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these alterations in vocalization were not related to body mass index (BMI) because obese OSAS patients exhibited similar alterations to nonobese patients. In addition, only a few studies10,11
have directly analyzed the impact of obesity on vocal quality
and function. One study10 described that obese people exhibited
an elevated prevalence of altered laryngoscopic analysis, associated with enhanced acoustic parameters (jitter, shimmer, and
noise) but reduced maximum phonation time (MPT). Accordingly, this study concludes that voice in obese people can be characterized as hoarse (62%), murmuring (27%), and with phonation
instability (44%). On the other hand, Solomon et al11 reported that
obese patients had similar acoustic parameters (ie, jitter, shimmer,
noise-to-harmonic ratio [NHR], fundamental frequency [F0],
MPT) when compared with nonobese controls. Among several
methodological differences between these two studies, it is interesting to highlight that both include overweight people as nonobese controls. Therefore, we believe that stratification of
participants according to BMI may elucidate whether excessive
body fat deposits impair voice production.
On the other hand, Verdolini Abbott et al12 have described that
the acute response to vocal fold injury in healthy people may
include the secretion of proinflammatory markers such as matrix
metalloproteinase-8, interleukin 1b (IL-1b), and interleukin 6
(IL-6).12 In particular, elevation of IL-6 detected in laryngeal
secretion after 24 hours post initial 60-minute vocal loading session was partially reverted by voice resting and completely overcome by resonant voice therapy.12 Furthermore, this same group13
has described that fibroblasts from rabbit vocal folds exposed
to IL-1b activate proinflammatory gene transcription, an effect
reversed by exposure to various magnitudes of cyclic tensile
strain (00.5 Hz), suggesting that vibratory therapy might induce
wound healing in the vocal folds. Despite the promise of interleukins (ILs) measurements, particularly IL-6, as a biomarker for
2
detecting vocal fold alterations and its healing process after injury,
one limitation is the accessibility to laryngeal secretion.
IL-6 has been detected in saliva in normal volunteers,14 the
levels being associated with the activity of salivary glands, as
well as oral epithelial cells, periodontal ligament cells, and
gingival fibroblasts among other cells.15,16 Salivary IL-6 may
reflect localized inflammation in the upper airway that is relatively independent of the general systemic level of inflammation.17 There is no information regarding the association
between salivary IL-6 levels and voice analysis. However, it
has been reported that salivary IL-6 increases in approximately
50% of people after acute psychosocial stress induced by delivering a speech and performing a mental arithmetic task in front
of two audiences,17 suggesting that salivary IL-6 may increase
after vocal loading. Because obesity has been related with
elevated circulating levels of proinflammatory cytokines
including IL-6,1820 it is intriguing how BMI and vocal
loading may affect salivary levels of IL-6. We aim to investigate
whether a vocal loading task increases acoustic parameters of
voice and also salivary IL-6 in overweight and obese people
compared with healthy weight controls.
PARTICIPANTS AND METHODS
This study was approved by The Ethical Committee from the
Universidad Pedro de Valdivia, Chillan, Chile. All participants
signed a written informed consent. In this study, a total of 33
self-reported healthy schoolteachers were included. Schoolteachers were studied because they have high occupational
voice demands.21 All teachers were subjectively free from upper airway infections and allergies at the time of the examination during an ordinary workweek.
Teachers were classified into normal weight, overweight, and
obese groups following the World Health Organization classification. Thus, BMI <25 kg/m2 was considered as normal weight,
BMI 2530 kg/m2 was classified as overweight, and BMI
>30 kg/m2 as obese. Inclusion criteria were school teacher, volunteers, in good overall health by self-report, and ability to produce a loud voice (ie, between 85 and 95 dB). Exclusion criteria
were a self-report of a current voice problem or a voice problem
more than once monthly during the preceding year; current use
of any medications that might influence voice (eg, decongestants or antiinflammatory and antihistamines) or signs of
currently active allergic process; known or suspected allergy;
as well as current smoker and report of pregnancy.
All evaluations took place in a silenced classroom between
8:30 and 11.00 AM to minimize the circadian variation of
IL-6.14 Also, previous to experimentation, the participants
were instructed to maintain their regular activities, including
sleep patterns and no medication (in particular, antiinflammatory drugs). They were asked to refrain from eating and drinking at least 1 hour before the experimental session. A single
voice or saliva sample was taken before and after vocal load.
