) and Arivan et al. (2018), covering frequency, type, and quantity, with an additional item developed to assess the durability of coffee consumption [12, 13]. The whole coffee instrument of short questionnaires demonstrated a Cronbach’s alpha of 0.670, indicating moderate internal consistency for this five-item instrument.

Statistical analysis

Data were analyzed using SPSS. Univariate and bivariate analyses were conducted using Chi-Square or Fisher’s Exact Test. Variables with a p-value < 0.20 in the bivariate analysis were entered into a multivariate logistic regression model using a backward elimination approach. Effect sizes were reported as odds ratios (ORs) with 95% confidence intervals (CIs), and statistical significance was set at p < 0.05.

Results

The average age of the participants was 20 years, with most subjects being female 142 (71%) as shown in Table 1.

Table 1.

Characteristics of medical students

Total variable	Category	N 200	(%) 100
Gender	Male	58	29
	Female	142	71
Coffee consumption	Routine	106	53
	Occasional	94	47
Level depression	Normal	145	72
	Mild	29	15
	Moderate	16	8
	Severe	5	2.5
	Very Severe	5	2.5
Level of anxiety	Normal	116	58
	Mild	17	8
	Moderate	29	15
	Severe	22	11
	Very Severe	16	8
Level of stress	Normal	140	70
	Stress	60	30
GERD	Positive	54	27
	Negative	146	73

Based on Table 1, more than half students (53%) regularly consumed coffee every day, while 47% drank it rarely or occasionally. In terms of mental health, 28% of all students experienced some degree of depression, with mostly mild-moderate (23%) compared to severe (5%). 42% of them had varying levels of anxiety, mostly mild to moderate (23%) and 30% reported experiencing psychological stress, with mild and moderate levels being the most common. GERD was present in 27% of students.

Table 2 shows that 39.5% of students drank coffee daily. Daily coffee drinkers (38%) had significantly related with GERD compared with occasionally drinkers (p = 0.015). This study also showed 77.8% of students who consumed more than 3 cups daily experienced GERD, compared with 24.6% of those who drank less coffee (p = 0.002). Instant coffee was most popular type of coffee (52%) and pure coffee drinkers were least consumed (18.5%), although pure coffee drinkers (47%) were significantly associated with GERD (p = 0.001). Regarding the duration of coffee consumption, most of students had consumed coffee for 0–3 years (62%), meanwhile 38% students had consumed coffee for over 4 years, were significantly associated with GERD (p = 0.001).

Table 2.

Association of coffee characteristics with GERD among medical students

Category		GERD		Total			p- value
		Negative	Positive
		N (%)	N (%)	N		%
Coffee Consumption Frequency	Rarely-occasionally	97 (80.1)	24 (19.9)	121		60.5	0.015*
	Everyday	49 (62.0)	30 (38)	79		39.5
	Total			200		100
Number of cups	0–2 cups	144 (75.3)	47 (24.6)	191		95.5	0.002*
	> 3 cups	2 (22,2)	7 (77.8)	9		4,5
	Total			200		100
Types of Coffee	Decaffeinated Coffee	51 (86.4)	8 (13.6)	59		29.5	0.001*
	Pure Coffee	19 (51.3)	18 (48.7)		37	18.5
	Instant Coffee	76 (73)	28 (27)	104		52
	Total			200		100
Duration of consumption	0–3 years	102 (51)	22 (11)	124		62	0.001*
	> 4 years	44 (22)	32 (16)	76		38
	Total			200		100

* p value < 0.05 for bivariate

39.2% among students experienced depression, while 36.8% had anxiety, and 43.6% had psychological stress. Depression, anxiety and psychological stress were significantly associated with GERD (p < 0.05) in bivariate analysis (Table 3) Multivariate analysis showed that psychological stress had the strongest risk factor significantly associated with GERD. Individuals experiencing stress having nearly four times higher odds of GERD (OR 3.968; 95% CI 1.59–5.90; p = 0.002). From a preventive health perspective, these findings indicate that effective stress management may meaningfully reduce the risk of GERD.

Table 3.

