Gastro-Oesophageal Reflux Disease (GERD) is defined by repeated and troublesome heartburn and regurgitation or GERD-specific problems and affects about 20% of the adult population in high-income countries [1]. GERD is originally a disease of the Lower Oesophageal Sphincter (LES) however, many factors could contribute to its occurrence. The factors facilitating GERD are both physiological and pathological. The most obvious cause is a transient lower oesophageal sphincter relaxation (TLESRs). TLESRs are short moments of lower oesophageal sphincter tone stopping that are independent of swallowing. While they are physiological in character, there is a high frequency in the post-prandial phase and they greatly contribute to acid reflux in patients having GERD. Other factors were represented with a reduced lower oesophageal sphincter (LES) pressure, hiatal hernia, reduced esophageal clearance and a delay gastric emptying [2]. Some drugs can cause GERD such as nonsteroidal anti-inflammatory drugs (NSAIDs) [3].   Among the common signs and symptoms of GERD are burning feeling in the chest, often known as heartburn. Heartburn usually occurs after eating and might be more badly detected at night or while lying in recumbency position. Backwash of ingested food or sour liquid in the throat. Upper tommy or chest pain. Troublesome swallowing, known as dysphagia. Sensation of lumping in the throat [4], also, there are atypical symptoms like pressure feeling in the chest known as noncardiac chest ache, Belching, Dyspepsia, epigastric ache, Nausea and halitosis. Sometimes there are features of GERD complications like aspiration pneumonia or aspiration pneumonitis. While in some cases there are extraesophageal symptoms like Chronic non-productive cough, nighttime cough, hoarseness, bronchospasm and teeth erosions [3].   Overweight has been cogitated to be a key risk factor of GERD. The increasing rates of weight gain are associated with an early onset of GERD Among the possible mechanisms by which obesity promotes GERD, increased intra- abdominal pressure, associated with a delayed gastric emptying, increased rate of TLESR and decreased LES resting pressure play a crucial role [5]. The rate of reflux symptoms increases progressively with rising BMI. It is highly accepted that even short-term gain in weight is associated with a three- to four-fold increased risk of GERD symptoms. An important potential factor in peptic acid illnesses is gastric acid fluid in the inter-prandial periods [6].   Metabolic syndrome or its components and especially hypertriglyceridemia, have been associated with erosive esophagitis or reflux symptoms respectively, coffee intake was well known to be a protective factor for GERD in men, in contrast to women, probably due to caffeine metabolic patterns differences [7]. Exercise at work encourages the presence of reflux symptoms; interestingly, the leisure-time exercise was protective against the disease [8].   For more than a decade, the importance of genes in gastroesophageal reflux disease and GERD-related disorders [Barrett’s oesophagus (BE), oesophagal adenocarcinoma (EAC)] has been recognised. This statement was announced through population-based studies on twins. many Single-Nucleotide Polymorphisms (SNPs) have been implicated in Genome-Wide Association Studies (GWAS) as important factors in reflux disease, such as age, sex and daily habits, GERD was found to be highly correlated to MZ [4,9].   The commonest complication of GERD is the Inflammation of esophageal tissues, known as esophagitis, where stomach fluid containing acid can hurt tissue in the esophagus. This can lead to inflammation, bleeding and occasionally an open sore, known as an ulcer. Esophagitis causes a swallowing difficulty [9], also can cause narrowing of the esophageal lumen, called an esophageal stricture [10].   Precancerous malformations to the esophagus, known as Barrett esophagus, that result from distractions of the tissue lining of the lower esophagus from acid. These are associated with a high risk of esophageal cancer [11,12].   Many studies in Iraq among the students of many Universities also study the subject where the prevalence was 13.3% in Baghdad college of medicine [13], while it was as high as 44.8% in Al Kindy college of medicine [14].   Objectives This study aims to:   Investigate the prevalence and impact of GERD among Iraqi medical students Exploring potential contributing factors Exploring symptoms of GERD Finding the risk factors and complications   Study Rationale GERD is a widespread issue that negatively affects quality of life and daily tasks. There are few published studies about GERD in Iraq and none of them focused on higher education students. University students are more susceptible to GERD risk factors (e.g., stress, skipping meals, inadequate sleep) and many students self-medicate or ignore symptoms, which can lead to complications.