Vocal loading task
After their regular schedule, teachers were asked to give their
first expositive class in the morning for 60 minutes minimum
Jesenia Acurio, et al
TABLE 1.
Characteristic of Included Teachers
ANOVA
Characteristic
Male/female
Age (y)
Weight (kg)
Height (m)
BMI (kg/m2)
Classes per week (h/wk)
Experience as teachers (y)
Normal (n 12)
Overweight (n 8)
Obese (n 7)
P value
4/8
31.1 1.5
67.8 3.1
1.7 0.03
23.2 0.3
34.6 3.2
6.5 1.3
4/4
38.0 3.1
76.1 2.7*
1.6 0.03
28.1 0.5*
34.0 5.0
8.1 2.0
1/6
45.2 6.8
87.1 3.3*
1.5 0.02
34.1 1.0*,y
32.2 4.3
19.4 6.1
0.067
0.008
0.197
<0.0001
0.641
0.055
3.9 1.1
10.0 2.5
1.0 0.5
14.9 3.9
3.0 1.3
9.1 1.9
1.0 0.5
13.1 2.5
Obese
(n 7)
ANOVA
4.7 2.1
7.5 2.6
3.1 1.7
15.4 6.2
0.73
0.82
0.61
0.96
P value
TABLE 3.
Acoustic Parameters in the Studied Groups
Normal
Characteristic
5
Overweight
Obese
Before
After
Before
After
Before
After
2.99 0.51
0.49 0.08
0.3 0.1
0.3 0.1
9921 1019
0.87 0.08
5364 579
6018 650
7453 939
0.06 0.01
3.97 0.82
0.51 0.06
0.3 0.1
0.3 0.0
11 594 1387
1.03 0.12
5330 765
5664 817
6656 965
0.11 0.02
4.97 1.01
0.63 0.11
0.4 0.1
0.4 0.1
12 876 2369
1.14 0.20
6195 715
7186 898
9063 1315
0.20 0.08
2.48 0.33
0.43 0.08
0.5 0.1
0.5 0.1
9549 1456
0.85 0.13
6279 865
7333 1009
8736 1482
0.06 0.02
6.38 2.29
0.51 0.09
0.4 0.1
0.3 0.1
12 012 1651
1.09 0.14
6694 1309
7846 1499
10 459 1927
0.10 0.05
4.57 0.92
0.59 0.07
0.4 0.1
0.4 0.1
14 149 1976
1.25 0.16
7045 916
9068 1335
10 799 1885
0.13 0.04
Abbreviations: rap, relative average perturbation; ppq, period perturbation quotient; apq, amplitude perturbation quotient.
Notes: Acoustic parameters measured before and after vocal loading. Frequency perturbation (jitter) expressed as absolute value. Amplitude perturbation
(shimmer) expressed as local in decibels (dB). Numeral subtypes accompanying analysis indicates the specific calculation performed by the Praat software.
Before and after indicates before and after vocal loading, respectively. Values in mean SEM.
The value for the MPT was not statistically significant between groups or when values were compared before and after
vocal loading (Figure 1C). However, a trend to higher levels
of MPT was observed in the overweight group compared with
the other two groups, before and after vocal loading but which
did not reach statistically significant values (P > 0.05 in all
comparisons).
Taking into account the significant differences in F0 and
HNR, we performed a post hoc analysis considering the
behavior of these two acoustic parameters before and after
loading in the analyzed groups. Thus, Figure 2 describes the
proportion (%) of participants in each group who showed an increase or decrease in the value of these two parameters after
vocal loading. The percentage of overweight teachers who exhibited an increase in F0 (Figure 2A) and HNR (Figure 2B) was
higher than in the normal weight group (c2, 10.4 and 16.2,
respectively, P < 0.05 in both cases). A lower percentage of
obese teachers (n 1, 14%) exhibited an increase in the
HNR value after vocal loading compared with normal weight
teachers (n 4, 33%). In the same analysis, a lower percentage
of overweight teachers showed increased jitter or shimmer
compared with normal weight group (data not shown).
Table 4 shows the characteristics of the individual that
showed an increase or decrease in the HNR (Figure 2). No significant changes were observed in age, BMI, years of service,
hours of classes per week, or score in the VHI test, when the
subgroups were compared within or across the various BMI
groups.
