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Obesity Surgery (2018) 28:1372–1376

https://doi.org/10.1007/s11695-017-3018-6

ORIGINAL CONTRIBUTIONS

Effects of Weight Loss on Acoustic Parameters After Bariatric Surgery


Lourdes Bernadete Rocha de Souza 1 & Marquiony Marques dos Santos 2 &
Leandro Araújo Pernambuco 3 & Cynthia Meira de Almeida Godoy 2 &
Deysianne Meire da Silva Lima 4

Published online: 12 December 2017


# Springer Science+Business Media, LLC, part of Springer Nature 2017

Abstract
Background Patients with morbid obesity may present vocal alterations, since large accumulation of fat in the vocal tract may
interfere with voice production of these individuals.
Objective Verify the neck circumference and the acoustic parameters of voice in obese women, before and after the bariatric
surgery, and compare the results with a control group, with normal weight.
Methods Observational, longitudinal, descriptive study with patients referred to the SCODE (Obesity Surgery and Related
Disorders Center) in a university hospital. The sample consisted of 25 morbidly obese women, age range 28–43 years and 23
non-obese women, aged 21–41 years control group. To measure the neck circumference, a tape measure was used and all
participants were seated upright with the head positioned in the Frankfort horizontal plane. The fundamental frequency was
calculated through the sustained emission of vowel [a] at usual intensity and pitch, to measure the fundamental frequency of the
voice, that is, how much the vocal fold vibrates per second. After the recording, participants were prompted to produce vowels
[a], [i], and [u] sustained at usual intensity and pitch, and a stopwatch was used to measure the maximum phonation time, to verify
the balance between myoelastic and dynamic forces of the larynx. After 8 months post-surgery, the patients were recruited to be
re-evaluated using the same pre-surgical data collection procedures.
Results There was an increase in the mean value of f0. The maximum phonation time of all vowels increased after surgery.
Conclusion Obese individuals with post-surgery weight loss may present neck circumference, fundamental frequency, and
maximum phonation time values closer to the mean values of normal weight individuals. In this study, weight loss was sufficient
to adjust the acoustic parameter measurements.

Keywords Voice . Morbid obesity . Adipose tissue . Bariatric surgery

This study was conducted at the Department of Speech-Language Introduction


Pathology of the Federal University of Grande do Norte—UFRN and
Obesity Surgery and Related Disorders Center of the University
Hospital Onofre Lopes, Federal University of Rio Grande do Norte-
Obesity is considered a public health problem with significant
Natal-RN, Brazil. comorbidities. Overweight individuals are at greater risk of
developing diabetes mellitus, cardiovascular disease, dyslip-
* Lourdes Bernadete Rocha de Souza idemia, and other chronic diseases such as obstructive sleep
hsouza660@gmail.com apnea syndrome (OSAS), whose incidence exceeds 50%, due
1
Department of Speech-Language Pathology and Audiology, Federal to the accumulation of adipose tissue in the trunk and neck
University of Rio Grande do Norte, Av. General Gustavo de Farias, region [1].
S/N. Petrópolis, Natal, RN, Brazil There is a high prevalence of modification of the respira-
2
Health Sciences, Federal University of Rio Grande do Norte, tory pattern in obese people for several reasons, including the
Natal, RN, Brazil greater amount of upper airway mass. This modified respira-
3
Department of Speech-Language Pathology and Audiology, Federal tory pattern and the changes in pharyngeal size and configu-
University of Paraíba, João Pessoa, PB, Brazil ration may therefore affect the acoustic parameters in obese
4
Federal University of Rio Grande do Norte, Natal, RN, Brazil individuals [1, 2].
OBES SURG (2018) 28:1372–1376 1373