Association between depression, anxiety, psychological stress with GERD among medical students

Category			GERD					p-value
			Negative		positive		Total
			N	%	N	%	N
Depression		Normal	112	77.2	33	62.8	145 72.5	0.033*
		Mild to Very Severe	34	61.8	21	39.2	55 27.5
		Total					200 (100)
Anxiety		Normal	91	80.5	22	19.5	113 56.5	0.010*
		Mild to Very Severe	55	63.2	32	36.8	87 43.5
		Total					200 100
Stress		Normal	112	80	28	20	140 70	0.001*
		Stress	34	56.6	26	43.6	6030
		Total					200 (100)

*p value < 0.05 for bivariate, 95% CI

Discussions

This study showed coffee consumption is common among medical students at the State Islamic University Indonesia (53%), due to demanding schedules and the need for sustained alertness. The prevalence of GERD observed in this study is higher than previously reported rates among Indian medical students, which ranged from 16.8% to 19.4%. Indian medical students consumed coffee to stay awake and reduce drowsiness, with intake increasing during exams periods, reflecting the influence of academic pressure on caffeine use [14, 15].

This study indicated that many medical students experience mild to moderate levels of depression and anxiety. While the prevalence was notable, the severity remained within the mild to moderate range. These results align with evidence showing that stressors such as frequent examinations, heavy academic workloads, high expectations, and unmet study goals contribute significantly to psychological strain [16, 17]. Additional challenges, including adapting to the medical environment, high educational costs, and poor learning conditions–further increase the risk of mental health problems [17].

GERD was observed in 27% of medical students, consistent with global prevalence rates of 15%- 25%.¹⁷ In Jakarta, the incidence of GERD diagnosed via endoscopy was 22.8%, and other studies have shown that around 25% of patients experienced GERD symptoms [2, 3]. Daily coffee consumption was reported by 39.5% of students, with 38% experienced GERD, indicating a significant association. Coffee has been reported to aggravate GERD symptoms by reducing lower esophageal sphincter pressure and increasing gastric acid secretion [18, 19]. Caffeine also interacts with TAS2R receptors, overstimulating G cells, which leading to increase gastrin release and excessive gastric acid production. These mechanisms help explain the link between frequent coffee intake and GERD symptoms among medical students [20].

Only 4.5% of students consumed more than three cups of coffee daily, yet 77.8% of them experienced GERD, suggesting a strong association between high coffee intake and GERD. This pattern is consistent with previous studies reporting similar relationships in different populations [13, 21].

This study also found that coffee type and processing methods are associated with GERD, as different preparation techniques can influence caffeine levels and other bioactive compounds. Pure coffee is produced through water extraction from roasted beans and therefore retains its full caffeine content. Decaffeinated coffee, however, undergoes additional processing—using water, organic solvents, or carbon dioxide—to substantially reduce caffeine levels. Instant coffee is formulated for convenience and may still contain variable amounts of caffeine depending on the brand and processing technique. Choosing decaffeinated varieties may help reduce the likelihood of GERD symptoms by limiting overall caffeine intake [22–24].

This study found that most students (52%) consumed instant coffee, and 27% of them experienced GERD. In comparison, only 18.5% of students drank pure coffee, yet 48.7% of this group had GERD, indicating a notable association between pure coffee consumption and GERD symptoms. Among the 29.5% of students who consumed decaffeinated coffee, only 13.6% reported GERD, supporting reports that caffeinated coffee is associated with a higher likelihood of GERD than decaffeinated varieties [5]. Instant coffee has also been shown to stimulate gastric acid secretion, which may exacerbate GERD symptoms, whereas decaffeinated coffee—with its reduced caffeine content—tends to producer milder psychological effects [20]. Other factors like bean elevation, roast level, and brewing method also affect acidity [19]. However, some studies have found no significant association between coffee type and GERD, suggesting considerable individual variability in response to coffee [25].

This study also indicated that 16% medical students with GERD had a history of coffee consumption for more than four years, showing a statistically significant association between long-term coffee intake and the presence of GERD. Nonetheless, these findings require further investigation to better understand the potential mechanisms and contributing factors underlying this relationship.

The pathophysiology of GERD is multifactorial, influenced by diet, lifestyle, and individual susceptibility, including emotional state. In this study, emotional state was assessed using the DASS-42 questionnaire, classifying participants into depression, anxiety, and psychological stress. According to the American Psychological Association, psychological stress refers to the physical, mental, and emotional responses elicited by specific stimuli, termed “stressors.” Stress represents the body’s natural reaction to demands or challenges. Common stressors include environmental noise, interpersonal conflicts, heavy traffic, occupational demands, financial burdens, and family problems, all of which may contribute to heightened psychological strain and exacerbate gastrointestinal disorders such as GERD [26].