Setting A cross-sectional study conducted on 151 medical students of different medical colleges in Iraq between November 17, 2024 and February 18, 2025. This study recruited participants voluntarily to fill out an online self-administered questionnaire, assessing their demographic characteristics, academic stressors, lifestyle habits and symptoms of Gastro-Esophageal Reflux Disease (GERD). The participants selected after fulfilling the inclusion and exclusion criteria were administered randomly after their willingness to participate, so that the study sample covers many study grades with different numbers of participants. Medical students aged ≥18 years who were willing to participate in the survey. Students with well-known chronic gastrointestinal diseases, rather than GERD and those under treatment with long-term gastrointestinal medications were excluded. The questionnaire included sections on sociodemographic information (age, sex, academic level and place of residence), lifestyle factors (dietary habits, caffeine consumption, smoking behavior, sleep quality by the Pittsburgh Sleep Quality Index [PSQI] and physical activity), along with GERD-associated symptoms. Study Design: The data collected were analyzed to determine the relationship between academic stress, lifestyle habits and severity of GERD symptoms among medical students.   Procedure A Google Form-structured questionnaire was utilized for data collection. Questionnaire designed for the study after reviewing the research of previous studies. The questionnaire was self-developed and then tested by a panel of experts in the field of specialty for its validity and piloted for its reliability. The questionnaire form was distributed electronically to the academic online groups following their academic year.   The questionnaire includes three sections; the first one covers basic demographic characteristics of the study participants, including grade, housing and gender. The second section includes blood group and characteristics of pain. The last section is about the associated symptoms of GERD.   Data Analysis Data was entered and checked by using the export form of Google Form, then analyzed using Microsoft Excel 2026. Data was presented in the form of frequencies and percentages in tables and figures.

Demographic Characteristics Gender Distribution: The sample consisted of both male and female participants, with a slightly higher proportion of males (approximately 53% (80)) compared to females (47% (71)) (Figure 1).     Figure 1: Gender Distribution   Year Stage in the College Most participants were in their fourth year of college (63 cases), followed by fifth year (23cases), then third-year students (22 cases) and then second-year students (22 cases). A smaller number of participants were in first grade (1 case), their sixth year (20) (Figure 2).     Figure 2: Year Stage in the College   Residential Area Most participants lived in city areas (109), with a smaller proportion residing in suburban neighborhoods (21) and rural areas (21) (Figure 3).     Figure 3: Residential Area   Prevalence of GERD Symptoms Heartburn: 60.9% (92) of participants reported experiencing heartburn, a common symptom of GERD (Figure 4).     Figure 4: The Percentage of Students with Heartburn   Location of Pain The most frequently reported location of pain was the chest (upper abdomen) (in 46cases), followed by the stomach (upper abdomen) (in 32 cases) and neck (7 cases) (Figure 5).     Figure 5: The Percentage of Site of Pain   Nature of Pain Most participants described their pain as "burning"(85 cases) or "tightening" (12), which are typical symptoms of GERD (Figure 6).     Figure 6: The Percentage of the Nature of Pain   Radiation of Pain A small percentage of participants reported that the pain radiated to other areas (13 cases), such as the throat or arms.   Frequency and Duration of Symptoms Frequency: The frequency of symptoms varied widely, with some participants experiencing symptoms multiple times per day, while others reported symptoms occurring only a few times per week or month (Table 1).   Table 1: Frequency of Symptoms Symptom Frequency No. of students 0-1 times per day 15 1-2 times per day 25 2-3 times per day 30 3-4 times per day 22 4-5 times per day 11 5+ times per day 8 Not specified 40 Total 151   Duration The duration of pain episodes ranged from a few minutes to several hours, with some participants reporting chronic pain lasting for years (Table 2).   