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

Association between coffee consumption and psychological stress with gastroesophageal reflux disease among Indonesian medical students | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report Association between coffee consumption and psychological stress with gastroesophageal reflux disease among Indonesian medical students Femmy Nurul Akbar, Intan Nurjannah, Amira Calista Patria, Ainaya Hanif Nabila, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7584587/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Jan, 2026 Read the published version in BMC Research Notes → Version 1 posted 8 You are reading this latest preprint version 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 explored the relationship between coffee consumption, psychological stress, and GERD among medical students. A cross-sectional survey was conducted among 200 students at the Faculty of Medicine, Syarif Hidayatullah State Islamic University Jakarta. Results Results showed that 53% of students consumed coffee, 28% had depression, 42% had anxiety, and 30% experienced psychological stress. GERD was found in 27% of students and was significantly related to drinking more than 3 cups of coffee daily (p=0.015), long-term consumption more than 4 years (p=0.001), instant coffee (p=0.001), depression (p=0.033), anxiety (p=0.010), and psychological stress (p=0.001). However, only psychological stress remained significant in multivariate analysis (p=0.002). 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. coffee consumption depression anxiety psychological stress GERD medical students 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% with frequent coffee consumption was 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 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 caffeine. 3 , 5 However, some investigations, including Atta et al., identified no significant relationship between coffee consumption and GERD. 6 Several studies have shown a strong relationship between psychological diseases 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 with the occurrence of GERD among medical students at the Faculty of Medicine, Syarif Hidayatullah State Islamic University, Indonesia. MATERIAL AND METHODS Study Design and Participants This study employed observational analytic design with quantitative, cross-sectional methods. The population consisted of preclinical and clinical students at the Faculty of Medicine, Syarif Hidayatullah State Islamic University, Indonesia. Samples were selected according to inclusion and exclusion criteria. Inclusion comprised medical students who provided informed consent, while exclusion criteria included prior GERD diagnosis based on gastroscopy, history of gastrointestinal bleeding, unexplained weight loss exceeding 10%, abdominal mass, or alcohol consumption. 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. Variable Definition and Assessments Data collection was conducted using a four-part Google Form questionnaire. The first section gathered demographic information, while GERD symptoms were measured using the GERD-Q, as published in the National Guideline of Gastroesophageal Reflux Disease (GERD) Management in Indonesia (2022). 9 The GERD-Q is widely used in clinical and research settings in Indonesia. Depression, anxiety, and stress levels were assessed using the DASS-42, originally developed by Lovibond & Lovibond (1995) 10 and later translated into Indonesian by Damanik E.D. (2011), showing high internal consistency (Cronbach’s Alpha = 0.9053). 11 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 durability of coffee consumption. 12 , 13 The whole instrument of short questionnaires showed acceptable validity and reliability test (Cronbach’s Alpha = 0.610). Sample Size and Statistical Analysis This study included 200 medical students from Syarif Hidayatullah State Islamic University, selected by simple random sampling. Data were analyzed using SPSS with univariate, bivariate (Chi-Square or Fisher’s Exact Test), and multivariate analyses, the latter performed via backward regression. 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 (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% had varying levels of anxiety, mostly mild to moderate (23%) and 30% reported experiencing stress, with mild and moderate levels being the most common. GERD was present in 27% of students. Table 2 Association of coffee consumption frequency, type, and duration 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 Table 2 shows that 39.5% of students drank coffee daily, while 60.5% consumed it rarely or occasionally. Among daily drinkers, 38% had GERD, significantly higher than 19.9% of infrequent drinkers (p = 0.015). A strong link was found between high coffee intake and GERD: 77.8% of students consuming more than three cups daily experienced GERD, compared to 22.2% of those drinking less (p = 0.002). Coffee type was also significant (p = 0.001); instant coffee was most popular (52%) and pure coffee was least consumed (18.5%) was associated GERD (48.7%). Regarding the duration coffee consumption, 62% students consumed coffee for 0–3 years 11% had GERD, while 38% student consumed for over 4 years, showing 16% had GERD (p = 0.001). These results suggest frequency, type, and duration of coffee intake affect the risk of GERD. Table 3. Association between depression, anxiety, and psychological with GERD in medical students Table 3 demonstrated significant associations between psychological variables and GERD, with prevalence rates of 39.2% among students with depression (p = 0.033), 36.8% with anxiety (p = 0.010), and 43.6% with stress (p = 0.001). Stress exhibited the strongest correlation, underscoring its potential role in GERD development. The multivariate analysis indicates that individuals reporting higher levels of stress had a significantly lower odds of experiencing GERD (OR = 0.353; p = 0.002). Interpreting this from a preventive health perspective, it is plausible that effective stress management may contribute to a reduction in GERD incidence. Based on the odds ratio, individuals with well-managed stress could potentially experience up to a 64.7% reduction in the odds of developing GERD compared to those with unmanaged or lower reported stress levels. Depression (OR = 0.989; p = 0.981) and anxiety (OR = 0.764; p = 0.559) did not exhibit statistically significant associations with GERD in the multivariate model. This suggests that, within the parameters of this study, these psychological conditions may not serve as independent predictors of GERD, although coffee consumption yielded an odds ratio suggestive of a potential association (OR = 0.551), the lack of statistical significance ( p = 0.078) indicates that no definitive conclusions can be drawn from this data. DISCUSSIONS Due to demanding schedules and the need for sustained alertness, coffee consumption is common among medical students, including 53% at State Islamic University Indonesia. Edward et al. reported that 16.8% and 19.4% of Indian medical students consumed coffee to stay alert and combat drowsiness, with intake rising during exams. 14 Similarly, Devi et al. noted that students often drink coffee while preparing for exams, highlighting academic pressure as a major factor influencing this habit. 15 This study indicated that many medical students experience mild to moderate levels of depression and anxiety. While the numbers are significant, the severity remains generally low, ranging from mild to moderate. These results are consistent with previous studies. The symptoms were due to stressors related to the challenging and demanding educational environment, creating unique pressures for students. 16 , 17 The most challenging factors during medical studies included various types of exams, a large amount of material to be learned, high demands, and failure to complete tasks as planned. Other stressors commonly observed were adapting to medical environment, high educational costs, and a poor learning environment, contributing to a higher risk of mental health problems. 