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-
Natal-RN, Brazil.
* Lourdes Bernadete Rocha de Souza
hsouza660@gmail.com
1
Department of Speech-Language Pathology and Audiology, Federal
University of Rio Grande do Norte, Av. General Gustavo de Farias,
S/N. Petrópolis, Natal, RN, Brazil
2
Health Sciences, Federal University of Rio Grande do Norte,
Natal, RN, Brazil
3
Department of Speech-Language Pathology and Audiology, Federal
University of Paraíba, João Pessoa, PB, Brazil
4
Federal University of Rio Grande do Norte, Natal, RN, Brazil
Obesity is considered a public health problem with significant
comorbidities. Overweight individuals are at greater risk of
developing diabetes mellitus, cardiovascular disease, dyslip-
idemia, and other chronic diseases such as obstructive sleep
apnea syndrome (OSAS), whose incidence exceeds 50%, due
to the accumulation of adipose tissue in the trunk and neck
region [1].
There is a high prevalence of modification of the respira-
tory pattern in obese people for several reasons, including the
greater amount of upper airway mass. This modified respira-
tory pattern and the changes in pharyngeal size and configu-
ration may therefore affect the acoustic parameters in obese
individuals [1, 2].
OBES SURG (2018) 28:1372–1376
Through acoustic pharyngometry, one study showed a
strong correlation between body mass index (BMI) and pha-
ryngeal size in obese women [3]. This is possibly due to ab-
normal fat deposition in structures belonging to the vocal tract,
such as accumulation of fat in the upper airways, increased
thickening of the pharyngeal lateral walls, tongue size, and
soft palate volume [4], characteristics that may interfere with
vocal quality. In addition, obesity can impair lung function
and voice production as a result of increased adiposity around
the ribs, abdomen, and viscera [3].
Other authors [5, 6] argue that excessive weight can inter-
fere with vocal resistance and contribute to general fatigue. In
some cases, it may influence voice resonance as excess fat can
modify the size and configuration of the aerodigestive tract
and significantly reduce the lumen of the pharyngeal region
above the glottis.
There are several studies that seek to understand the rela-
tion between body weight indicators and vocal function. One
study investigated the possible effects of obesity on acoustic
and perceptual voice parameters in people who reduced BMI
after bariatric surgery but did not find differences between
obese and non-obese individuals [7]. However, other studies
have shown that BMI and body fat volume appear to be relat-
ed to some objective measures of voice quality, vocal aerody-
namics, and phonatory range performance [6, 8, 9].
BMI is the traditional measure of obesity. However, other
simple, practical, and low cost anthropometric markers such
as neck circumference (NC) can be used to determine if an
individual is overweight [10–12].
Regarding abdominal circumference, the studies showed
conflicting results. Researchers state that there is a relation
between respiratory function and abdominal circumference
[6]. On the other hand, other authors [13] did not find such
relation and argue that obese individuals tend to present low
respiratory muscle strength when they have a larger NC.
Increased NC seems to delay the capacity to metabolize respi-
ratory flow comparing with general adiposity. Therefore, NC
can be considered an anthropometric measure that presents a
positive correlation with respiratory strength in obese individ-
uals [13].
In this regard, this study aimed to verify the NC and the
acoustic parameters of voice in obese women, before and after
bariatric surgery, and to compare the results with a control
group, with normal weight.
Method
This is an observational, longitudinal, and comparative study
conducted with patients referred to the SCODE (Obesity
Surgery and Related Disorder Center of a university hospital).
The sample consisted of 25 morbidly obese women [14],
experimental group (EG), aged 28–43 years, mean age 34.32
1373
(±6.77) years, mean BMI44.88 kg/m2 (±7.38) before surgery
and 33.28 kg/m2 (±5.60) 8 months after surgery, and 23 non-
obese women [14], aged 21–41 years, mean age 25.00 (±6.37)
years and mean BMI 22.55 (±2.50),control group (CG). All
obese patients underwent gastric bypass surgery in Y-Roux
and none of them underwent speech therapy before or after
surgery.
The female gender was selected for this study because
women more frequently seek medical/speech therapy care
and are more likely to have voice disorders [15].