Table 2: Duration of Symptoms Symptom Duration No. of Responses Few minutes 20 10-15 minutes 9 30 minutes 12 1 hour 15 1-2 hours 11 2-3 hours 7 3+ hours 5 Days 10 Weeks 12 Months 15 Years 10 Not specified 25 Total 151   Associated Symptoms Sour/Bitter Taste: A significant proportion of participants (approximately 40% (59 cases)) reported experiencing a sour or bitter taste in their mouth, which is a common symptom of acid reflux.   Difficulty Swallowing Around 20% of participants reported difficulty swallowing (20 cases), while a smaller percentage experienced pain when swallowing (17 cases).   Coughing and Hoarseness Some participants reported coughing when lying down (29 cases) or changes in their voice (hoarseness) (15 cases), which are also associated with GERD.   Relief with Antacids or Milk Approximately 30% of participants found relief from their symptoms by using antacids or drinking milk (59 cases) (Figure 7).     Figure 7: Associated Symptoms   Lifestyle Factors Smoking: About 25% of participants reported smoking, with some indicating that smoking exacerbated their symptoms (cigarette 31 cases, vape 20 cases).   Alcohol Consumption A smaller percentage of participants reported consuming alcohol, with no clear pattern of alcohol type affecting symptoms (almost zero).   Exercise and Heavy Clothing Some participants noted that their symptoms increased after heavy exercise (42 cases) or when wearing tight clothing (approximately 39 cases) (Figure 8).     Figure 8: Lifestyle Distribution   Family History Family History of GERD: A significant number of participants (approximately 50%) reported having a first-degree relative with the same condition, suggesting a possible genetic predisposition to GERD (83 cases).   Impact on Daily Activities Interference with Activities: Many participants reported that their symptoms interfered with daily activities, such as studying, lifting heavy objects (21 cases) or even simple tasks like dressing up (9 cases).   Sleep Disturbance A notable proportion of participants mentioned that their symptoms woke them up at night or were worse when lying down (15 cases) (Figure 9).     Figure 9: Daily Activities   Blood Group Distribution Blood Groups: The most common blood groups among participants were O+(53 cases) and B+(28), with a smaller number of participants having A+(22cases), AB+(8cases) or unknown blood types. There was no clear correlation between blood group and GERD symptoms (Figure 10).     Figure 10: Blood Group Distribution   Other Observations Stress and Diet: Some participants linked their symptoms to stress, particularly during exam periods or to specific dietary habits, such as consuming fatty meals.   Bleeding A few participants reported experiencing bleeding (e.g., hematochezia(4cases) or melena (2 cases)), which may indicate more severe complications of GERD.

Gender Males: 80 participants, 53% reported GERD symptoms Females: 47% reported GERD symptoms. This is slightly higher in males, which is also observed by other researchers [15-17]. This is contracted to Hashem Fakhre Yaseri in his study [18], which states that GERD is more common in females   Grade In the first year, there was only 1 participant and they reported having GERD. From Second Year, there were 22 participants, from Third Year, there were 22 participants, from Fourth Year, there were 63 participants, from Fifth Year, there were 23 participants and lastly from Sixth Year, there were 15 reported GERD.   The percentage of students with GERD increases as the grade level increases, with the highest prevalence in sixth-year students (75%).   This trend may reflect the cumulative effects of stress, irregular eating habits and lifestyle changes as students’ progress through medical school and we can see similar patterns in other studies [19,20] and different patterns in other studies [21] where the third year was the highest, then the fourth, then the second and a small portion of the first and sixth grades.   Residency In the City Area, there were 109 participants (72.2%), from Suburban Neighborhoods, there were 21 reported GERD (13.9%) and from Rural Areas, there were 21 (13.9%).   Students living in city areas had the highest percentage of GERD, followed by those in suburban neighborhoods and rural areas. This could be due to differences in lifestyle, diet or access to healthcare between urban and rural areas.   