17 GERD was observed in 27% of subjects, which aligns with global prevalence rates of 15%- 25%. 17 In Jakarta, the incidence of GERD diagnosed via endoscopy was 22,8%. Similarly, Sharma et al. reported that 25% of patients experienced GERD symptoms. 2 , 3 Daily coffee consumption was reported by 39.5% of students, with 38% experiencing GERD, indicating a significant association, as also found by Hartoyo et al. and Polese et al. reported that coffee can reduce lower esophageal sphincter (LES) pressure and stimulate gastric acid secretion 18 , 19 Nehlig et al. explained that caffeine binds to TAS2R receptors, overstimulating G cells, leading to increased 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 over three cups of coffee daily, yet 77.8% of them had GERD, showing a strong link. This aligns with Arivan et al. and Martinucci et al., who found similar associations in India and Italy. These findings highlight that high coffee intake significantly contributes to GERD risk among students. 13 , 21 This study also found that coffee type and processing methods are associated with GERD, as different processes may affect caffeine content and other compounds. Pure coffee is made by water extraction from roasted beans, retaining full caffeine levels. In contrast, decaffeinated coffee undergoes further processing using water, organic solvents, or carbon dioxide to significantly reduce caffeine. Instant coffee is designed for convenience but may still contain varying caffeine amounts. Choosing decaffeinated options may help reduce GERD symptoms by lowering caffeine intake. 22 – 24 This study found that most students (52%) drank instant coffee, and 27% of them experienced GERD. In contrast, only 18.5% of students drank pure coffee, but 48.7% of them had GERD. This shows a significant link between coffee consumption—especially pure coffee—and GERD. The study also found that among the 29.5% of students who drank decaffeinated coffee, only 13.6% had GERD. This supports the findings of Mehta et al., who reported that caffeinated coffee carries a higher risk of causing GERD than decaffeinated coffee. 5 Nehlig et al. noted that instant coffee increases gastric acid secretion, worsening GERD, while decaffeinated coffee, with less caffeine, has milder effects 20 Other factors like bean elevation, roast level, and brewing method also affect acidity. 19 However, Wei et al. found no significant link between coffee type and GERD, suggesting individual variability. 25 This study also indicated that 16% medical students with GERD had a history of coffee consumption exceeding four years demonstrating a statistically significant relationship between prolonged coffee consumption and the occurrence of GERD. However, these results necessitate further discussion to explore the potential causative mechanisms and contributing factors underlying this association. 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, including tachycardia, shallow breathing, and muscle tension, impairing daily function. Depression involves persistent sadness, anhedonia, and low energy, often accompanied by poor self-esteem, guilt, suicidal ideation, impaired concentration, sleep and appetite disturbances, and multiple somatic symptoms. 27 This study stated 27.5% experienced depression with 39.2% of them reported symptoms of GERD. Furthermore, the data showed that most medical students in this study had symptoms consistent with mild depression 5 . There is also significant relationship between depression and GERD in medical students. This result was similar with Bai et al. that showed a relationship between depression and anxiety with GERD among the young population of South Korea. 28 Furthermore, this study reported 43.5% of students had anxiety, with most of them were mild to moderate anxiety, and 36.8% of them experienced GERD. This study is consistent with Mohammad, et al study that also reported a relationship between anxiety and GERD with or without chest pain. 8 Li,et al. used logistic regression modeling and found that higher anxiety levels were related to an increased rate of GERD and showed significant connection between mild anxiety and an increased risk of GERD. 29 Golinejad et al. also reported significant relationship between anxiety and GERD in health science students in Saudi Arabia (p = 0.017). 30 Thirty percent 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 the report of Wickramasinghe et al. which showed a correlation between stress levels and GERD symptoms, such as heartburn, regurgitation, chest pain, coughing, and burping. Another study conducted by Bulqaini et al, found a significant relationship between psychological stress and the severity of GERD in medical students in Medan, Indonesia. 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 stress as the sole significant factor linked to GERD, surpassing depression, anxiety, and coffee consumption. Stress may increase esophageal acid exposure, delay gastric emptying, or cause esophageal hypersensitivity, intensifying heartburn symptoms. 31 Both acute and chronic stress can trigger GERD. No previous studies have compared depression, anxiety, and stress effects on GERD directly. Further research is needed to explore how interactions between stress, environmental factors, and habitual coffee intake might collectively influence GERD risk, aiding in understanding the complex relationship between 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 stress, highlighting the strong link between mental well-being and gastrointestinal function. Daily coffee consumption, especially exceeding three cups, demonstrated higher GERD prevalence. Instant and pure coffee conferred greater risks compared to decaffeinated forms, while long-term intake beyond four 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, 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. Abbreviations GERD : Gastroesophageal reflux disease LES : Lower Esophageal Sphincter NERD : Non-erosive reflux disease GERD-Q : Gastroesophageal reflux disease TAS2R : Type 2 sensory receptor Declarations Ethics approval and consent to participate 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. Consent for publication Not applicable. Availability of data and materials The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request Competing interests No conflict of interest is declared by authors. Funding This work was supported and funded in part by Center for Research and Publication Universitas Islam Negeri Syarif Hidayatullah Jakarta grant in 2023. 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. Acknowledgements We would like to thank medical students at the Faculty of Medicine, Universitas Islam Negeri Syarif Hidayatullah Jakarta who participated in this study. Author information Department of Internal Medicine, Faculty of Medicine, Universitas Islam Negeri Syarif Hidayatullah Jakarta. Femmy Nurul Akbar, Intan Nurjannah, Amaliya Mata’ul Hayah, Regina Stefani Anwar , Sayid Ridho, Hari Hendarto Medical Study Program, Faculty of Medicine Universitas Islam Negeri Syarif Hidayatullah Jakarta. Amira Calista Patria, Ainaya Hanif Nabila Corresponding author: Femmy Nurul Akbar, Department of Internal Medicine, Faculty of Medicine, Universitas Islam Negeri Syarif Hidayatullah Jakarta, Pisangan, Ciputat, South Tangerang, Indonesia. Email: [email protected] References Kahrilas PJ, HI. The disease of esophagus. In: Harrison, editor. Principles of Internal Medicine. McGraw-Hill Education; 2022. p. 1716. Syam AF, Hapsari PF, Makmun D. The prevalence and risk factors of GERD among Indonesian medical doctors. Makara J Heal Res. 2016;20(2):35–40. Sharma A, Sharma PK, Puri P. Prevalence and the risk factors of gastro-esophageal reflux disease in medical students. Med J Armed Forces India. 2018;74(3):250–4. Saragih AF, Purba DN, Silaen M, Fibrini D. Quality of life and GERD incidence in medical students: A cross-sectional study. J Prima Med Sains. 2023;5(2):130–4. Mehta RS, Song M, Staller K, Chan AT. Association between beverage intake and incidence of gastroesophageal reflux symptoms. Clin Gastroenterol Hepatol. 