Anxiety manifests through physical and emotional responses to stress, such as tachycardia, shallow breathing, and muscle tension, which can interfere with daily functioning. Depression is characterized by persistent sadness, anhedonia, low energy, poor self-esteem, guilt, suicidal ideation, impaired concentration, and disturbances in sleep, appetite, and somatic health [27]. In this study, 27.5% of students experienced depression, and 39.2% of them reported GERD symptoms. Most cases were classified as mild depression [5]. A significant association was also observed between depression and GERD among medical students, aligning with findings from similar research conducted in young populations of South Korea [28]. Additionally, 43.5% of students experienced anxiety, with most cases falling within the mild to moderate range, and 36.8% of these students reported GERD symptoms. This pattern is consistent with previous studies demonstrating an association between anxiety and GERD, both in individuals with and without chest pain [8]. Logistic regression analyses in other populations have similarly shown that higher anxiety levels are associated with an increased likelihood of experiencing GERD, including among those with mild anxiety [29]. Further evidence from studies in health science students in Saudi Arabia has also reported a significant relationship between anxiety and GERD (p = 0.017) [30].

30% of the subjects of this study had psychological stress, and 43.6% of them experienced GERD in medical students at the Faculty of Medicine, Syarif Hidayatullah State Islamic University, Indonesia. This categorization was consistent with previous research that found an association between stress levels and common GERD-related symptoms, such as heartburn, regurgitation, chest pain, coughing, and burping. Another study conducted among medical students in Medan, Indonesia, also reported a significant relationship between psychological stress and the severity of GERD symptoms [27]. Psychological factors like depression and anxiety may raise reflux risk by disrupting esophageal motility, boosting gastric acid secretion, and impairing acid clearance. These conditions influence functional gastrointestinal disorders by altering pain perception via the gut-brain axis, which links emotional and cognitive brain centers to digestive function. Depression and anxiety can also cause hypochondriasis, lowering the symptom perception threshold and intensifying reflux sensations [2, 6].

This study identified psychological stress remained as strongest risk factor significantly associated with GERD, exceeding the influence of depression, anxiety, and coffee consumption. Stress might contribute to increased esophageal acid exposure, delayed gastric emptying, or heightened esophageal sensitivity, which could intensify heartburn symptoms [31]. Both acute and chronic stress have been shown to exacerbate GERD-related manifestations. To date, no previous studies have directly compared the relative impact of depression, anxiety, and stress on GERD. Further research is needed to examine how stress interacts with environmental influences and habitual coffee intake, as these combined factors may contribute to GERD symptoms and help clarify the complex interplay among these variables.

Conclusions

Gastroesophageal reflux disease (GERD) was identified in 27% of medical students, accompanied by depression (28%), anxiety (42%), and psychological stress (30%), predominantly mild to moderate. Significant associations emerged between GERD and psychological determinants, particularly psychological stress, as strongest independent factor (OR 3.968, 95% CI 1.59–5.90).

Daily coffee consumption, especially exceeding 3 cups, was associated with higher GERD prevalence. Instant and pure coffee conferred greater risks than decaffeinated forms, and long-term intake beyond 4 years further increased susceptibility. These findings suggest moderating caffeine intake and adopting decaffeinated alternatives alongside considering genetics, nutrition, sleep, and physical activity, as essential preventive approaches.

Limitation

A limitation of this study was the small sample size and gender disparity of (71% of female), which reduced the generalizability of the results. A larger, more uniform sample could provide better insights into GERD prevalence among medical students. A longitudinal study with follow-up would help assess whether these risk factors directly influence GERD over time. Other limitation, students could understate caffeine or stress, as well as memory bias caused by questionnaire usage.

Abbreviations

GERD

Gastroesophageal reflux disease

LES

Lower Esophageal Sphincter

NERD

Non-erosive reflux disease

GERD-Q

Gastroesophageal reflux disease

TAS2R

Type 2 sensory receptor

Author contributions

FNA, IN, ACP, AHN, AMH and RSA contributed to manuscript writing and editing, and data collection; FNA, IN, SR, HH contributed to data analysis; FNA, SR, HH contributed to conceptualization and supervision; all authors have read and approved the final manuscript.

Funding

This work was supported and funded in part by Center for Research and Publication Universitas Islam Negeri Syarif Hidayatullah Jakarta grant in 2023.

Data availability

The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the principles outlined in the Declaration of Helsinki, ensuring that all ethical standards for research involving human participants were strictly observed. Ethical Clearance was obtained from the Faculty of Medicine, UIN Syarif Hidayatullah Jakarta, the Research Ethics Committee, with reference number No: B-001/F12/KEPK/TL.00/01/2023. Informed written consent was obtained from all participants. All participants were voluntary and anonymous. All participants completed this survey.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.