REVIEW ❙

Effect of diabetes mellitus on voice:

a systematic review
Dr Rohit Ravi1
PhD
Dr Dhanshree R Gunjawate1
PhD
1
Department of Audiology and Speech
Language Pathology, Kasturba Medical
College, Mangalore, Manipal Academy of
Higher Education, Manipal, Karnataka, India
Correspondence to:
Dr Dhanshree R Gunjawate, Department
of Audiology and Speech Language
Pathology, Kasturba Medical College,
Mangalore, Manipal Academy of Higher
Education, Manipal, Karnataka, India; email:
dhanshreeg@yahoo.co.in
Received: 18 April 2019
Accepted in revised form: 25 June 2019
Abstract
A systematic review of literature was conducted to identify the influence of diabetes mellitus
on voice. The search was carried out on PubMed, Scopus, CINAHL and Cochrane databases.
Articles that discussed the effect of diabetes mellitus on voice were included in the review.
Five studies were found to be suitable for inclusion. There is limited literature available on
the effect of diabetes mellitus on voice. The studies pointed to a higher prevalence (12.5%)
of voice problems among individuals with diabetes mellitus as compared to the general
population, and higher gastro-oesophageal reflux disorder related symptoms. Further, higher
reflux symptom index and voice handicap index scores have been reported in these
individuals. The other voice related changes reported across the studies include the presence
of laryngeal involvement, hoarseness, and increased strained voice. Even though there is
limited literature available, it points towards the presence of voice changes among people
with diabetes. This information would help professionals to better counsel and refer patients
with diabetes to laryngologists or voice therapists if they complain of voice changes.
Copyright © 2019 John Wiley & Sons.
Practical Diabetes 2019; 36(5): 177–180
Key words
systematic review; voice; diabetes mellitus

Introduction Since DM has an effect on neuro­

Diabetes mellitus is known to affect
the neurological, vascular and
muscular systems. The American
Diabetes Association has described
the major symptoms of diabetes
as follows: polydipsia, polyphagia,
polyuria, extreme fatigue, blurred
vision, slow healing sores, weight
loss, tingling, pain or numbness in
hands.1 Further, a high prevalence
of gastrointestinal symptoms has
been reported in people with dia­
betes mellitus (DM) in comparison
to the general population.2–4
Gastro-oesophageal reflux disor­
der (GORD) leads to reflux of stom­
ach contents into the oesophagus;
when this reflux affects the oesoph­
agus, upper oesophageal sphincter
and up to the level of the throat, it
is called laryngopharyngeal reflux
(LPR). LPR leads to macroscopic
and microscopic changes in the
vocal fold mucosa that could lead to
voice problems.5 LPR can have a
negative influence on a person’s
voice quality as well as the overall
quality of life.6 A higher prevalence
of upper and lower gastrointestinal
symptoms is associated with individ­
uals with DM.2
Voice problems can be the result
of structural, neurologic, func­
tional, and psychogenic influence.7
logical, vascular, muscular and
gastro-oesophageal systems, studies
explored its effect on voice changes.
Studies have also reported a higher
prevalence of vocal fold paralysis
(either spontaneous or after thy­
roid surgery) among individuals
with DM as compared to those with­
out DM.8,9
To date, no systematic review of
literature on voice changes in people
with DM is available. Thus, the pres­
ent systematic review was planned
in order to identify all the studies
that have explored voice changes in
people with DM.
Method
A systematic literature search was
carried out to identify the eligible
studies exploring the effect of DM on
voice. The eligible studies published
up to December 2018 were included.
Four electronic databases, namely
PubMed/Medline, Scopus, Cochrane
and CINAHL, were searched using
suitable keywords and Boolean opera­
tors. The PICOS search terms were:
• Population – adults with diabetes
mellitus.
• Intervention – no intervention.
• Comparison – comparison with
people without diabetes mellitus/
no comparison group.

Copyright © 2019 John Wiley & Sons PRACTICAL DIABETES Vol. 36 No. 5 177
❙ REVIEW
Effect of diabetes mellitus on voice

• Outcomes – voice changes.