2020;18(10):2226–34. e4. Atta MM, Sayed MH, Zayed MA, Alsulami SA, Al-Maghrabi AT, Kelantan AY. Gastro-oesophageal reflux disease symptoms and associated risk factors among medical students Saudi Arabia. Int J Gen Med. 2019; 2:293–8. Choi JM, Yang JI, Kang SJ, Han YM, Lee J, Lee C, et al. Association between anxiety and depression and gastroesophageal reflux disease: Results from a large cross-sectional study. J Neurogastroenterol Motil. 2018;24(4):593–602. Baklola M, Terra M, Badr A, Fahmy FM, Elshabrawy E, Hawas Y, et al. Prevalence of gastro-oesophageal reflux disease, and its associated risk factors among medical students: a nation-based cross-sectional study. BMC Gastroenterol. 2023; 23:1–7. Makmun D, Fauzi A, Maulahela H, Pribadi RR. Konsensus nasional penatalaksanaan penyakit refluks gastroesofageal (Gastroesophageal reflux disease/GERD) di Indonesia. Perkumpulan Gastroenterologi Indonesia (PGI) [National consensus on the management of gastroesophageal reflux disease/GERD in Indonesia. Indonesian society of gastroenterology/ISG]. 2022. https://pbpgigastro.com/wp-content/uploads/2024/07/Konsensus-Nasional-Penatalaksanaan-GERD-di-Indonesia-Revisi-2022.pdf. Accessed 17 th September 2025. Lovibond SH, Lovibond PF. Manual for the depression anxiety stress scales. 2nd ed. Sydney: Psychology Foundation. 1995. Damanik ED. The measurement of reliability, validity, items analysis and normative data of depression anxiety stress scale (DASS). Universitas Indonesia; 2011. Czarniecka-Skubina E, Pielak M, Sałek P, Korzeniowska-Ginter R, Owczarek T. Consumer choices and habits related to coffee consumption by poles. Int Environ. Res Public Health. 2021 Apr 2;18(8). Arivan R, Deepanjali S. Prevalence and risk factors of gastro-esophageal reflux disease among undergraduate medical students from a southern Indian medical school: A cross-sectional study. BMC Res Notes. 2018;11(1):448. Edward S, Kumar MS, Gopalkrishnan S. Trend of caffeine consumption among medical students and its side effects. Drug Invent Today. 2019;12(11):2764–8. Devi SSL, Abilash SC, Basalingappa S. The rationale of caffeine consumption and its symptoms during preparatory and non-preparatory days: A study among medical students. Biomed Pharmacol J. 2018;11(2):1153–9. Ramadianto AS, Kusumadewi I, Agiananda F, Raharjanti NW. Symptoms of depression and anxiety in Indonesian medical students: association with coping strategy and resilience. BMC Psychiatry. 2022; 22:1–11. Mao Y, Zhang N, Liu J, Zhu B, He R, Wang X, et al. A systematic review of depression and anxiety in medical students in China. BMC Med Educ. 2019; 19:1–13. Hartoyo FZ, Tandarto K, Sidharta V, Tenggara R. The correlation between coffee consumption and gastroesophageal reflux disease. Indones J Gastroenterol Hepatol Dig Endosc. 2022; 23:11–6. Polese B, Izzo L, Mancino N, Pesce M, Rurgo S, Tricarico MC, et al. Effect of dewaxed coffee on gastroesophageal symptoms in patients with GERD: A randomized pilot study. Nutrients. 2022;14(12):2510. Nehlig A. Effects of coffee on the gastro-intestinal tract: A narrative review and literature update. Nutrients. 2022;14(2):399. Martinucci I, Natilli M, Lorenzoni V, Pappalardo L, Monreale A, Turchetti G, et al. Gastroesophageal reflux symptoms among Italian university students: Epidemiology and dietary correlates using automatically recorded transactions. BMC Gastroenterol. 2018;18(1):116. Mulvaney D, Robbins P. International coffee agreement. In: Green food an A-to-Z guide. Sage Publication; 2012. Sukrasno S, Aria RI, Ruslan WK. The caffeine content in coffee beverages commercially distributed in Indonesia. J Food Nutr Res. 2018;6(8):513–7. dePaula J, Farah A. Caffeine consumption through coffee: Content in the beverage, metabolism, health benefits and risks. Beverages. 2019;5(2):37. Wei TY, Hsueh PH, Wen SH, Chen CL, Wang CC. The role of tea and coffee in the development of gastroesophageal reflux disease. Tzu Chi Medical Journal. 2019 Jul 1;31(3):169–76. Wickramasinghe N, Thuraisingham A, Jayalath A, Wickramasinghe D, Samarasekara N, Yazaki E, et al. The association between symptoms of gastroesophageal reflux disease and perceived stress: A countrywide study of Sri Lanka. PLoS One. 2023;18(11): e0294135. Bulqaini AA, Darmadi. Relationship between degrees of severity gastroesophageal reflux disease with quality of life. J Endocrinol Trop Med Infect Dis. 2023;4(3):96–103. Bai P, Bano S, Kumar S, Sachdev P, Ali A, Dembra P, et al. Gastroesophageal reflux disease in the young population and its correlation with anxiety and depression. Cureus. 2021;13(5): e12589. Li Q, Duan H, Wang Q, Dong P, Zhou X, Sun K, et al. Analyzing the correlation between gastroesophageal reflux disease and anxiety and depression based on ordered logistic regression. Sci Rep. 2024;14 :1–11. Gholinejad N, Teimouri A. Investigation of gastroesophageal reflux disease among medical students. Govaresh. 2021;26(1):49–54. Sujaritha J, Deepa N, Nandhini J, Vandhana V, Mahalakshmi D. Stress and stress management: A review. Indian J Nat Sci. 2022;13(73):45563–70. Additional Declarations No competing interests reported. Supplementary Files ModifiedCoffeeConsumptionQuestionnaireENGLISHandBAHASAVER.docx Cite Share Download PDF Status: Published Journal Publication published 20 Jan, 2026 Read the published version in BMC Research Notes → Version 1 posted Editorial decision: Revision requested 28 Nov, 2025 Reviews received at journal 20 Oct, 2025 Reviewers agreed at journal 18 Oct, 2025 Reviewers invited by journal 16 Oct, 2025 Editor assigned by journal 15 Oct, 2025 Editor invited by journal 18 Sep, 2025 Submission checks completed at journal 18 Sep, 2025 First submitted to journal 18 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7584587","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":535020958,"identity":"eb4bc28d-1377-47c9-b9ff-75dd29799907","order_by":0,"name":"Femmy Nurul Akbar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+klEQVRIiWNgGAWjYBAC9gY4k7nxAYMBA7MEhCfB2IBVAwMDzwE4k7HZAKyFjQQtbWALoFoYcGth707dzMNwJ3H7jMS2ap6CO+yS8xsYP/xgsJDFqYXn7LbbPAzPEufcSGy7zWPwjFmajYFZsodBwhiXFnuJXJCWw4kzJMBaDjPLAR0mDXRfIk5b5N8itBRDtTD/xqtFghehhRmkBegwNvy28ORuuznH4LDxDJ6HzZJABrNkW2KbZY8Bbr/wsJ/dduNNxWHZGezJBz+8+XM4WeLw4cM3flTU4QwxEGDiMUBwkiExYoBTNRgw/kDi2OFXOwpGwSgYBSMRAADttlGKozNr1AAAAABJRU5ErkJggg==","orcid":"","institution":"Universitas Islam Negeri Syarif Hidayatullah Jakarta. South Tangerang","correspondingAuthor":true,"prefix":"","firstName":"Femmy","middleName":"Nurul","lastName":"Akbar","suffix":""},{"id":535020959,"identity":"dc9f7a65-2fc1-4a7d-b27b-6085955aeb55","order_by":1,"name":"Intan Nurjannah","email":"","orcid":"","institution":"Universitas Islam Negeri Syarif Hidayatullah Jakarta. South Tangerang","correspondingAuthor":false,"prefix":"","firstName":"Intan","middleName":"","lastName":"Nurjannah","suffix":""},{"id":535020960,"identity":"d7edb184-8c57-42b3-8c43-77edbf5df74e","order_by":2,"name":"Amira Calista Patria","email":"","orcid":"","institution":"Universitas Islam Negeri Syarif Hidayatullah Jakarta. South Tangerang","correspondingAuthor":false,"prefix":"","firstName":"Amira","middleName":"Calista","lastName":"Patria","suffix":""},{"id":535020962,"identity":"acbcafd8-bbb2-49cd-9605-e5dbb8949cf5","order_by":3,"name":"Ainaya Hanif Nabila","email":"","orcid":"","institution":"Universitas Islam Negeri Syarif Hidayatullah Jakarta. South Tangerang","correspondingAuthor":false,"prefix":"","firstName":"Ainaya","middleName":"Hanif","lastName":"Nabila","suffix":""},{"id":535020963,"identity":"732b00f1-74d8-4703-87fd-ffa8ab668f31","order_by":4,"name":"Amaliya Mata’ul Hayah","email":"","orcid":"","institution":"Universitas Islam Negeri Syarif Hidayatullah Jakarta. South Tangerang","correspondingAuthor":false,"prefix":"","firstName":"Amaliya","middleName":"Mata’ul","lastName":"Hayah","suffix":""},{"id":535020964,"identity":"4198f926-061a-448d-a690-783562336ad2","order_by":5,"name":"Regina Stefani Anwar","email":"","orcid":"","institution":"Universitas Islam Negeri Syarif Hidayatullah