|Year : 2016 | Volume
| Issue : 4 | Page : 268-272
Effect of examination stress on blood sugar in medical students
Sunil Kumar Jena1, Akshaya Kumar Misra1, Arati Mohanty2
1 Department of Physiology, Veer Surendra Sai Institute of Medical Sciences and Research, Burla, Odisha, India
2 Department of Physiology, IMS and Sum Hospital, Bhubaneswar, Odisha, India
|Date of Web Publication||14-Sep-2016|
Dr. Sunil Kumar Jena
Department of Physiology, Veer Surendra Sai Institute of Medical Sciences and Research, Burla - 768 017, Odisha
Source of Support: None, Conflict of Interest: None
Background: It has been proved by different research works that examination is a stress factor for students. Medical curriculum is as such stressful for students. Thus, in this study, researchers proposed to observe the changes in blood sugar level owing to examination stress in medical students. Materials and Methods: A general questionnaire was distributed among 1st year MBBS students for selection of subjects. The questionnaire included demographic data, history of diseases, history of drug abuse, and family history of diseases. After the return of questionnaires, 49 1st year MBBS students were selected for this study. Baseline data of heart rate (HR), blood pressure (BP), and fasting blood sugar (FBS) were observed 1 month before beginning of the first professional examination. Then, the second setting of the same data as baseline was observed on the day of practical and viva examination. Data analysis was done by paired t-test to find out the effect of examination on different parameters. P< 0.05 was considered to be significant. Results: Examination stress was responsible to raise HR, systolic and diastolic BP, and FBS from baseline significantly at P< 0.001. Conclusion: As shown in results, the effect of examination raises HR and BP from baseline, confirming that examination creates some stress on students. Thus, it was assumed that examination stress is responsible to raise blood sugar level that is essential to supply extra energy to vital organs.
Keywords: Blood pressure, examination stress, fasting blood sugar, heart rate, medical students
|How to cite this article:|
Jena SK, Misra AK, Mohanty A. Effect of examination stress on blood sugar in medical students. CHRISMED J Health Res 2016;3:268-72
|How to cite this URL:|
Jena SK, Misra AK, Mohanty A. Effect of examination stress on blood sugar in medical students. CHRISMED J Health Res [serial online] 2016 [cited 2021 Aug 5];3:268-72. Available from: https://www.cjhr.org/text.asp?2016/3/4/268/190573
| Introduction|| |
Stress is defined as “a physical or psychological stimulus, can evoke physiological reactions that may cause serious bodily dysfunctions.” Mild level of stress may be beneficial in cognitive tasks and performance whereas persistently high degree of stress may lead to anxiety and depression, which are definable as neuropsychiatric disease entities. Although the basic neurochemistry of the stress response is now very well understood, so many things are remain to be discovered about how the components of this system interact with each other in the brain and throughout the body. Both negative and positive stressors are responsible to develop stress. The intensity and duration of stress depend on the circumstances and emotional condition of the person suffering from it as well as stressors range from sensory input such as pain to life events such as poverty and financial constraints. Apart from releasing of typical stress metabolites, specific enzymes, and hormones, different possible reactions and variety of symptomatic changes are also seen in individuals under stress. Exposure to psychological stressors can modulate the primary antibody response and increased permanent stress levels can lead to pathological changes in organs, psychological changes as well as psychosomatic diseases. In human beings, a range of stressful events have been associated with lowering the immune system functioning such as examinations, workplace, vigilance, sleep deprivation, and divorce. Academic examinations have often been used in stress research because they are predictable, standardized, and typical examples of stressors. They are all associated with changes in the emotional and physical health such as increasing the level of anxiety, increasing the negative mood, and changes in the immune system functioning. Academic examinations have been reported to also have a significant impact on the student's well-being. An individual when challenged to a situation or threatened leads to activation of sympathetic adrenal medullary (SAM) system so that secretion of epinephrine and norepinephrine increases. Activation of SAM system prepares the individual to face the challenges or threats. Prolonged stress is associated with the activation of hypothalamo pituitary adrenal (HPA). Activation of HPA axis is associated with increase in the release of hormones such as adrenocorticotropic hormone (ACTH) and cortisol. The activation of HPA and SAM increases the arousal level, therefore energy is mobilized and aids the body in the fight or flight reaction. Energy is mobilized to vital organs for the purpose of proper functioning. The energy mobilization leads to an elevated blood concentration of glucose and free fatty lipids, and anabolism is downregulated. The anabolic processes are central to the body's defense of all organ systems that need constant rebuilding and restoration. The reduced anabolism associated with prolonged stress is likely to be of great importance for stress-related disease.
