Body mass index and acoustic voice parameters: is there a relationship?,

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www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

ORIGINAL

ARTICLE

Body

mass

index

and

acoustic

voice

parameters:

is

there

a

relationship?

夽,夽夽

Lourdes

Bernadete

Rocha

de

Souza

a,∗

,

Marquiony

Marques

dos

Santos

b

a_Universidade_Federal_do_Rio_Grande_do_Norte_(UFRN),_Departamento_de_{Fonoaudiologia,}_Natal,_RN,_Brazil

b_Universidade_Federal_do_Rio_Grande_do_Norte_(UFRN),_Programa_de_Pós-graduac_¸ão_em_Ciências_da_Saúde,_Natal,_RN,_Brazil

Received11August2016;accepted12April2017 Availableonline6May2017

KEYWORDS Bodymassindex; Obesity;

Phonation; Voice

Abstract

Introduction:Speciﬁcelementssuchasweightandbodyvolumecaninterfereinvoice produc-tionandconsequentlyinitsacousticparameters,whichiswhyitisimportantfortheclinician tobeawareoftheserelationships.

Objective:Toinvestigatetherelationshipbetweenbodymassindexandtheaverageacoustic voiceparameters.

Methods:Observational,cross-sectionaldescriptivestudy.Thesampleconsistedof84women, agedbetween18and40years,anaverageof26.83(±6.88).Thesubjectsweregrouped accord-ingtobodymassindex:19underweight;23normalranges,20overweightand22obeseand evaluated thefundamental frequency ofthesustained vowel [a]and themaximum phona-tiontimeofthevowels[a],[i],[u],usingPRAATsoftware.Thedata weresubmittedtothe Kruskal---Wallis test to verify if there were differences between the groups regarding the study variables. All variables showed statistically signiﬁcant resultsand were subjected to non-parametrictestMann---Whitney.

Results:Regardingtotheaverageofthefundamentalfrequency,therewasstatistically signiﬁ-cantdifferencebetweengroupswithunderweightandoverweightandobese;normalrangeand overweightandobese.Theaveragemaximumphonationtimerevealedstatisticallysigniﬁcant differencebetweenunderweightandobeseindividuals;normalrangeandobese;overweight andobese.

夽 _This_study_was_conducted_at_the_Department_of_Speech_Therapy,_UFRN_and_Obesity_Surgery_and_Associated_Diseases_Service_of_a_university hospital(SCODE).

夽夽_Please _cite_this_article _as:_Souza_LB,_Santos_MM. _Body_mass_index_and _acoustic _voice_parameters: _is_there _a_{relationship.}_Braz _J Otorhinolaryngol.2018;84:410---5.

∗_{Corresponding}_author.

E-mail:hsouza660@gmail.com(L.B.Souza).

PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial. https://doi.org/10.1016/j.bjorl.2017.04.003

1808-8694/©2017AssociaçãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

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Conclusion: Bodymassindexinﬂuencedtheaveragefundamentalfrequencyofoverweightand obeseindividualsevaluatedinthisstudy.Obesityinﬂuencedinreducingmaximumphonation timeaverage.

© 2017 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/). PALAVRAS-CHAVE ÍndicedeMassa Corporal; Obesidade; Fonação; Voz

Índicedemassacorporaleparâmetrosacústicosdevoz:existeumarelac¸ão?

Resumo

Introdução: Elementosespecíficoscomopesoevolumecorporalpodeminterferirnaprodução davoze,consequentemente,emseusparâmetrosacústicos,razãopelaqualéimportanteque omédicoestejacientedessasrelações.

Objetivo: Investigar a relac¸ão entreo índice de massa corporal e os parâmetrosacústicos médiosdavoz.

Método: Estudoobservacional,transversal,descritivo.Aamostrafoicompostapor84mulheres, comidadeentre18e40anos,médiade26,83(_±6,88).Asparticipantesforamagrupadasde acordocomoíndicedemassacorporal:19abaixodopeso;23comintervalosnormais,20com sobrepesoe22obesoseavaliadasquantoafrequênciafundamentaldavogalsustentada[a]eo tempomáximodefonaçãodasvogais[a],[i],[u],utilizandoosoftwarePRAAT.Osdadosobtidos foramsubmetidosaotestedeKruskal-Wallisparaverificarsehouvediferençaentreosgrupos comrelaçãoasvariáveisdoestudo.Todasasvariáveisapresentaramresultadosestatisticamente significativoseforamsubmetidasaotestenãoparamétricodeMann-Whitney.