Jakarta. South Tangerang","correspondingAuthor":false,"prefix":"","firstName":"Regina","middleName":"Stefani","lastName":"Anwar","suffix":""},{"id":535020965,"identity":"dc9d3f7c-fe9b-4690-b51a-aadea53bfd8c","order_by":6,"name":"Sayid Ridho","email":"","orcid":"","institution":"Universitas Islam Negeri Syarif Hidayatullah Jakarta. South Tangerang","correspondingAuthor":false,"prefix":"","firstName":"Sayid","middleName":"","lastName":"Ridho","suffix":""},{"id":535020966,"identity":"5427f856-428a-4bdc-ac29-0ec16e2d6147","order_by":7,"name":"Hari Hendarto","email":"","orcid":"","institution":"Universitas Islam Negeri Syarif Hidayatullah Jakarta. South Tangerang","correspondingAuthor":false,"prefix":"","firstName":"Hari","middleName":"","lastName":"Hendarto","suffix":""}],"badges":[],"createdAt":"2025-09-10 15:53:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7584587/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7584587/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13104-026-07655-3","type":"published","date":"2026-01-20T15:58:19+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":94685013,"identity":"51f3f496-c1a1-4ff7-abd1-c23ea9c2a428","added_by":"auto","created_at":"2025-10-29 15:15:09","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":72594,"visible":true,"origin":"","legend":"","description":"","filename":"BMC18SEPT2025CLEANVERFINAL.docx","url":"https://assets-eu.researchsquare.com/files/rs-7584587/v1/062662789bb41d36d14c48eb.docx"},{"id":94685009,"identity":"48e0fd0c-c619-4fc0-8117-db8b856d87a1","added_by":"auto","created_at":"2025-10-29 15:15:09","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":8702,"visible":true,"origin":"","legend":"","description":"","filename":"c56385723b7f4c1fbf465f79df65ee12.json","url":"https://assets-eu.researchsquare.com/files/rs-7584587/v1/eab938118ea0691310f6fef6.json"},{"id":94685015,"identity":"91a0949f-cf2b-4161-87e1-a2cb3cde37ef","added_by":"auto","created_at":"2025-10-29 15:15:09","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":15806,"visible":true,"origin":"","legend":"","description":"","filename":"ModifiedCoffeeConsumptionQuestionnaireENGLISHandBAHASAVER.docx","url":"https://assets-eu.researchsquare.com/files/rs-7584587/v1/f73d2779ac2fc41911fbb7f4.docx"},{"id":94729126,"identity":"60e09184-f875-44bc-8813-67214a89a412","added_by":"auto","created_at":"2025-10-30 07:04:37","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":97694,"visible":true,"origin":"","legend":"","description":"","filename":"c56385723b7f4c1fbf465f79df65ee121enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7584587/v1/f0fc097385f1979d452beb49.xml"},{"id":94685008,"identity":"462950e9-f6ef-4940-8b0b-d6784ff308c5","added_by":"auto","created_at":"2025-10-29 15:15:09","extension":"jpeg","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1074,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7584587/v1/c6cab90a7e6c7875af8a97fb.jpeg"},{"id":94728417,"identity":"51fdad66-b856-4fcf-bc5d-530f9c410f71","added_by":"auto","created_at":"2025-10-30 07:03:46","extension":"jpeg","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":8752,"visible":true,"origin":"","legend":"","description":"","filename":"groupimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7584587/v1/3ac486602d6abe7efde67026.jpeg"},{"id":94728569,"identity":"51bb861e-d5b1-4c65-9c10-72401212a2ce","added_by":"auto","created_at":"2025-10-30 07:04:01","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":935,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7584587/v1/55fac69ae2d0fafd41a818b5.png"},{"id":94685011,"identity":"b2aa9957-696d-4fe6-8da2-3b8398752e42","added_by":"auto","created_at":"2025-10-29 15:15:09","extension":"png","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":5218,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinegroupimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7584587/v1/4c1b537ce105bcc7d891b9ad.png"},{"id":94685017,"identity":"5006adc4-6843-478b-8210-94c02026548e","added_by":"auto","created_at":"2025-10-29 15:15:09","extension":"xml","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":94395,"visible":true,"origin":"","legend":"","description":"","filename":"c56385723b7f4c1fbf465f79df65ee121structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7584587/v1/e4568e0a2483d9c1531e3867.xml"},{"id":94685018,"identity":"5c78798d-d948-446f-a349-af1f08479cfc","added_by":"auto","created_at":"2025-10-29 15:15:09","extension":"html","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":105197,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7584587/v1/1ac27de1d4bd439ec2d14cdb.html"},{"id":101151769,"identity":"c200cedd-0159-4c24-9f5c-6978ed003703","added_by":"auto","created_at":"2026-01-26 16:05:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":768229,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7584587/v1/f9d6511c-79bf-4b5d-a8dd-5ce0e83736c2.pdf"},{"id":94728247,"identity":"ccccc1d2-d705-4b85-9c73-9758b3d95251","added_by":"auto","created_at":"2025-10-30 07:03:24","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":15806,"visible":true,"origin":"","legend":"","description":"","filename":"ModifiedCoffeeConsumptionQuestionnaireENGLISHandBAHASAVER.docx","url":"https://assets-eu.researchsquare.com/files/rs-7584587/v1/430772b5848ee4e57580586a.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Association between coffee consumption and psychological stress with gastroesophageal reflux disease among Indonesian medical students","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eGERD is the reflux of gastric contents causing heartburn, epigastric pain, dysphagia, regurgitation, chest discomfort, respiratory symptoms, and affects approximately 20% of the global population.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e 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%.\u003csup\u003e2\u003c/sup\u003e A study conducted by Sharma et al, reported that the incidence of this disease among medical students was 58.8% with frequent coffee consumption was significant risk factor.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e 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. \u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eCoffee consumption is recognized as 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 caffeine.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e However, some investigations, including Atta et al., identified no significant relationship between coffee consumption and GERD.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Several studies have shown a strong relationship between psychological diseases 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.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e 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.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eMedical 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.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e 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 with the occurrence of GERD among medical students at the Faculty of Medicine, Syarif Hidayatullah State Islamic University, Indonesia.\u003c/p\u003e"},{"header":"MATERIAL AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Participants\u003c/h2\u003e\u003cp\u003eThis study employed observational analytic design with quantitative, cross-sectional methods. The population consisted of preclinical and clinical students at the Faculty of Medicine, Syarif Hidayatullah State Islamic University, Indonesia. Samples were selected according to inclusion and exclusion criteria. Inclusion comprised medical students who provided informed consent, while exclusion criteria included prior GERD diagnosis based on gastroscopy, history of gastrointestinal bleeding, unexplained weight loss exceeding 10%, abdominal mass, or alcohol consumption. 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.