This study included morbidly obese women (EG) and non-
obese women (CG), aged 18–45 years, considering the vocal
efficiency period [16, 17]. We excluded volunteers in the pre-
menstrual period [18], smoking, those with upper airway viral
disease at the time of collection, and/or neck and head surgery.
An identification form was answered by the participants. In
order to control the exclusion criteria, participants were asked
to respond to a questionnaire for the information to be
collected.
These criteria were adopted to minimize the chances that
factors secondary interfered with the evaluation of the param-
eters studied.
All participants were properly informed on the objectives
and methods involved in the current study and agreed on
participating signing and informed consent.
The neck circumference was determined in centimeters
using a measuring tape. Obesity was established with a NC
cutoff of ≥35 cm [19]. Two measurements were taken of all
participants while seated upright with the head positioned in
the Frankfurt horizontal plane, one at the base of the neck by
the cricoid cartilage, and another at the mid-cervical spine.
Voice recording was performed in a quiet environment, on
a laptop computer, with a clone-branded unidirectional exter-
nal microphone, using ANAGRAF software for the acoustic
analysis of speech sounds [20], considering sampling rate of
22,050. For voice collection, each participant was seated with
the microphone within 5 cm of their mouth. The participants
were requested to produce the vowel [a] at the usual intensity
and pitch, for an average period of 3 s, to measure the funda-
mental frequency of the voice, that is, how much the vocal
fold vibrates per second. After the recording, participants were
asked to produce vowels [a], [i], and [u] sustained at usual
intensity and pitch, using a stopwatch to measure the maxi-
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-
evaluated using the same procedures of the pre-surgical data
collection. For recording the voice of the control group, the
same procedures were used, as well as for the NC
measurement.
Data analysis was carried out by measures of central ten-
dency to verify the mid-point (median) and the dispersion of
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
relation to the study variables. All variables presented statisti-
cally significant result and were submitted to the non-
parametric Mann Whitney test. All tests considered the signif-
icance level of 5%.
The data of this study belong to the database of previous
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,
agreeing to participate in the research.
Results
Table 1 shows the comparisons between groups. Regarding
the pre (EG1) and post-surgery (EG2) moments, it was ob-
served that the NC decreased (median = 36.00 cm; p < 0.001)
and the MPT of all vowels increased ([a] = 12.00 s; [i] =
13.00 s; [u] = 14.00 s; p = < 0.001; p = 0.011; p = 0.002, re-
spectively) 8 months after the bariatric surgery. F0 also in-
creased (f0 = 206.00 Hz; p = 0.094), but the difference was
not statistically significant.
When analyzing Table 1 for the comparison between the
experimental groups and the control group, it was verified that
EG1 had larger NC (36.00 cm), lower f0 (f0 = 194.00 Hz), and
lower MPT ([a] = 10.00 s; [i] = 10.00 s; [u] = 10.00 s) when
compared to CG ([a] = 12.00 s; [i] = 14.00 s; [u] = 14.00 s).
The decreased NC (36.00 cm) after surgery was not enough to
eliminate the difference in relation to CG (32.00 cm). All vo-
cal parameters improved after weight loss and the differences
from CG ceased to exist.
Discussion
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
surgery.
Statistically significant difference was observed between
the groups EG1 (obese pre-surgery), EG2 (obese post-sur-
gery), and CG regarding the median NC in all comparisons.
This result indicates that NC [18, 20, 21] could be reported as
a good anthropometric marker related to obesity because it
considers fat deposition in the upper airway region [7].
It is noteworthy that, although NC remained somewhat
higher in EG2 when compared to CG, there was a reduction
of this measure and all vocal parameters improved after sur-
gery. Therefore, it is possibly inferred that the reduction of the
accumulation of fat in the neck region after weight loss may
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
of the process of accommodation of the vocal tract structures
to the new morphophysiology. This result corroborates au-
thors [3, 4] by citing that accumulation of fat in the upper
airways and increased adiposity around the ribs, abdomen,
and viscera may interfere with vocal quality.