Through acoustic pharyngometry, one study showed a (±6.77) years, mean BMI44.88 kg/m2 (±7.38) before surgery
strong correlation between body mass index (BMI) and pha- and 33.28 kg/m2 (±5.60) 8 months after surgery, and 23 non-
ryngeal size in obese women [3]. This is possibly due to ab- obese women [14], aged 21–41 years, mean age 25.00 (±6.37)
normal fat deposition in structures belonging to the vocal tract, years and mean BMI 22.55 (±2.50),control group (CG). All
such as accumulation of fat in the upper airways, increased obese patients underwent gastric bypass surgery in Y-Roux
thickening of the pharyngeal lateral walls, tongue size, and and none of them underwent speech therapy before or after
soft palate volume [4], characteristics that may interfere with surgery.
vocal quality. In addition, obesity can impair lung function The female gender was selected for this study because
and voice production as a result of increased adiposity around women more frequently seek medical/speech therapy care
the ribs, abdomen, and viscera [3]. and are more likely to have voice disorders [15].
Other authors [5, 6] argue that excessive weight can inter- This study included morbidly obese women (EG) and non-
fere with vocal resistance and contribute to general fatigue. In obese women (CG), aged 18–45 years, considering the vocal
some cases, it may influence voice resonance as excess fat can efficiency period [16, 17]. We excluded volunteers in the pre-
modify the size and configuration of the aerodigestive tract menstrual period [18], smoking, those with upper airway viral
and significantly reduce the lumen of the pharyngeal region disease at the time of collection, and/or neck and head surgery.
above the glottis. An identification form was answered by the participants. In
There are several studies that seek to understand the rela- order to control the exclusion criteria, participants were asked
tion between body weight indicators and vocal function. One to respond to a questionnaire for the information to be
study investigated the possible effects of obesity on acoustic collected.
and perceptual voice parameters in people who reduced BMI These criteria were adopted to minimize the chances that
after bariatric surgery but did not find differences between factors secondary interfered with the evaluation of the param-
obese and non-obese individuals [7]. However, other studies eters studied.
have shown that BMI and body fat volume appear to be relat- All participants were properly informed on the objectives
ed to some objective measures of voice quality, vocal aerody- and methods involved in the current study and agreed on
namics, and phonatory range performance [6, 8, 9]. participating signing and informed consent.
BMI is the traditional measure of obesity. However, other The neck circumference was determined in centimeters
simple, practical, and low cost anthropometric markers such using a measuring tape. Obesity was established with a NC
as neck circumference (NC) can be used to determine if an cutoff of ≥35 cm [19]. Two measurements were taken of all
individual is overweight [10–12]. participants while seated upright with the head positioned in
Regarding abdominal circumference, the studies showed the Frankfurt horizontal plane, one at the base of the neck by
conflicting results. Researchers state that there is a relation the cricoid cartilage, and another at the mid-cervical spine.
between respiratory function and abdominal circumference Voice recording was performed in a quiet environment, on
[6]. On the other hand, other authors [13] did not find such a laptop computer, with a clone-branded unidirectional exter-
relation and argue that obese individuals tend to present low nal microphone, using ANAGRAF software for the acoustic
respiratory muscle strength when they have a larger NC. analysis of speech sounds [20], considering sampling rate of
Increased NC seems to delay the capacity to metabolize respi- 22,050. For voice collection, each participant was seated with
ratory flow comparing with general adiposity. Therefore, NC the microphone within 5 cm of their mouth. The participants
can be considered an anthropometric measure that presents a were requested to produce the vowel [a] at the usual intensity
positive correlation with respiratory strength in obese individ- and pitch, for an average period of 3 s, to measure the funda-
uals [13]. mental frequency of the voice, that is, how much the vocal
In this regard, this study aimed to verify the NC and the fold vibrates per second. After the recording, participants were
acoustic parameters of voice in obese women, before and after asked to produce vowels [a], [i], and [u] sustained at usual
bariatric surgery, and to compare the results with a control intensity and pitch, using a stopwatch to measure the maxi-
group, with normal weight. mum phonation time of each vowel, to verify the balance
between myoelastic and dynamic forces of the larynx. After
8 months post-surgery, the patients were recruited to be re-
Method evaluated using the same procedures of the pre-surgical data
collection. For recording the voice of the control group, the
This is an observational, longitudinal, and comparative study same procedures were used, as well as for the NC
conducted with patients referred to the SCODE (Obesity measurement.
Surgery and Related Disorder Center of a university hospital). Data analysis was carried out by measures of central ten-
The sample consisted of 25 morbidly obese women [14], dency to verify the mid-point (median) and the dispersion of
experimental group (EG), aged 28–43 years, mean age 34.32 the data (percentiles). The data were submitted to the Kruskal-
1374 OBES SURG (2018) 28:1372–1376