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eVariable Definition and Assessments\u003c/h3\u003e\n\u003cp\u003eData collection was conducted using a four-part Google Form questionnaire. The first section gathered demographic information, while GERD symptoms were measured using the GERD-Q, as published in the National Guideline of Gastroesophageal Reflux Disease (GERD) Management in Indonesia (2022).\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e The GERD-Q is widely used in clinical and research settings in Indonesia. Depression, anxiety, and stress levels were assessed using the DASS-42, originally developed by Lovibond \u0026amp; Lovibond (1995)\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e and later translated into Indonesian by Damanik E.D. (2011), showing high internal consistency (Cronbach\u0026rsquo;s Alpha\u0026thinsp;=\u0026thinsp;0.9053).\u003csup\u003e11\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eCoffee 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 durability of coffee consumption.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e The whole instrument of short questionnaires showed acceptable validity and reliability test (Cronbach\u0026rsquo;s Alpha\u0026thinsp;=\u0026thinsp;0.610).\u003c/p\u003e\n\u003ch3\u003eSample Size and Statistical Analysis\u003c/h3\u003e\n\u003cp\u003eThis study included 200 medical students from Syarif Hidayatullah State Islamic University, selected by simple random sampling. Data were analyzed using SPSS with univariate, bivariate (Chi-Square or Fisher\u0026rsquo;s Exact Test), and multivariate analyses, the latter performed via backward regression.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe average age of the participants was 20 years, with most subjects being female 142 (71%).\u003c/p\u003e\u003cp\u003eas shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of medical students\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN\u003c/p\u003e\u003cp\u003e200\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(%)\u003c/p\u003e\u003cp\u003e100\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e142\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eCoffee Consumption\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRoutine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e106\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOccasional\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e47\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLevel Depression\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e145\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMild\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSevere\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVery Severe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLevel of Anxiety\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e116\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMild\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSevere\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVery Severe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLevel of Stress\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e140\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGERD\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePositive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNegative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e146\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e73\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eBased on Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, more than half (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% had varying levels of anxiety, mostly mild to moderate (23%) and 30% reported experiencing stress, with mild and moderate levels being the most common. GERD was present in 27% of students.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAssociation of coffee consumption frequency, type, and duration with GERD among medical students.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" morerows=\"2\" nameend=\"c2\" namest=\"c1\" rowspan=\"3\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u003cp\u003eGERD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" morerows=\"1\" nameend=\"c8\" namest=\"c6\" rowspan=\"2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eNegative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePositive\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eCoffee Consumption Frequency\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRarely-occasionally\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e97 (80.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e24 (19.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e121\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e60.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003e0.015\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEveryday\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e49 (62.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e30 (38)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e39.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u003cb\u003e200\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e100\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eNumber of cups\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u0026ndash;2 cups\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e144 (75.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e47 (24.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e191\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e95.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;3 cups\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e2 (22,2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7 (77.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e4,5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u003cb\u003e200\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e100\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eTypes of Coffee\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDecaffeinated Coffee\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e51 (86.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8 (13.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e29.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePure Coffee\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e19 (51.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e18 (48.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e18.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInstant Coffee\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e76 (73)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e28 (27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e104\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u003cb\u003e200\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e100\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eDuration of consumption\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u0026ndash;3 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e102 (51)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e22 (11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e124\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;4 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e44 (22)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e32 (16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e\u003cb\u003e200\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e100\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows that 39.5% of students drank coffee daily, while 60.5% consumed it rarely or occasionally. Among daily drinkers, 38% had GERD, significantly higher than 19.9% of infrequent drinkers (p\u0026thinsp;=\u0026thinsp;0.015). A strong link was found between high coffee intake and GERD: 77.8% of students consuming more than three cups daily experienced GERD, compared to 22.2% of those drinking less (p\u0026thinsp;=\u0026thinsp;0.002). Coffee type was also significant (p\u0026thinsp;=\u0026thinsp;0.001); instant coffee was most popular (52%) and pure coffee was least consumed (18.5%) was associated GERD (48.7%). Regarding the duration coffee consumption, 62% students consumed coffee for 0\u0026ndash;3 years 11% had GERD, while 38% student consumed for over 4 years, showing 16% had GERD (p\u0026thinsp;=\u0026thinsp;0.001). These results suggest frequency, type, and duration of coffee intake affect the risk of GERD.