• Study design – any study design.
Identification Records identified
The inclusion criteria incorporated (n=495)
studies published in peer-reviewed
journals in English language. The Duplicates excluded
exclusion criteria were animal/ (n=155)
pharmaceutical trials, case reports,
case series, letters to editors, studies Screening Records after duplicates
in children with diabetes and removed (n=340)
post-partum diabetes.
Both of the authors carried out a Titles/abstracts excluded
three-stage screening process inde­ (n=335)
pendently. All of the searches were
compiled using Mendeley desktop Eligibility Full-text articles assessed for
reference management software and eligibility (n=5)
duplicates were eliminated. Inclusion
and exclusion criteria were applied
to the titles and abstracts; disagree­
ments were discussed and agreed Included Studies included in
upon by consensus. qualitative synthesis (n=5)
The relevant data were extracted
using a pre-designed data extraction
sheet. The extracted information Figure 1. PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses)
was study ID (authors and year), flow diagram for study inclusion
location of study, study design,
participant characteristics (people Study ID Study design Participant details
with DM and control group), voice
outcomes and key conclusions. Type 2 diabetes Control/
Since there were inconsistencies mellitus group comparison group
noted across the studies, in terms of
outcome measures and measure­ Wang et al. Cross-sectional (clinician n=150 –
ment procedures, findings have (2008)12 developed self-reported Males: 63 (42%)
been described in a narrative man­ questionnaire) Females: 87 (58%)
ner. A quality appraisal of the
included studies was carried out Hamdan et al. Case-control n=82 n=29
based on the GRADE approach (2012)13 Males: 50 (61%) Males: 16 (55.2%)
(Grading of Recommendations Females: 32 (39%) Females: 13 (44.8%)
Assessment, Development and
Evaluation),10 and the McMaster Hamdan et al. Case-control (using n=105 n=33
critical review for quantitative study (2012)14 validated questionnaire) Males: 42 (40%) Males: 19 (57.6%)
designs checklist.11 Females: 63 (60%) Females: 14 (42.4%)

Results Hamdan et al. Cross-sectional, with n=100 n=33

Figure 1 illustrates the process involved
for article screening and selection
using the Preferred Reporting Items
for Systematic reviews and Meta-
Analyses (PRISMA) statement. Five
studies12–16 were found to be suitable
for inclusion. The study characteristics
in terms of study design and partici­
pant details are depicted in Table 1.
Three publications were found
from one research group13–15 based
on a similar study population; how­
ever, each reported different voice
outcome measures. Since these three
articles suited the inclusion criteria
and were rated to be of good–very
good methodological quality, they
were included in the review.
(2013)15 matched controls (using Males: 59 (59%) Males: 19 (57.6%)
validated questionnaire) Females: 41(41%) Females: 14 (42.4%)
Bainbridge et Cross-sectional analysis n=417 –
al. (2017)16 of data from National
Longitudinal Study of
Adolescent to Adult
Health
Table 1. Characteristics of the included studies
The McMaster critical review for only by one study.16 The GRADE
quantitative study designs checklist approach rated all studies as a low
rated the studies to be of good–very rating, since all used an observa­
good quality. All the studies men­ tional study design.
tioned taking informed consent
from the participants, except Wang Summary of study findings
et al.12 The sample size and drop- Four of five studies had a component
out rate justification was provided of a self-reported questionnaire to