Resultados: Comrelaçãoàmédiadafrequênciafundamental,houvediferençaestatisticamente significativaentreosgruposcompesonormalesobrepesoeentreosgruposcompesonormal eobesidade.Amédiadotempomáximodefonaçãoreveloudiferençaestatisticamente signi-ficativaentreindivíduoscombaixopesoeobesidade;pesonormaleobesidade;sobrepesoe obesidade.

Conclusão:Oíndicede massacorporalinfluenciounamédiadafrequênciafundamentaldos indivíduos com sobrepesoe obesosavaliados nesteestudo. A obesidade mórbidainfluiu na reduçãodamédiadotempomáximodefonação.

© 2017 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Publicado por Elsevier Editora Ltda. Este é um artigo Open Access sob uma licença CC BY (http:// creativecommons.org/licenses/by/4.0/).

Introduction

The clinical assessment includes a number of

possibili-ties to evaluate voice production and perception. Among

the parameters evaluated in the acoustic analysis of

voice are the fundamental frequency and the maximum

phonation time (MPT),measurements of interest in voice

evaluations.1,2

Thefundamentalfrequency(f0),oneofthemain

meas-ures used to characterize the human voice, is directly

relatedtothemass,elasticityandlengthofthevocalfolds,

anddependsonthesubglotticpressureandtheconﬁguration

oftheindividualvocaltract.3_It_provides_information_about

thespeaker’scharacteristics,suchasgender,age,emotional

state,hormonalcompetenceandbodysize.4---6

Severalstudiesseektounderstandtheinﬂuenceofbody

massindex(BMI),musclemassgainandmenopausein

acous-ticparametersofvoice.

D’haeseleer etal.7 _conducted _a _study _in _order_to

ver-ify the correlation between theBMI and thefundamental

frequencyofspeechinagroupofpreandpost-menopausal

women withandwithout hormone treatment.The results

showed that in post-menopausal women not undergoing

hormone treatment increased BMI was correlated with

increasedf0ofspeech.Thiscorrelationisexplainedbythe

authorsthroughthehigheramountofestrogenproduction

intheadiposetissueinwomenwithhigherBMI.

Inordertoanalyzethecorrelationbetweentheacoustic

parametersofvoiceandbodyheight,weightand

composi-tionof bodymass inyoungmaleadultsanotherstudy was

carriedout.Theresultsshowednocorrelationbetweenthe

compositionand distribution of bodymass withf0 at the

usualpitch.4

However,asregardsBMI,fewstudies1,2,8_state_that_body

weightinterferes with f0 values,which is lowerin obese

individualsandhigherinunderweightwomen.9

Another veriﬁed measure in voice evaluation is the

MaximumPhonationTime(MPT).Itisanacoustic,

comple-mentary measure, quantiﬁed in seconds and used in the

diagnosis of patients with dysphonia as well as to check

treatmentprogress.It providesinformationonrespiratory

support,glottalefﬁciencyandneuromuscularand

aerody-namicbalanceofvoiceproduction.3,10

TheMPTperformancecanbeinﬂuencedbyvital

capac-ity and varies according to age, gender and body height

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bodyweightindividualsgiventheirbadperformanceinlung

capacity tests, which can be explained by their physical

conditionandlessmuscularﬁrmness.12---14

Salomonetal.14_reported_on_their_studies_a_weak

correla-tionbetweenlungcapacityandMPT,butastrongcorrelation

between larynx airway resistance and MPT. Studies2,9,15,16

withthe purposeof assessing theMPT in individuals with

orwithoutvoicechanges,regardlessofageandsex,should

considertheinterference oftheBMIdue totheimpactof

excessivebodyweightin abdominalbreathingsupportfor

voiceproduction.

These measurements, available at areasonable cost,17

havebeensuccessfulincomparingthedataobtainedpreand

post-speech therapy, thus allowing to understand patient

evolution3_and_therapy_efﬁcacy._The_gap_caused_by_the_lack

ofstudiesdedicatedtoverifytheaverageMPTandthef0

inadultswithdifferentBMImotivatedthisresearch,which

aimedtoverifyiftheBMIinterferesintheaverageofthese

parameters.Itisbelievedthatthisstudywillprovide

knowl-edge and subsidies for acoustic evaluation of voice and

analysisstudiesinindividualswithhigherBMI.