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;3. Association between depression, anxiety, and psychological with GERD in medical\u003c/p\u003e\n\u003cp\u003estudents\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"data:image/png;base64,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\"\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Table 3 demonstrated significant associations between psychological variables and GERD, with prevalence rates of 39.2% among students with depression (p = 0.033), 36.8% with anxiety (p = 0.010), and 43.6% with stress (p = 0.001). Stress exhibited the strongest correlation, underscoring its potential role in GERD development. The multivariate analysis indicates that individuals reporting higher levels of stress had a significantly lower odds of experiencing GERD (OR = 0.353; \u003cem\u003ep\u003c/em\u003e = 0.002). Interpreting this from a preventive health perspective, it is plausible that effective stress management may contribute to a reduction in GERD incidence. Based on the odds ratio, individuals with well-managed stress could potentially experience up to a \u003cstrong\u003e64.7% reduction in the odds of developing GERD\u003c/strong\u003e compared to those with unmanaged or lower reported stress levels. Depression (OR = 0.989; \u003cem\u003ep\u003c/em\u003e = 0.981) and anxiety (OR = 0.764; \u003cem\u003ep\u003c/em\u003e = 0.559) did not exhibit statistically significant associations with GERD in the multivariate model. This suggests that, within the parameters of this study, these psychological conditions may not serve as independent predictors of GERD, although coffee consumption yielded an odds ratio suggestive of a potential association (OR = 0.551), the lack of statistical significance (\u003cem\u003ep\u003c/em\u003e = 0.078) indicates that no definitive conclusions can be drawn from this data.\u003c/p\u003e"},{"header":"DISCUSSIONS","content":"\u003cp\u003eDue to demanding schedules and the need for sustained alertness, coffee consumption is common among medical students, including 53% at State Islamic University Indonesia. Edward et al. reported that 16.8% and 19.4% of Indian medical students consumed coffee to stay alert and combat drowsiness, with intake rising during exams.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Similarly, Devi et al. noted that students often drink coffee while preparing for exams, highlighting academic pressure as a major factor influencing this habit.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThis study indicated that many medical students experience mild to moderate levels of depression and anxiety. While the numbers are significant, the severity remains generally low, ranging from mild to moderate. These results are consistent with previous studies. The symptoms were due to stressors related to the challenging and demanding educational environment, creating unique pressures for students.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e The most challenging factors during medical studies included various types of exams, a large amount of material to be learned, high demands, and failure to complete tasks as planned. Other stressors commonly observed were adapting to medical environment, high educational costs, and a poor learning environment, contributing to a higher risk of mental health problems.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eGERD was observed in 27% of subjects, which aligns with global prevalence rates of 15%- 25%.\u003csup\u003e17\u003c/sup\u003e In Jakarta, the incidence of GERD diagnosed via endoscopy was 22,8%. Similarly, Sharma et al. reported that 25% of patients experienced GERD symptoms.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Daily coffee consumption was reported by 39.5% of students, with 38% experiencing GERD, indicating a significant association, as also found by Hartoyo et al. and Polese et al. reported that coffee can reduce lower esophageal sphincter (LES) pressure and stimulate gastric acid secretion\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Nehlig et al. explained that caffeine binds to TAS2R receptors, overstimulating G cells, leading to increased gastrin release and excessive gastric acid production. These mechanisms help explain the link between frequent coffee intake and GERD symptoms among medical students.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eOnly 4.5% of students consumed over three cups of coffee daily, yet 77.8% of them had GERD, showing a strong link. This aligns with Arivan et al. and Martinucci et al., who found similar associations in India and Italy. These findings highlight that high coffee intake significantly contributes to GERD risk among students.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThis study also found that coffee type and processing methods are associated with GERD, as different processes may affect caffeine content and other compounds. Pure coffee is made by water extraction from roasted beans, retaining full caffeine levels. In contrast, decaffeinated coffee undergoes further processing using water, organic solvents, or carbon dioxide to significantly reduce caffeine. Instant coffee is designed for convenience but may still contain varying caffeine amounts. Choosing decaffeinated options may help reduce GERD symptoms by lowering caffeine intake.\u003csup\u003e\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThis study found that most students (52%) drank instant coffee, and 27% of them experienced GERD. In contrast, only 18.5% of students drank pure coffee, but 48.7% of them had GERD. This shows a significant link between coffee consumption\u0026mdash;especially pure coffee\u0026mdash;and GERD. The study also found that among the 29.5% of students who drank decaffeinated coffee, only 13.6% had GERD. This supports the findings of Mehta et al., who reported that caffeinated coffee carries a higher risk of causing GERD than decaffeinated coffee.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Nehlig et al. noted that instant coffee increases gastric acid secretion, worsening GERD, while decaffeinated coffee, with less caffeine, has milder effects\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Other factors like bean elevation, roast level, and brewing method also affect acidity.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e However, Wei et al. found no significant link between coffee type and GERD, suggesting individual variability.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e This study also indicated that 16% medical students with GERD had a history of coffee consumption exceeding four years demonstrating a statistically significant relationship between prolonged coffee consumption and the occurrence of GERD. However, these results necessitate further discussion to explore the potential causative mechanisms and contributing factors underlying this association. 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 \u0026ldquo;stressors.\u0026rdquo; Stress represents the body\u0026rsquo;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.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eAnxiety manifests through physical and emotional responses to stress, including tachycardia, shallow breathing, and muscle tension, impairing daily function. Depression involves persistent sadness, anhedonia, and low energy, often accompanied by poor self-esteem, guilt, suicidal ideation, impaired concentration, sleep and appetite disturbances, and multiple somatic symptoms.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e This study stated 27.5% experienced depression with 39.2% of them reported symptoms of GERD. Furthermore, the data showed that most medical students in this study had symptoms consistent with mild depression\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. There is also significant relationship between depression and GERD in medical students. This result was similar with Bai et al. that showed a relationship between depression and anxiety with GERD among the young population of South Korea.