We performed a nonparametric correlation between BMI and
every single acoustic parameter analyzed in this research. We
did not find significant correlations in any of the analyses
when all teachers were included (see Supplementary Table
S1). However, in the analysis within groups, HNR (r 0.66;
95% confidence interval, 0.120.89; P 0.01) and F0
(r 0.72; 95% confidence interval, 0.220.91; P 0.01)
were positively correlated with BMI only in the normal weight
group.
DISCUSSION
Overweight and obesity are well-recognized public health problems worldwide;25,26 however, its impact on voice alterations is
unclear. Initially, indirect evidence suggested OSAS, a
pathology commonly related with obesity,27,28 might be
associated with reduction in the compliance of the upper
airway or vocal tract that will cause a change in damping,
which in turn will change perceived vocal quality and may be
identified as a resonance disorder.29 Indeed, fat deposits in
the tongue and pharyngeal walls as well as changes in the
Jesenia Acurio, et al
TABLE 4.
Characteristics of the Participants According to Delta of HNR Between Measurements Before and After Vocal Load
Normal
Characteristic
BMI (kg/m2)
Age (y)
Classes per week (h/wk)
Experience as teacher (y)
VHI total
Overweight
Obese
Increase
(n 4)
Decrease
(n 8)
Increase
(n 5)
Decrease
(n 3)
Increase
(n 1)
Decrease
(n 6)
23.5 0.5
33.7 5.8
26.7 11.0
10.0 3.6
9.8 5.2
23.1 0.4
30.3 0.8
37.6 1.7
5.3 1.1
17.9 5.4
28.4 0.5
39.4 3.8
32.0 7.1
9.4 2.7
16.5 3.0
27.7 1.2
34.5 6.5
39.0 1.0
5.0 1.0
8.7 2.9
36.0
35.0
38.0
7.0
10.0
33.8 1.2
47.8 8.3
30.8 5.4
22.5 6.8
16.3 7.3
Notes: Increase and decrease indicates trend of value after vocal loading, respectively. Values in mean SEM.
sight, our results may suggest that obesity may impact voice
generation, via restriction of vocal fold vibration that is evidenced after vocal loading, as suggested by da Cunha et al10
and partially supported by Solomon et al.11 However, we could
not find a significant correlation between any of the acoustic
parameters and BMI. Lack of statistical significance might
be explained by sample size. Alternatively, the site of fat distribution, abdominal versus upper airway, may induce selective
changes in vocal fold vibration that are not revealed just by
measuring BMI.
There are many methodological differences between our
study and those of Solomon et al11 and da Cunha et al.10 We
did not include individuals with morbid obesity
(BMI > 40 kg/m2) and categorized the participants into three
groups, normal, overweight, and obese. Solomon et al11
included only two participants with normal weight (BMI
<25 kg/m2) in the control group, whereas the rest (n 6)
were overweight people. In the study by da Cunha et al,10
only 51% of participants in the control group had a BMI
<25 kg/m2, whereas 49% were overweight. In our study, we
included teachers, who are trained in the use of their voice.
FIGURE 4. Correlation between salivary IL-6 levels and harmonicto-noise ratio in the studied groups. Relative concentration of IL-6 was
correlated with harmonic-to-noise ratio in normal (B), overweight
(,), and obese teachers (6). Comparisons were performed using
the respective values (A) before vocal load or (B) after vocal load. In
(A) significant inverse correlation was observed in normal group
(r2 0.44, P < 0.05). In (B) significant positive correlation was
observed in overweight group (r2 0.61, P < 0.05). Each dot represents an individual participant.
Jesenia Acurio, et al
Acknowledgments
We thank teachers in the Sidney School Chillan, Chile, research
staff at Vascular Physiology Laboratory, Group of Investigation
of Tumor Angiogenesis (GIANT), and Group of Research and
Innovation in Vascular Health for their technical support. Also,
we thank Prof Leslie Myatt from Center for Pregnancy and
Newborn Research, University of Texas Health Science Center
San Antonio for his diligent review of this manuscript. We
thank Prof Rodrigo Fuenzalida for helping with sample collection. Fondecyt Regular 1100684, Conicyt 79112027, DIUBB
122109 GI/EF financed this study.
Individual contribution: This work was carried out in collaboration between all authors. C.E. and J.P. defined the research
topic. J.P. and C.E. designed the experiments. C.C. and J.A. performed all experiments. All authors cowrote the manuscript. All
authors approved final version of the manuscript.
Supplementary material
Supplementary data related to this article can be found at http://
dx.doi.org/10.1016/j.jvoice.2014.03.002.
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