Methods

Subjects

Initially,thesampleincluded99women,but27ofthemwere

excludedbasedontheexclusion/inclusioncriteria. Atthe

end,thesampletotaled84women,aged18---40,andmean

age26.83 (±6.88). The reason whyfemale subjectswere

selectedforthisstudyliesinthefactthatwomenaremore

likelytovoicechangesandmoreoftenseekmedical/speech

care.18 _Participants _were_grouped _according_to_the _BMI_as

follows:Group 1(G1)19underweightsubjects(BMIbelow

18.50kg/m2_);_Group₂_(G2)₂₃_normal_weight_subjects_(BMI

between 18.50 and 24.99kg/m2_); _Group ₃ _(G3) ₂₀

over-weightsubjects(BMIbetween 25.00and29.99kg/m2₎_and

Group4(G4)22obeseindividuals(BMIabove30.00kg/m2_).19

InordertoestablishtheBMIofeachparticipant,allofthem

wereweighedandbodymassmeasured inkilograms using

adigitalscale.TheBMIwascalculatedasbodyweight(kg)

divided by height(m) and squared. Height was measured

usingatapemeasure.The subjectwasupright,witharms

hanging along the body and heels together,wearing light

clothesandbarefoot.

Exclusioncriteria

Voiceprofessionals, smokers,individuals withahistory of

voicedisordersandvoicequalitychangefrommoderateto

intense(CAPE-V),20 _asthma,_{gastroesophageal}_reﬂux,

aller-giesand/orinfectionsoftheupperand/orlowerrespiratory

tractandindividualswhowereinthepre-menstrualperiod21

atthetimeofdatacollection.The exclusioncriteriawere

established toavoid confoundingfactors that could

inﬂu-encevoiceproductionandvoicequality.

Methods

The data werecollected at the Clinical School of Speech

Therapy, in aroom withminimal noise −50db, measured

using a decibelimeter iCEL DL40-20. Participants were

seatedwiththemicrophone5cmfromtheirmouth.The

fun-damentalfrequencywascollectedthroughvoicerecording

usingthevowel[a]inusualintensityandpitchforan

aver-ageperiodofthreesecondsinanHP-brandedcomputerwith

external unidirectional Clone-branded microphone, using

programPRAAT22 _for_the_analysis_and_considering_sampling

range of 44,100Hz. Forthe vowel analysis,the beginning

andthe endof emissionwerediscardeddue tophonation

instability.InordertochecktheMPT,eachparticipantwas

askedtotake adeepbreathandsustainthevowelaslong

aspossible,inusualintensityandpitch,usingthe

narrow-bandspectrogramincludedintheacousticanalysisprogram

tomeasurethebeginningandendofspeechwiththe

high-estprecision.9_Vowels_[a],_[i]_and_[u]_were_used_in_this_task.

Eachparticipantwasaskedtosustaintheproductionofeach

voweltwice,andthebestMPTwasselected.

Statisticalmethod

For the analysis of data the measures of central

ten-dency were used to verify data midpoint (median) and

datadispersion(percentiles).Thedatawereanalyzedusing

Kruskal---Wallis test for differences between the groups

regardingstudyvariables.Allvariablesshowedstatistically

signiﬁcantresultsandweresubmittedtothenon-parametric

Mann---Whitneytest.

ThisstudywasapprovedbytheResearchEthics

Commit-teeinHumanBeingsoftheinstitutionandcomplieswithall

theprovisionsofResolution466/2012oftheNationalHealth

Council(CNS),underno.851,082/14.Participantssignedthe

Free Informed Consent form acknowledging awareness of

theconﬁdentiality ofthe work.Onlythe quantitativeand

qualitative informationrelatedtothis researchhad value

forscientiﬁcdisclosurepurposes.

Results

Theproﬁleofthesampleisconcentratedinthe18---40years

agegroup,meanage26.83,asfollows:G1(22.37±4.57);G2

(22.43±2.35);G3(29.35±8.71)andG4(33.00±4.19)and

theirrespectiveBMI:G1(17.47±1.16); G2(22.09±1.59);

G3(28.97±2.47)andG4(44.88±7.38).Table1showsthat

the average valueof f0 washigherin G2. G3showed the

lowest average for this variable. Although the amplitude

differenceof G1 andG2 mediansis 11Hz, thisdifference

wasnotsigniﬁcant (Table2).Asfor G3andG4,thevalues

betweenmediansshowedupveryclose.Theaverage MPT

washigherinG2invowel[i],andlowerinG4invowel[a].