Regarding f0, it was observed that in obese women (EG1),
the values were lower when compared to CG, which differs
from studies reporting no relation between body weight and
this variable [8, 22]. This result corroborates other studies with
obese women in which the mean fundamental frequency was
lower than expected for the female pattern [9, 23]. The reduc-
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
production [5, 23, 25].
In this study, the fact that f0 increased after weight loss and
did not differ from CG corroborates this argument. It is also
believed that the reduction of abnormal fat deposition in the
vocal tract structures, such as accumulation of fat in the upper
airways, pharyngeal lateral walls, tongue size, and soft palate
volume, may have contributed to the result found.
The MPT aims to evaluate glottic efficiency and respiratory
support in voice production by the interaction between the
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].
In this study, morbidly obese women (EG1) presented re-
duced MPT of all vowels when compared to CG, but after
surgery (EG2), the values were adjusted and approached CG
values. Reduced values in MPT in obese individuals were also
found in previous studies [6, 23, 25]. One of the hypotheses
for this result is the increased neck circumference in obese
individuals (G1). The accumulation of fat in the neck region
can cause imbalance between the myoelastic and aerodynamic
forces of the larynx and contribute to reduce MPT3.
In addition to these factors, the excessive accumulation of
fat in the ribs, abdomen, and viscera, usually found in obese
individuals, contributes to modify the respiratory function [6,
28]. In this case, there may be an increase in subglottic pres-
sure in individuals with higher body weight and a greater need
to overcome the effects of increased pharyngeal resistance
[10], which maximizes the phonatory effort and reduces the
mean MPT of obese individuals. With the reduction of weight
after surgery, NC remained different between EG2 and CG,
but the difference in MPT between obese and eutrophic pa-
tients ceased to exist. It is believed that the reduced sensitivity
of chemoreceptors found in obese subjects [29] was normal-
ized after weight loss and collaborated to increase phonation
time of vowels in EG2.
In addition to these factors, the excessive accumulation of
fat in the ribs, abdomen, and viscera, usually found in obese
individuals, may have contributed to modify the respiratory
function in this task [6, 28]. Despite this, studies show that fat
1375
deposition around the neck and increased BMI are the most
important factors in the impairment of thoracic mobility in
women, influencing the movements of the chest wall and
restricting its expansion [30].
Despite these evidences, the results found differ from a
previous study [8] in which the mean values of MPT, although
reduced in the obese group in relation to the eutrophic group,
did not present a statistically significant difference. The reason
for this disagreement is possibly related to the smaller number
of individuals allocated in the previous study and the measure
of central tendency used.
Limitations of the Study
This study has some limitations. The item exclusion, in order
to avoid misleading factors, influenced the reduction of sam-
ple. The endoscopic evaluation of the vocal tract diameter and
the videolaryngoscopy were not feasible due to logistic rea-
sons and lack of subsidies. The authors suggest that next stud-
ies investigate other parameters of the multidimensional eval-
uation of the voice and other anthropometric measures, such
as abdominal circumference.
Conclusion
After surgery, obese individuals may present values of NC, f0,
and MPT closer to the mean values of normal weight
individuals.
In this study, weight loss was sufficient to adjust the mea-
surements of the acoustic parameters evaluated.
Authors’ Contribution Lourdes Bernadete Rocha de Souza participated
in the general coordination of the study, in the project, data collection,
design, and writing of the manuscript.
Marquiony Marques dos Santos contributed in the analysis and inter-
pretation of the results.
Leandro Araújo Pernambuco contributed in the design and writing of
the manuscript.
Cynthia Meira de Almeida Godoy participated in the data collection.
DeysianneMeire da Silva Lima participated in the data collection.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interest.
Statement of Informed Consent Informed consent was obtained from
all individual participants included in the study. This study was approved
by the Ethics Research Committee of the institution no. 207.630/2013 for
the EG and no. 809.761/1 for the CG.
Statement of Human and Animal Rights All procedures performed in
studies involving human participants were in accordance with the ethical
standards of the institutional and/or national research committee and with
1376
the 1964 Helsinki declaration and its later amendments or comparable
ethical standards.
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