Students react to medical college in a variety of ways. Abrupt change from higher secondary education to medical college could be stressful, as would be separation from home, drastic changes in the education system, and advances in science. A major stressor for the 1st year medical students is the amount and complexity of the material to be learned. The stressors discussed above add to the stress of examinations, which most of the students perceive as an evil, they would rather do away from it. In a medical student, the situation is aggravating by the added pressure to secure better grades than his peer for securing the residency program of his choice. As in medical education, the schedule for the academic curriculum along with time-to-time assessment creates lots of stress in medical students, particularly in the 1st year MBBS students who are in the transition phase of their life. Researchers in this study tested the hypothesis that examination stress may lead to increase in fasting blood glucose (FBG). The present study was, therefore, aimed at evaluating the change in FBG during academic examination stress in Veer Surendra Sai Institute of Medical Sciences and Research (VIMSAR). The findings from this study will highlight the possible need for the continuous assessment of students which will help to reduce the associated stress-related disorders. For clinicians, these findings will enhance the understanding of the students' plights and possible medical conditions in the management of students.
| Materials and Methods|| |
The study was conducted in the Department of Physiology, VIMSAR, Burla, Odisha, India. The study was done from January to December 2015 after getting approval from the Institutional Ethics Committee of VIMSAR. The 1st year MBBS students of VIMSAR were taken as the subjects for this study. Selection of subjects was done by taking the history of students. The history sheet is provided at the end of the materials and methods heading. The history sheet included demographic data, history of diseases, history of drug abuse, and family history of diseases. The history sheet was filled up by the principal investigator in the face-to-face interview of students. After the completion of interview, the history sheets were analyzed for subject selection. Students having no disease history, no family history of diabetes or hypertension, nonsmoker, and nonalcoholic were included in this study. Students having any psychiatric disorder, neurological disease, cardiovascular disease, renal disease or any chronic disease, diabetics, family history of diabetes or hypertension, smokers, and alcoholics were excluded from this study. Thus, a total of 49 healthy 1st year MBBS students (34 males and 15 females) were selected for this study after considering the inclusion and exclusion criteria. A written consent was taken from each subject. Data were taken at two sittings, i.e. baseline data 1 month before the beginning of the first professional MBBS examination and second sitting on the day of the first professional MBBS viva and practical examination. Each subject was allowed to take 5–10 min rest before measuring heart rate (HR) and blood pressure (BP). Then, in seating position, baseline and second sitting HR and BP were recorded, followed by blood drawn for fasting blood sugar recording (FBS) in the morning between 8 and 9 am. BP was recorded by sphygmomanometer and HR was calculated by palpatory method of carotid artery. The day before the FBS test, the subjects were instructed to maintain a minimum of 8 h of fasting. Two milliliter blood was drawn from the cubital vein of each subject between 8 and 9 am, and the anticoagulant used was sodium fluoride. The FBS was done by glucose oxidase–peroxidase method. Statistical analysis was done by statistical software SPSS version 16 (IBM Corporation, Armonk, New York). Examination stress was considered as the intervening factor for this study so that paired t-test was used to compare the changes in HR, BP, and FBS before and during examination.
- Name – _____
- Age – _____
- Sex – _____
- Smoking history – Yes/no
- Disease history – Neurological/psychiatric/cardiovascular/endocrinal/renal/any other chronic disease
- Family history of disease – Diabetes/hypertension
- History of drug or alcohol abuse – Yes/no.s
| Results|| |
In this study, 49 healthy medical students were selected as subjects including 34 male and 15 female students as shown in [Figure 1]. All subjects were within the age group of 18–20 years.
Baseline HR of subjects was 81/min with a standard deviation of 5.19 and HR due to the effect of examination was 105/min with a standard deviation of 5.69. This change in HR was compared by paired t-test and a significant rise in HR owing to examination stress having P < 0.001 was found as shown in [Table 1] and [Figure 2].
|Figure 2: Comparison of Heart rate, Systolic blood pressure and Diastolic blood pressure |
Click here to view
Baseline systolic BP (SBP) of subjects was 109 mmHg with a standard deviation of 4.50 and SBP due to the effect of examination was 124 mmHg with a standard deviation of 5.54. This change in SBP was compared by paired t-test and a significant increase in SBP owing to examination stress having P < 0.001 was found as shown in [Table 1] and [Figure 2].