178 PRACTICAL DIABETES Vol. 36 No. 5 Copyright © 2019 John Wiley & Sons

identify voice changes; however,
each explored variable outcome
measures. One study used an author-
developed questionnaire to analyse
the prevalence of GORD among
people with DM.12 Two studies used
a previously validated questionnaire,
one on voice handicap14 and the
other on reflux symptoms.15 One
study provided an analysis of larger
data collected as a national longitu­
dinal study and had limited ques­
tions on DM.16
The voice change outcome meas­
ures varied across the studies, which
are as follows: acoustic measures,
self-reported voice changes, reflux
symptoms, maximum phonation
time and perceptual voice evalua­
tion. The discussion is based on the
voice changes noted across the dif­
ferent voice outcome measures.
Discussion
The systematic review aimed to iden­
tify the available literature on voice
changes in people with DM. Four
electronic databases were searched
to obtain maximum studies and
reduce publication bias. Both of the
authors independently screened the
studies at different levels to eliminate
reviewer bias. Five studies suited the
selection criteria and were included
in the final review.
Acoustic and perceptual measures
Acoustic and perceptual measures are
routine clinical voice assessment pro­
cedures. Acoustic voice evaluation
involves the use of instrumental/
objective procedures to characterise
vocal quality. Perceptual evaluation
also known as auditory perceptual
evaluation of voice relies on expert
rating of the vocal quality. Hamdan et
al.13 reported no significant differ­
ences on acoustic and perceptual
measures between people with DM
and controls.
Self-reported measures
Self-reported measures are fre­
quently used in clinical voice evalua­
tion for assessing what a patient feels
about his/her voice quality. Hamdan
et al.14 compared the self-reported
phonatory measures between people
with DM and controls. Significantly,
a higher percentage of people with
DM reported hoarseness as com­
pared to the controls (33.3% vs
Copyright © 2019 John Wiley & Sons PRACTICAL DIABETES Vol. 36 No. 5
KEY POINTS
● This is the first review conducted
exploring the voice changes in
individuals with diabetes mellitus
● This review helps to alert health care
professionals towards the possible
voice changes in diabetes mellitus
● The findings have implications in
counselling, assessment and treatment
15.2%) and vocal strain (21% vs
3%). The reflux symptom index
(RSI) is a self-reported nine-item
instrument developed to assess the
severity of LPR. It is easy to adminis­
ter, gives reproducible results and
has high psychometric reliability and
validity.17 Hamdan et al.15 compared
RSI scores in patients with DM with
age- and gender-matched controls.
Individuals with DM had higher
mean total scores on RSI as com­
pared to controls. Further, symptoms
such as throat clearing, lump sensa­
tion in the throat and annoying
cough were significantly higher in
people with DM as compared to con­
trols. Bainbridge et al.16 reported a
higher prevalence of voice problems
among people with DM (12.5%) as
compared to those without DM.
Wang et al.12 analysed the prevalence
of GORD among people with DM as
compared to controls. About 40% of
people with DM reported at least one
symptom associated with GORD,
while 30% complained of heartburn
once a week.
Influence of presence of neuropathy
People with neuropathy had signifi­
cantly higher complaints of vocal
straining, aphonia and hoarseness
as compared to those without neu­
ropathy.14 Hamdan et al.15 noted a
higher occurrence of LPR among
people with neuropathy as com­
pared to those without. Wang et al.12
found a significantly higher preva­
lence of GORD symptoms in people
with neuropathy (58.7%) as com­
pared to those without (32.7%).
They also had a significantly higher
prevalence of heartburn (43.5% vs
24%), chest pain (10.9% vs 4.8%)
and chronic cough (17.8% vs 6.7%).
The studies included in this
review varied in terms of their
voice-related outcome measures
REVIEW ❙
Effect of diabetes mellitus on voice
and, hence, comparison across the
studies is difficult. A high occur­
rence of LPR among people with
DM has been attributed to the dura­
tion of DM, obesity, overweight,
medications, complications, and
blood glucose levels.18,19 Further,
the results across all the studies
point to a higher occurrence of
voice changes and LPR symptoms in
people with DM, especially those
with neuropathy. The exact cause of
voice changes cannot be traced to
any single factor. This review helps
to highlight the voice changes and
symptoms observed in this popula­
tion about which health care provid­
ers should be aware. This would
help them to better counsel as well
as refer any patients with DM to
laryngologists or voice therapists if
they complain of voice changes. The
individuals with DM, especially
those who use their voice exces­
sively, should also be alert towards
voice changes or LPR-related symp­
toms and seek guidance.
Limitations/future recommendations
Studies published in peer-reviewed
journals in English language were
only included; grey literature on
this topic might have been missed
out. The studies included in the
review had certain drawbacks: lack
of laboratory testing and laryngeal
examination through endoscopy.
Three publications were found from
one research group13–15 and could
have a data overlap; however, since
the outcome measures are different
they were included as separate stud­
ies. There is a certain need to carry
out further studies in this popula­
tion in order to establish the exact
relationship between DM and the
nature of voice changes, and
whether these voice changes have
any long-term impact. This will help
in better establishing dietary modifi­
cations and counselling for patients
with DM.
Declaration of interests
There are no conflicts of interest
declared.
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