Wallis test to check for differences between the groups in lower MPT ([a] = 10.00 s; [i] = 10.00 s; [u] = 10.00 s) when
relation to the study variables. All variables presented statisti- compared to CG ([a] = 12.00 s; [i] = 14.00 s; [u] = 14.00 s).
cally significant result and were submitted to the non- The decreased NC (36.00 cm) after surgery was not enough to
parametric Mann Whitney test. All tests considered the signif- eliminate the difference in relation to CG (32.00 cm). All vo-
icance level of 5%. cal parameters improved after weight loss and the differences
The data of this study belong to the database of previous from CG ceased to exist.
studies, approved by the Human Research Ethics Committee
of the institution No. 207.630/2013 for the EG and No.
809.761/1 for the CG. All participants before being submitted
to the collection procedures signed an Informed Consent, Discussion
agreeing to participate in the research.
This study showed that obese women have larger NC, lower
f0, and lower MPT in relation to eutrophic women. All these
measures improved 8 months after weight loss due to bariatric
Results surgery.
Statistically significant difference was observed between
Table 1 shows the comparisons between groups. Regarding the groups EG1 (obese pre-surgery), EG2 (obese post-sur-
the pre (EG1) and post-surgery (EG2) moments, it was ob- gery), and CG regarding the median NC in all comparisons.
served that the NC decreased (median = 36.00 cm; p < 0.001) This result indicates that NC [18, 20, 21] could be reported as
and the MPT of all vowels increased ([a] = 12.00 s; [i] = a good anthropometric marker related to obesity because it
13.00 s; [u] = 14.00 s; p = < 0.001; p = 0.011; p = 0.002, re- considers fat deposition in the upper airway region [7].
spectively) 8 months after the bariatric surgery. F0 also in- It is noteworthy that, although NC remained somewhat
creased (f0 = 206.00 Hz; p = 0.094), but the difference was higher in EG2 when compared to CG, there was a reduction
not statistically significant. of this measure and all vocal parameters improved after sur-
When analyzing Table 1 for the comparison between the gery. Therefore, it is possibly inferred that the reduction of the
experimental groups and the control group, it was verified that accumulation of fat in the neck region after weight loss may
EG1 had larger NC (36.00 cm), lower f0 (f0 = 194.00 Hz), and result in adjustments in the vocal parameters as a consequence

Table 1 Median and percentile


values Q.25 and Q.75 and p value Variables Obese pre-surgery Obese post-surgery p
for the NC, f0, MPT of the groups
evaluated before and after the Median Q25–Q75 Median Q25–Q75
bariatric surgery and control
group. Natal, 2015 NC(cm) 42.00 40.50–43.00 36.00 34.00–37.50 < 0.001
f0(Hz) 194.00 185.50–207.00 206.00 193.00–218.00 0.094
MPT [a] (s) 10.00 9.00–9.50 12.00 11.50–14.50 < 0.001
MPT [i] (s) 11.00 8.00–13.50 13.00 12.50–15.50 0.011
MPT [u] (s) 10.00 7.50–13.00 14.00 12.00–15.00 0.002
Variables Obese pre-surgery Control group p
Median Q25–Q75 Median Q25–Q75
NC(cm) 42.00 40.50–43.00 32 31.00–33.00 0.001
f0(Hz) 194.00 185.50–207.00 214 198.00–221.00 0.005
MPT [a] (s) 10.00 9.00–9.50 12.00 11.00–14.00 < 0.001
MPT [i] (s) 11 8.00–13.50 14.00 13.00–15.50 0.011
MPT [u] (s) 10.00 7.50–13.00 14.00 12.00–16.00 < 0.001
Variables Obese post-surgery Control group p
Median Q25–Q75 Median Q25–Q75
NC(cm) 36.00 34.00–37.50 32 31.00–33.00 0.001
f0(Hz) 206.00 193.00–218.00 214 198.00–221.00 0.196
MPT [a] (s) 12.00 11.50–14.50 12.00 11.00–14.00 0.730
MPT [i] (s) 13.00 12.50–15.50 14.00 13.00–15.50 0.953
MPT [u] (s) 14.00 12.00–15.00 14.00 12.00–16.00 0.611