Baseline diastolic BP (DBP) of subjects was 78 mmHg with a standard deviation of 1.66 and DBP due to the effect of examination was 88 mmHg with a standard deviation of 1.98. This change in DBP was compared by paired t-test and a significant increase in DBP owing to examination stress having P < 0.001 was found as shown in [Table 1] and [Figure 2].
Baseline FBS of subjects was 84 mg/dl with a standard deviation of 9.29 and FBS due to the effect of examination was 92 mg/dl with a standard deviation of 4.46. This change in FBS was compared by paired t-test and that showed a significant rise in FBS owing to examination stress having P < 0.001 as shown in [Table 1] and [Figure 3].
| Discussion|| |
Examination is an established stressor for students and it is proved by different researchers. Thus, in this study, examination was considered a stressor for medical students and hence, researchers wanted to find out the change of blood sugar due to the effect of examination stress.
In this study, researchers found that the effect of examination stress increased the HR, BP, and FBS. This variation in HR and BP between baseline and the effect of examination stress found a significant result, P < 0.001, as shown in [Table 1] and [Figure 2]. There was a significant increase in the FBS of subjects due to the effect of examination stress than the baseline, P < 0.001, as shown in [Table 1] and [Figure 3].
When a person face any stress stimuli, the information is transmitted first upward through the brainstem and eventually to the median eminence of hypothalamus, from which corticotropin-releasing hormone (CRH) is secreted into hypothalamo-hypophysial portal system. CRH stimulates anterior pituitary to increase ACTH secretion that leads to the secretion of large quantity of cortisol from adrenal cortex. CRH also activates the sympathetic nervous system (SNS) including adrenal medulla, and catecholamines are released.
Examination pattern of medical curriculum is such that the students are exposed to examination stress for a prolonged period such as months. In fact, there is no definition of chronic stress. For example, should a stressful month be labeled as a chronic stress? Most experts define that chronic stress refers to a prolonged period of exposure to stress factor. With respect to the physiological responses, one could expect that chronic stress should result in hyperarousal, for example, elevated levels of HR, BP, cortisol, etc., which is observed in depressive and anxiety disorders. Similar changes were observed regarding HR and BP of subjects owing to examination stress in this study.
Systolic levels are a good indicator of BP even without the diastolic readings. However, the stress response is a more likely explanation for the observed results. The initial rise in SBP when considering the stress response would be primarily due to the increase in circulating catecholamines caused by activation of the hypothalamic-pituitary adrenal (HPA) axis and stimulation by the SNS. It is well-known that exposure to novel, stressful environments increases catecholamine-mediated SNS stimulation of the cardiovascular system, thereby increasing HR and BP. DBP is increased by constricting muscle vasculature and by increasing peripheral vascular resistance. Glucocorticoids secreted during stress enhance the synthesis and secretion of catecholamines, thereby further enhancing these effects.
Glucocorticoid is a functional antagonist of insulin, thus it decreases insulin sensitivity as well as increases blood glucose via a number of pathways such as (a) upregulating the transcription of rate-limiting enzymes of gluconeogenesis such as phosphoenolpyruvate carboxykinase (PEPCK) and glucose-6-phosphatase, (b) increasing proteolysis and lipolysis, leading to increasing amino acids and glycerol levels which act as substrates for gluconeogenesis, (c) decreasing insulin secretion from pancreas, and (d) inhibiting glucose transporter-4, which is involved in the uptake of glucose into peripheral tissues.,, Meanwhile, catecholamines can also increase blood glucose concentrations by stimulating the secretion of cortisol and glucagon, as well as by enhancing metabolic rate, glycogenolysis, and gluconeogenesis. Thus, glucocorticoid and catecholamine induced raise in blood glucose that would help meet the increased energy demands of the stressor. This study also had shown a similar result of raised FBS that is essential for energy mobilization to vital organs during examination stress. A study was done on hospitalized patients to find out stress-induced blood glucose level and they found that stress induces hyperglycemia. However, in our study, we did not found hyperglycemia, but found raise in blood glucose from baseline.
However, chronic exposure to stress could lead to a variety of metabolic breakdowns due to continuously high concentrations of glucocorticoids and catecholamines, eventually leads to a number of stress-related malfunctions. Thus, higher FBS than baseline may be used as an indicator of stress and is helpful to provide necessary advice to students so that they can cope to stressors well along with free from stress-related disorders.
| Conclusion|| |
This study concluds that examination is a stressful condition which affects mind and body. Increaed level of blood sugar from basal level can be considered as an indicator of stress. Thus estimation of blood sugar will be helpful to make the students aware about bad consequences of stress as well as essential counselling of coping of stress
It is a pleasure for the researchers to acknowledge the students' satisfactory cooperation in this study without whom this study could not be accomplished. We are also thankful to the paramedical staffs of Jyoti Laboratory, Burla, for their active collaboration in laboratory procedures.