Itis noteworthytohighlight thatthegroup ofobese

indi-viduals(G4)showedaverageMPTlowerthan10slimit.11_G2

showedhigherf0withstatisticallysigniﬁcantresultswhen

comparedtoG3andG4(Table2).

Discussion

The objective of this study wasto investigate ifthe

fun-damentalfrequency ofvoiceand themaximum phonation

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Table1 Averageandstandarddeviationofage,f0andMPTofthegroupsassessedastoBMI. Variables Age(years)

AverageSD f0(Hz) AverageSD MPT(s) Vowel[a] AverageSD Vowel[i] AverageSD Vowel[u] AverageSD (G1)Underweight 22.37_±4.57 213.79_±24.67 11.42_±2.77 12.63_±3.20 13.16_±3.04 (G2)Normalrange 22.43±2.35 223.48±16.79 12.48±2.69 13.00±3.42 12.70±2.70 (G3)Overweight 29.35_±8.71 206.09_±27.07 11.45_±2.59 11.35_±2.25 11.70_±2.31 (G4)Obese 33.0±4.19 208.55±24.32 9.27±1.90 9.91±3.36 9.41±3.34

s,seconds;f0,fundamentalfrequency,MPT,maximumphonationtime;BMI,bodymassindex.

Table2 AveragevaluesandpercentilesQ25andQ75and

p-valueoftheassessedgroupsasage,f0andMPT.

Group Median Q25---Q75 p-Value

Age 1 21.00a _{20.00---22.00} _<0.001 2 22.00a _{21.00---23.00} 3 27.50b _{22.00---39.75} 4 33.00b _{28.75---35.00} f0 1 211.00a _{193.00---235.00} _0.033 2 222.00a _{211.00---230.00} 3 200.00b _{187.50---217.00} 4 195.50b _{191.75---226.50} MPT [a] 1 11.00a _9.00---13.00 _0.001 2 12.00a _{10.00---14.00} 3 11.50a _9.00---13.75 4 9.00b _9.00---10.25 MPT [i] 1 12.50a _{10.00---16.00} _0.012 2 12.00a _{11.00---15.00} 3 11.00a,b _{10.00---13.00} 4 9.00b _7.75---12.25 MPT [u] 1 13.00a _{11.00---16.00} _0.001 2 12.00a _{10.00---15.00} 3 11.50a _{10.00---13.00} 4 8.50b _7.00---12.25

f0,fundamentalfrequency;MPT,maximumphonationtime. Kruskal---Wallistest,p<0.05.

a _No_{statistically}_signiﬁcant_difference. b _With_a_{statistically}_signiﬁcant_difference.

theaverageoftheseparametersintofourgroupsoffemales

withdifferentBMI.

Importantly, despite the statistically signiﬁcant

differ-ence between the groups as regards age (Table 1), this

variablewas not relevant because allparticipants belong

tothesameperiodofgreatestvocalefﬁciency.

The relation between bodyweightand voice hasbeen

subject of discussion in some studies, suggesting that

obese individuals areexpected topresent different vocal

characteristics.1,2,8_However,_the_literature_is_scarce_in

eval-uatingtheseparametersinsubjectswithdifferentBMI.

One of the main acoustics components of voice, the

fundamental frequency, provides information about the

speaker’sphysicalattributessuchasgender,age,emotional

state,hormonalcompetenceandbodysize.4---6

Studies23 _report _that _acoustic _track _of _voice _may _be

closely relatedto body size. However,Titze24 _shows _that

vocalfoldlength,biomechanicalstress,andlaryngeal

mus-cleactivityarethemainfactorsresponsibleforf0change.

G2 had an average f0 higherthan G1, but this

differ-encewasnotstatisticallysigniﬁcant.Thisresultdiffersfrom

anotherstudy that found higher average f0 in individuals

with low weight and signiﬁcant difference between low

weightandnormalweightindividuals,9_and_supports_Titze24

statementbyarguingthatvocalfoldlength,biomechanical

stressandlaryngealmuscleactivityarethemainvariables

responsibleforf0change.

There was statistically signiﬁcant difference between

G1 and G3/G4, and between G2 and G3/G4 as regards

this variable,which corroboratesstudies that show

aver-age of fundamental frequency for female pattern in

obese women.1,2,24 _A _possible _explanation _for _this

differ-encebetween thegroups is the interference ofexcessive

body weight in abdominal breathing support for voice

production,2,9,15,16 _driving _to _increased _laryngeal _muscle

activity,12 _thus_resulting_in_the_reduction_of_this_parameter

value.