Mann Whitney—p < 0.05


NC neck circumference, f0 fundamental frequency, MPT maximum phonation time, s seconds, cm centimeters
OBES SURG (2018) 28:1372–1376 1375

of the process of accommodation of the vocal tract structures deposition around the neck and increased BMI are the most
to the new morphophysiology. This result corroborates au- important factors in the impairment of thoracic mobility in
thors [3, 4] by citing that accumulation of fat in the upper women, influencing the movements of the chest wall and
airways and increased adiposity around the ribs, abdomen, restricting its expansion [30].
and viscera may interfere with vocal quality. Despite these evidences, the results found differ from a
Regarding f0, it was observed that in obese women (EG1), previous study [8] in which the mean values of MPT, although
the values were lower when compared to CG, which differs reduced in the obese group in relation to the eutrophic group,
from studies reporting no relation between body weight and did not present a statistically significant difference. The reason
this variable [8, 22]. This result corroborates other studies with for this disagreement is possibly related to the smaller number
obese women in which the mean fundamental frequency was of individuals allocated in the previous study and the measure
lower than expected for the female pattern [9, 23]. The reduc- of central tendency used.
tion of f0 in obese individuals can be explained by the increase
in laryngeal muscle activity [24] due to the interference of
excessive body weight in the respiratory support for voice Limitations of the Study
production [5, 23, 25].
In this study, the fact that f0 increased after weight loss and This study has some limitations. The item exclusion, in order
did not differ from CG corroborates this argument. It is also to avoid misleading factors, influenced the reduction of sam-
believed that the reduction of abnormal fat deposition in the ple. The endoscopic evaluation of the vocal tract diameter and
vocal tract structures, such as accumulation of fat in the upper the videolaryngoscopy were not feasible due to logistic rea-
airways, pharyngeal lateral walls, tongue size, and soft palate sons and lack of subsidies. The authors suggest that next stud-
volume, may have contributed to the result found. ies investigate other parameters of the multidimensional eval-
The MPT aims to evaluate glottic efficiency and respiratory uation of the voice and other anthropometric measures, such
support in voice production by the interaction between the as abdominal circumference.
aerodynamic and myoelastic forces of the larynx [26]. It is
the simplest aerodynamic parameter and one of the most used
measures in the clinical evaluation of voice [27]. Conclusion
In this study, morbidly obese women (EG1) presented re-
duced MPT of all vowels when compared to CG, but after After surgery, obese individuals may present values of NC, f0,
surgery (EG2), the values were adjusted and approached CG and MPT closer to the mean values of normal weight
values. Reduced values in MPT in obese individuals were also individuals.
found in previous studies [6, 23, 25]. One of the hypotheses In this study, weight loss was sufficient to adjust the mea-
for this result is the increased neck circumference in obese surements of the acoustic parameters evaluated.
individuals (G1). The accumulation of fat in the neck region
can cause imbalance between the myoelastic and aerodynamic Authors’ Contribution Lourdes Bernadete Rocha de Souza participated
forces of the larynx and contribute to reduce MPT3. in the general coordination of the study, in the project, data collection,
In addition to these factors, the excessive accumulation of design, and writing of the manuscript.
Marquiony Marques dos Santos contributed in the analysis and inter-
fat in the ribs, abdomen, and viscera, usually found in obese pretation of the results.
individuals, contributes to modify the respiratory function [6, Leandro Araújo Pernambuco contributed in the design and writing of
28]. In this case, there may be an increase in subglottic pres- the manuscript.
sure in individuals with higher body weight and a greater need Cynthia Meira de Almeida Godoy participated in the data collection.
DeysianneMeire da Silva Lima participated in the data collection.
to overcome the effects of increased pharyngeal resistance
[10], which maximizes the phonatory effort and reduces the Compliance with Ethical Standards
mean MPT of obese individuals. With the reduction of weight
after surgery, NC remained different between EG2 and CG, Conflict of Interest The authors declare that they have no conflict of
but the difference in MPT between obese and eutrophic pa- interest.
tients ceased to exist. It is believed that the reduced sensitivity
of chemoreceptors found in obese subjects [29] was normal- Statement of Informed Consent Informed consent was obtained from
ized after weight loss and collaborated to increase phonation all individual participants included in the study. This study was approved
by the Ethics Research Committee of the institution no. 207.630/2013 for
time of vowels in EG2.
the EG and no. 809.761/1 for the CG.
In addition to these factors, the excessive accumulation of
fat in the ribs, abdomen, and viscera, usually found in obese
Statement of Human and Animal Rights All procedures performed in
individuals, may have contributed to modify the respiratory studies involving human participants were in accordance with the ethical
function in this task [6, 28]. Despite this, studies show that fat standards of the institutional and/or national research committee and with
1376 OBES SURG (2018) 28:1372–1376

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