Financial support and sponsorship
This study was supported by Jyoti laboratory, Burla, Sambalpur, by supplying equipment and chemicals.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Singh R, Goyal M, Tiwari S, Ghildiyal A, Nattu SM, Das S. Effect of examination stress on mood, performance and cortisol levels in medical students. Indian J Physiol Pharmacol 2012;56:48-55.
Keil RM. Coping and stress: A conceptual analysis. J Adv Nurs 2004;45:659-65.
Schore A. Affect Regulation & the Repair of the Self. New York: W.W. Norton; 2003.
Moraska A, Campisi J, Nguyen KT, Maier SF, Watkins LR, Fleshner M. Elevated IL-1beta contributes to antibody suppression produced by stress. J Appl Physiol 2002;93:207-15.
Shamsdin SA, Anvar M, Mehrabani D. The effect of exam stress on IL-6, cortisol, CRP and IgE levels. Iran Red Crescent Med J 2009;12:484-8.
Loft P, Thomas MG, Petrie KJ, Booth RJ, Miles J, Vedhara K. Examination stress results in altered cardiovascular responses to acute challenge and lower cortisol. Psychoneuroendocrinology 2007;32:367-75.
Lundberg U. Catecholamines. In: Fink G, editor. Encyclopedia of Stress. Vol. 1. New York: Academic Press; 2000. p. 408-13.
McCarty R, Pacak K. Alarm phase and general adaptation syndrome. In: Fink G, editor. Encyclopedia of Stress. Vol. 1. New York: Academic Press; 2000. p. 126-30.
Theorell T. Psychosomatic medicine. In: Fink G, editor. Encyclopedia of Stress. Vol. 3. New York: Academic Press; 2000. p. 304-9.
Brown MS, Kovanen PT, Goldstein JL. Receptor-mediated uptake of lipoprotein-cholesterol and its utilization for steroid synthesis in the adrenal cortex. Recent Prog Horm Res 1979;35:215-57.
Grings WW, Dawson ME. Emotions and Bodily Responses. New York: Academic Press; 1978.
Lichtenstein MJ, Shipley MJ, Rose G. Systolic and diastolic blood pressures as predictors of coronary heart disease mortality in the Whitehall study. Br Med J (Clin Res Ed) 1985;291:243-5.
Morimoto A, Watanabe T, Morimoto K, Nakamori T, Murakami N. Possible involvement of prostaglandins in psychological stress-induced responses in rats. J Physiol 1991;443:421-9.
Handy DE, Johns C, Bresnahan MR, Tavares A, Bursztyn M, Gavras H. Expression of alpha2-adrenergic receptors in normal and atherosclerotic rabbit aorta. Hypertension 1998;32:311-7.
Kvetnanský R, Fukuhara K, Pacák K, Cizza G, Goldstein DS, Kopin IJ. Endogenous glucocorticoids restrain catecholamine synthesis and release at rest and during immobilization stress in rats. Endocrinology 1993;133:1411-9.
Andrews RC, Rooyackers O, Walker BR. Effects of the 11 beta-hydroxysteroid dehydrogenase inhibitor carbenoxolone on insulin sensitivity in men with type 2 diabetes. J Clin Endocrinol Metab 2003;88:285-91.
Cassuto H, Kochan K, Chakravarty K, Cohen H, Blum B, Olswang Y, et al.
Glucocorticoids regulate transcription of the gene for phosphoenolpyruvate carboxykinase in the liver via an extended glucocorticoid regulatory unit. J Biol Chem 2005;280:33873-84.
Vegiopoulos A, Herzig S. Glucocorticoids, metabolism and metabolic diseases. Mol Cell Endocrinol 2007;275:43-61.
Barth E, Albuszies G, Baumgart K, Matejovic M, Wachter U, Vogt J, et al.
Glucose metabolism and catecholamines. Crit Care Med 2007;35(9 Suppl):S508-18.
McAllister DA, Hughes KA, Lone N, Mills NL, Sattar N, McKnight J, et al.
Stress hyperglycaemia in hospitalised patients and their 3-year risk of diabetes: A Scottish retrospective cohort study. PLoS Med 2014 19;11:e1001708.
[Figure 1], [Figure 2], [Figure 3]