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e Furthermore, this study reported 43.5% of students had anxiety, with most of them were mild to moderate anxiety, and 36.8% of them experienced GERD. This study is consistent with Mohammad, et al study that also reported a relationship between anxiety and GERD with or without chest pain.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Li,et al. used logistic regression modeling and found that higher anxiety levels were related to an increased rate of GERD and showed significant connection between mild anxiety and an increased risk of GERD.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e Golinejad et al. also reported significant relationship between anxiety and GERD in health science students in Saudi Arabia (p\u0026thinsp;=\u0026thinsp;0.017).\u003csup\u003e30\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThirty percent 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 the report of Wickramasinghe et al. which showed a correlation between stress levels and GERD symptoms, such as heartburn, regurgitation, chest pain, coughing, and burping. Another study conducted by Bulqaini et al, found a significant relationship between psychological stress and the severity of GERD in medical students in Medan, Indonesia.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e 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.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThis study identified stress as the sole significant factor linked to GERD, surpassing depression, anxiety, and coffee consumption. Stress may increase esophageal acid exposure, delay gastric emptying, or cause esophageal hypersensitivity, intensifying heartburn symptoms.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e Both acute and chronic stress can trigger GERD. No previous studies have compared depression, anxiety, and stress effects on GERD directly. Further research is needed to explore how interactions between stress, environmental factors, and habitual coffee intake might collectively influence GERD risk, aiding in understanding the complex relationship between these variables.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eGastroesophageal 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 stress, highlighting the strong link between mental well-being and gastrointestinal function. Daily coffee consumption, especially exceeding three cups, demonstrated higher GERD prevalence. Instant and pure coffee conferred greater risks compared to decaffeinated forms, while long-term intake beyond four 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.\u003c/p\u003e"},{"header":"Limitation","content":"\u003cp\u003eA limitation of this study was the small sample size, 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.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eGERD\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e :\u003c/strong\u003e Gastroesophageal reflux disease\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eLES \u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e: \u003c/strong\u003eLower Esophageal Sphincter\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eNERD \u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e: \u003c/strong\u003eNon-erosive reflux disease\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eGERD-Q \u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e: \u003c/strong\u003eGastroesophageal reflux disease\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTAS2R \u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e: \u003c/strong\u003eType 2 sensory receptor\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical 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.\u0026nbsp;Informed written consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author on reasonable request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo conflict of interest is declared by authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported and funded in part by\u0026nbsp;Center for Research and Publication\u0026nbsp;Universitas Islam Negeri Syarif Hidayatullah Jakarta grant in 2023.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFNA, 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank medical students at the Faculty of Medicine, Universitas Islam Negeri Syarif Hidayatullah Jakarta who participated in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDepartment of Internal Medicine, Faculty of Medicine, Universitas Islam Negeri Syarif Hidayatullah Jakarta.\u003c/p\u003e\n\u003cp\u003eFemmy Nurul Akbar, Intan Nurjannah, Amaliya Mata\u0026rsquo;ul Hayah, Regina Stefani Anwar\u003csup\u003e,\u003c/sup\u003e Sayid Ridho,\u003c/p\u003e\n\u003cp\u003eHari Hendarto\u003c/p\u003e\n\u003cp\u003eMedical Study Program, Faculty of Medicine Universitas Islam Negeri Syarif Hidayatullah Jakarta.\u003c/p\u003e\n\u003cp\u003eAmira Calista Patria, Ainaya Hanif Nabila\u003c/p\u003e\n\u003cp\u003eCorresponding author:\u003c/p\u003e\n\u003cp\u003eFemmy Nurul Akbar, Department of Internal Medicine,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFaculty of Medicine, Universitas Islam Negeri Syarif Hidayatullah Jakarta, Pisangan, Ciputat, South Tangerang, Indonesia. Email: [email protected]\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKahrilas PJ, HI. The disease of esophagus. In: Harrison, editor. Principles of Internal Medicine. McGraw-Hill Education; 2022. p. 1716.\u003c/li\u003e\n\u003cli\u003eSyam AF, Hapsari PF, Makmun D. The prevalence and risk factors of GERD among Indonesian medical doctors. Makara J Heal Res. 2016;20(2):35\u0026ndash;40.\u003c/li\u003e\n\u003cli\u003eSharma A, Sharma PK, Puri P. Prevalence and the risk factors of gastro-esophageal reflux disease in medical students. Med J Armed Forces India. 2018;74(3):250\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eSaragih AF, Purba DN, Silaen M, Fibrini D. Quality of life and GERD incidence in medical students: A cross-sectional study. J Prima Med Sains. 2023;5(2):130\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eMehta RS, Song M, Staller K, Chan AT. Association between beverage intake and incidence of gastroesophageal reflux symptoms. Clin Gastroenterol Hepatol. 2020;18(10):2226\u0026ndash;34. e4.\u003c/li\u003e\n\u003cli\u003eAtta MM, Sayed MH, Zayed MA, Alsulami SA, Al-Maghrabi AT, Kelantan AY. Gastro-oesophageal reflux disease symptoms and associated risk factors among medical students Saudi Arabia. Int J Gen Med. 2019; 2:293\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eChoi JM, Yang JI, Kang SJ, Han YM, Lee J, Lee C, et al. Association between anxiety and depression and gastroesophageal reflux disease: Results from a large cross-sectional study. J Neurogastroenterol Motil. 2018;24(4):593\u0026ndash;602.\u003c/li\u003e\n\u003cli\u003eBaklola M, Terra M, Badr A, Fahmy FM, Elshabrawy E, Hawas Y, et al. Prevalence of gastro-oesophageal reflux disease, and its associated risk factors among medical students: a nation-based cross-sectional study. BMC Gastroenterol. 2023; 23:1\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eMakmun D, Fauzi A, Maulahela H, Pribadi RR. Konsensus nasional penatalaksanaan penyakit refluks gastroesofageal (Gastroesophageal reflux disease/GERD) di Indonesia. Perkumpulan Gastroenterologi Indonesia (PGI) [National consensus on the management of gastroesophageal reflux disease/GERD in Indonesia. Indonesian society of gastroenterology/ISG]. 2022. https://pbpgigastro.com/wp-content/uploads/2024/07/Konsensus-Nasional-Penatalaksanaan-GERD-di-Indonesia-Revisi-2022.pdf. Accessed 17\u003csup\u003eth\u003c/sup\u003e September 2025.\u003c/li\u003e\n\u003cli\u003eLovibond SH, Lovibond PF. Manual for the depression anxiety stress scales. 2nd ed. Sydney: Psychology Foundation. 1995.