Themaximum phonationtimeis obtainedbythe

inter-action between total capacity of air available for voice

production, expiratory force and adjustment of the

lar-ynxfor theefﬁcientuseofair, i.e.,glottaladductionand

resistance.3_This_is_the_simplest_aerodynamic_parameter_and

oneofthemostcommonlyusedmeasuresinclinical

evalu-ationof voice.18 _In_this_study,_the_average_of _this_variable

showedstatisticallysigniﬁcant differencebetweenG4and

theothergroups.

Underweightindividuals(G1)showedhigheraverageMPT

compared to overweight (G3) and obese individuals (G4)

(Table 2). Studies12,13 _report _that _this _parameter _can _be

impactedin underweight individuals due tothepoor

per-formanceobserved in their lung function. Ourresults did

notshowthishypothesis.

G1, G2 and G3 showed higher average MPT compared

toobeseindividualswithstatisticallysigniﬁcantdifference

(Table 2). This result maybe due to increased subglottic

pressurefoundin individualswithhigherbodyweightand

explaintheneedtoovercometheeffectsofincreased

pha-ryngeal resistance in these individuals.9 _This _effect _may

havecontributedtophonationeffortandreducedthe

aver-ageMPTamongobeseindividuals,explainingthedifference

foundbetweenthegroups.

Thereductioninlungfunctionduetoincreasedadipose

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complianceandrespiratorymusclestrengthcapacity.Thisis

basedonthefactthatoverweightincreasestissuemassin

theneck,chestandupperairways,particularlythelarynx,25

andmayhavedeterminedthedifferencefoundbetweenthe

groupsregardingthistask.

There was statistically signiﬁcant difference between

G1/G2/G3 and G4 (Table 2). This can also be explained

by the interference of weight gain in abdominal

breath-ingsupportduringthistask,16 _which_favored_the_reduction

of this parameter average. This result is consistent with

authors14_that_show_a_weak_correlation_between_lung

capac-ityandMPT,butastrongcorrelationbetweenlarynxairway

resistance and MPT. This assumption is based on results

and ﬁndings of other studies, because lung capacity and

vocaltractdiametermeasureswerenotinvestigatedinour

study.

G4 was the group that showed lower MPT average on

vowels [a] and [u] compared to other groups, with

sta-tistically signiﬁcant difference. This difference may be

explained by the interference of reduced chemoreceptor

sensitivityinobeseindividuals,whichisoffsetbythe

hyper-activityofthepharyngealdilatormuscles,26 _thus_reducing

thesustainedemissionofthesevowels.

No signiﬁcant differences werefound between G3 and

G4asregardstheMPTofvowel[i](Table2).Thisresultmay

reﬂectthecharacteristicsofthisvowel.Asatensevowel,

itmayrequiregreatervocal effort,theneedtoovercome

theeffectsofpharyngealresistance27_and_reduced_average

MPTinindividualswithhigherbodyweight.

Thisstudysoughttocollaboratewiththeliteratureand

providedpreliminaryresultsonacousticmeasuresofvoice

inwomenwithdifferentBMI. Basedonstudyresults, itis

suggestedthatduringtheevaluationofMPTmeasuresthe

BMIofoverweightandobese individualsis alsotaken into

account.

Studylimitations

This study had some limitations that were not possible

to solve. The number of participants could have been

higher,but theexclusion criteriontoavoid confusing

fac-torsreducedthesamplesize.Futurestudiescouldprovide

subsidiesinordertoobtainreliableinformationaboutthe

endoscopicevaluationofthevocaltractdiameterofwomen

withdifferentBMIandthevideolaryngoscopicassessment.

The access to these techniques, though, is limited and

expensive.

Conclusion

Theresults suggestthatthereduced f0valueswere

inﬂu-encedbybodyweightinoverweightandobeseindividuals.

ObesewomenshowedlowerMPT,whichmayhavebeen

inﬂuencedbytheincreasedadiposetissuearoundtheribs

andabdomen,favoringastrongreductionofthisparameter.

The results of this study showed that, although the

anatomicalelements are identical amongthe individuals,

theydonotpresentthesamephysiologicalcharacteristics,

reasonwhy theunderstandingof bodyweightinﬂuencein

theacousticparametersofvoiceduringvocalevaluationis

arelevanttasktobeconsidered.

Conﬂicts

of

interest

Theauthorsdeclarenoconﬂictsofinterest.

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