The Prevalence   Severe GERD patients, who are approximately 25-30 years old, represent around 16-20% of the total participants. That met the Criteria of Frequent symptoms (e.g., multiple times per day or week), Long duration of symptoms (e.g., hours or chronic pain lasting for years), Severe symptoms such as difficulty swallowing, pain radiating to other areas or complications like bleeding (hematochezia or melena) and significant interference with daily activities or sleep disturbance Moderate GERD Patients whose approximately 40-45 and represent Around 26-36% of the total participants that met the following criteria Symptoms occurring a few times per week, Moderate duration of symptoms (e.g., 30 minutes to a few hours), Symptoms such as heartburn, sour/bitter taste or occasional coughing when lying down, Some interference with daily activities but not severe Mild GERD Patients whose approximately 50-55 and represent Around 33-44% of the total participants that met the following criteria Symptoms occurring occasionally (e.g., once or twice a week), Short duration of symptoms (e.g., a few minutes to 30 minutes), Mild symptoms such as occasional heartburn or mild discomfort after meals, Minimal interference with daily activities   The prevalence is high, similar to other studies Baklola et al. [11]. Mu'taz et al. [15] reported severe symptoms in 17.1% of students with GERD from a sample of 947 students, while a study by Alrashed et al. [16] showed 42.3 % of students with symptoms of sever GERD.   Personal Data Smoking: 70% of smokers reported having GERD, compared to 60% of non-smokers. Smoking is a known risk factor for GERD, as it can weaken the lower esophageal sphincter (LES) and increase acid reflux.   However, there was no statistically significant association between smoking and GERD in this study. which is the same as other studies [9], unlike other studies that find a strong association between smoking and GERD [21]. Surprisingly, it has been reported by some studies that revealed the benefits of smoking cessation in the treatment of GERD symptoms [22].   Heavy Exercise 75% of students who engaged in heavy exercise reported having GERD, compared to 25% of those who did not. Heavy exercise, especially after meals, can increase intra-abdominal pressure and trigger GERD symptoms.   There is a statistically significant association between heavy exercise and GERD. Students who engage in heavy exercise are more likely to have GERD. a similar result by other researchers [23].   Wearing Heavy Clothing 70% of students who wore heavy clothing reported having GERD, compared to 30 % of those who did not. Tight or heavy clothing can increase abdominal pressure, contributing to GERD symptoms.   There is a statistically significant association between wearing heavy clothing and GERD in this study, unlike what is found by other researchers [23,24].   Family Relations Students with a first-degree relative with GERD had the highest prevalence of GERD (70%), followed by those with a second-degree relative (20%) and those with no family history (10%).   There is a statistically significant association between family history of GERD and GERD in students at the P value of 0.05 significance level. In Mu'taz et al. [15] this study revealed that GERD family history is significantly associated with GERD and is an independent predictor of it. Positive family history was also significant in other studies Riaz et al. [17] and Adeyemi [22].

GERD is highly prevalent among medical students at Al-Iraqia University, with a significant proportion experiencing moderate to severe symptoms from our sample (151). Lifestyle factors such as heavy exercise, smoking and wearing tight clothing may contribute to GERD symptoms, although not all associations were statistically significant. The increasing prevalence of GERD with higher academic years suggests that stress, irregular eating habits and lifestyle changes associated with medical school may contribute to the condition. Family history of GERD appears to be a significant risk factor, indicating a possible genetic component.   Recommendations Reduce obesity around the midsection. This can reduce the pressure on the stomach. Such pressure can push some stomach fluid back up into the oesophagus. A more thorough study of other factors, such as drug consumption or drug addiction, in a larger study sample is advisable. The awareness of the impact of GERD on the lifestyle of the medical student and the possible ways of avoiding it is a highly recommended subject to be studied.   Acknowledgement The authors are very thankful to all medical students involved in the study and appreciate their valuable time as well as cooperation. We also thank the medical colleges in Iraq for their help in distributing the online questionnaire and helping to collect the data.   Ethical Approval NO.Fm.SA.313, at 2025.10.20, the committee consists of specialists in community medicine.