\u003c/li\u003e\n\u003cli\u003eDamanik ED. The measurement of reliability, validity, items analysis and normative data of depression anxiety stress scale (DASS). Universitas Indonesia; 2011.\u003c/li\u003e\n\u003cli\u003eCzarniecka-Skubina E, Pielak M, Sałek P, Korzeniowska-Ginter R, Owczarek T. Consumer choices and habits related to coffee consumption by poles. Int Environ. Res Public Health. 2021 Apr 2;18(8).\u003c/li\u003e\n\u003cli\u003eArivan R, Deepanjali S. Prevalence and risk factors of gastro-esophageal reflux disease among undergraduate medical students from a southern Indian medical school: A cross-sectional study. BMC Res Notes. 2018;11(1):448.\u003c/li\u003e\n\u003cli\u003eEdward S, Kumar MS, Gopalkrishnan S. Trend of caffeine consumption among medical students and its side effects. Drug Invent Today. 2019;12(11):2764\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eDevi SSL, Abilash SC, Basalingappa S. The rationale of caffeine consumption and its symptoms during preparatory and non-preparatory days: A study among medical students. Biomed Pharmacol J. 2018;11(2):1153\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eRamadianto AS, Kusumadewi I, Agiananda F, Raharjanti NW. Symptoms of depression and anxiety in Indonesian medical students: association with coping strategy and resilience. BMC Psychiatry. 2022; 22:1\u0026ndash;11.\u003c/li\u003e\n\u003cli\u003eMao Y, Zhang N, Liu J, Zhu B, He R, Wang X, et al. A systematic review of depression and anxiety in medical students in China. BMC Med Educ. 2019; 19:1\u0026ndash;13.\u003c/li\u003e\n\u003cli\u003eHartoyo FZ, Tandarto K, Sidharta V, Tenggara R. The correlation between coffee consumption and gastroesophageal reflux disease. Indones J Gastroenterol Hepatol Dig Endosc. 2022; 23:11\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003ePolese B, Izzo L, Mancino N, Pesce M, Rurgo S, Tricarico MC, et al. Effect of dewaxed coffee on gastroesophageal symptoms in patients with GERD: A randomized pilot study. Nutrients. 2022;14(12):2510.\u003c/li\u003e\n\u003cli\u003eNehlig A. Effects of coffee on the gastro-intestinal tract: A narrative review and literature update. Nutrients. 2022;14(2):399.\u003c/li\u003e\n\u003cli\u003eMartinucci I, Natilli M, Lorenzoni V, Pappalardo L, Monreale A, Turchetti G, et al. Gastroesophageal reflux symptoms among Italian university students: Epidemiology and dietary correlates using automatically recorded transactions. BMC Gastroenterol. 2018;18(1):116.\u003c/li\u003e\n\u003cli\u003eMulvaney D, Robbins P. International coffee agreement. In: Green food an A-to-Z guide. Sage Publication; 2012.\u003c/li\u003e\n\u003cli\u003eSukrasno S, Aria RI, Ruslan WK. The caffeine content in coffee beverages commercially distributed in Indonesia. J Food Nutr Res. 2018;6(8):513\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003edePaula J, Farah A. Caffeine consumption through coffee: Content in the beverage, metabolism, health benefits and risks. Beverages. 2019;5(2):37.\u003c/li\u003e\n\u003cli\u003eWei TY, Hsueh PH, Wen SH, Chen CL, Wang CC. The role of tea and coffee in the development of gastroesophageal reflux disease. Tzu Chi Medical Journal. 2019 Jul 1;31(3):169\u0026ndash;76.\u003c/li\u003e\n\u003cli\u003eWickramasinghe N, Thuraisingham A, Jayalath A, Wickramasinghe D, Samarasekara N, Yazaki E, et al. The association between symptoms of gastroesophageal reflux disease and perceived stress: A countrywide study of Sri Lanka. PLoS One. 2023;18(11): e0294135.\u003c/li\u003e\n\u003cli\u003eBulqaini AA, Darmadi. Relationship between degrees of severity gastroesophageal reflux disease with quality of life. J Endocrinol Trop Med Infect Dis. 2023;4(3):96\u0026ndash;103.\u003c/li\u003e\n\u003cli\u003eBai P, Bano S, Kumar S, Sachdev P, Ali A, Dembra P, et al. Gastroesophageal reflux disease in the young population and its correlation with anxiety and depression. Cureus. 2021;13(5): e12589.\u003c/li\u003e\n\u003cli\u003eLi Q, Duan H, Wang Q, Dong P, Zhou X, Sun K, et al. Analyzing the correlation between gastroesophageal reflux disease and anxiety and depression based on ordered logistic regression. Sci Rep. 2024;14 :1\u0026ndash;11.\u003c/li\u003e\n\u003cli\u003eGholinejad N, Teimouri A. Investigation of gastroesophageal reflux disease among medical students. Govaresh. 2021;26(1):49\u0026ndash;54.\u003c/li\u003e\n\u003cli\u003eSujaritha J, Deepa N, Nandhini J, Vandhana V, Mahalakshmi D. Stress and stress management: A review. Indian J Nat Sci. 2022;13(73):45563\u0026ndash;70.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-research-notes","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"resn","sideBox":"Learn more about [BMC Research Notes](http://bmcresnotes.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/resn/default.aspx","title":"BMC Research Notes","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"coffee consumption, depression, anxiety, psychological stress, GERD, medical students","lastPublishedDoi":"10.21203/rs.3.rs-7584587/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7584587/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMedical students are experiencing gastroesophageal reflux disease (GERD) due to academic demands, dietary factors, such as coffee consumption and psychological stress. This study explored the relationship between coffee consumption, psychological stress, and GERD among medical students. A cross-sectional survey was conducted among 200 students at the Faculty of Medicine, Syarif Hidayatullah State Islamic University Jakarta.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResults showed that 53% of students consumed coffee, 28% had depression, 42% had anxiety, and 30% experienced psychological stress. GERD was found in 27% of students and was significantly related to drinking more than 3 cups of coffee daily (p=0.015), long-term consumption more than 4 years (p=0.001), instant coffee (p=0.001), depression (p=0.033), anxiety (p=0.010), and psychological stress (p=0.001). \u0026nbsp;However, only psychological stress remained significant in multivariate analysis (p=0.002). 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.\u003c/p\u003e","manuscriptTitle":"Association between coffee consumption and psychological stress with gastroesophageal reflux disease among Indonesian medical students","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-29 15:15:04","doi":"10.21203/rs.3.rs-7584587/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-28T12:49:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-20T11:25:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1737982607446448038433854971950030768","date":"2025-10-18T06:50:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-16T06:19:59+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-15T10:09:26+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-18T16:39:57+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-18T16:25:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Research Notes","date":"2025-09-18T15:39:48+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-research-notes","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"resn","sideBox":"Learn more about [BMC Research Notes](http://bmcresnotes.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/resn/default.aspx","title":"BMC Research Notes","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f3a8cecb-3a01-4f1d-93d7-748850712f77","owner":[],"postedDate":"October 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-26T16:01:23+00:00","versionOfRecord":{"articleIdentity":"rs-7584587","link":"https://doi.org/10.1186/s13104-026-07655-3","journal":{"identity":"bmc-research-notes","isVorOnly":false,"title":"BMC Research Notes"},"publishedOn":"2026-01-20 15:58:19","publishedOnDateReadable":"January 20th, 2026"},"versionCreatedAt":"2025-10-29 15:15:04","video":"","vorDoi":"10.1186/s13104-026-07655-3","vorDoiUrl":"https://doi.org/10.1186/s13104-026-07655-3","workflowStages":[]},"version":"v1","identity":"rs-7584587","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7584587","identity":"rs-7584587","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}