http://informahealthcare.com/dre ISSN 0963-8288 print/ISSN 1464-5165 online Disabil Rehabil, 2014; 36(26): 2262–2269 ! 2014 Informa UK Ltd. DOI: 10.3109/09638288.2014.902509
REHABILITATION IN PRACTICE
Current knowledge and impressions of speech-language pathologists of the swallow of persons who are obese Paul M. Evitts1, Michelle Kopf2, and Megan Kauffman3 1
Department of Audiology, Speech-Language Pathology, and Deaf Studies, Towson University, Towson, MD, USA, 2Department of Speech-Language Pathology, Hershey Medical Center, Hershey PA, USA, and 3Department of Speech-Language Pathology, Kennedy Krieger Institute, Baltimore MD, USA Abstract
Keywords
Purpose: The overall goal of this study was to provide insight on the topic of dysphagia in the obese population. More specifically, the purpose of this study was to obtain preliminary descriptive data on the knowledge and impressions of speech-language pathologists (SLPs) working in the field of dysphagia on the swallow of persons who are obese. Methods: One hundred seventy-seven SLPs responded to a web-based survey that was posted on two popular listserves that serve the dysphagia community. Results: Descriptive results showed that nearly all SLPs have assessed and treated patients who are obese for dysphagia, that there is little consensus as to how the obese swallow compares to the normal swallow, and that there is a consensus that dysphagia observed in the obese population is most likely related to other concomitant disorders. Conclusions: Results provide preliminary insight into the knowledge and impressions of SLPs working with dysphagia and highlight the need for future research to determine (1) if there is an increased incidence of dysphagia in the obese population, and (2) if obesity itself constitutes a risk factor for dysphagia or if any dysphagia observed in this population is related to other comorbidities.
Deglutition, deglutition disorders, dysphagia, obesity, swallowing muscles History Received 18 October 2013 Revised 27 February 2014 Accepted 5 March 2014 Published online 26 March 2014
ä Implications for Rehabilitation
Many healthcare professionals (i.e. speech-language pathologists [SLPs]) assess, diagnose and treat individuals for swallowing disorders who are obese in the absence of research or evidence-based medicine on the impact of obesity on the swallow or the impact of obesity on dysphagia rehabilitation (e.g. swallowing exercises). Results of this study suggest that: there is not a consensus among SLPs on the swallowing characteristics of persons who are obese; that persons who are obese are more at risk for swallowing disorders; and that the increased risk of dysphagia may be related to concomitant disorders and not the presence of obesity itself. Clinicians who work with dysphagia need to understand the impact of obesity on the swallow and on dysphagia rehabilitation with persons who are obese. Future research should focus on establishing estimates of swallowing function in persons who are obese. This information can provide a foundation for efficacy studies of various therapy techniques (e.g. exercises) and ultimately can assist with goal setting and intervention planning.
Introduction Obesity is a major public health problem and has been recognized as a worldwide epidemic [1]. In 2005, nearly 1.6 billion adults and 20 million children were considered to be overweight [2]. It is estimated that by 2015, approximately 2.3 billion adults will be overweight and more than 700 million adults will be obese [2]. In addition, obesity-related deaths outnumber all other preventable deaths in the United States except for tobacco-related
Address for correspondence: Paul M. Evitts, Department of Audiology, Speech-Language Pathology & Deaf Studies, 8000 York Road, Towson University, Towson, MD 21252, USA. Tel: 410-704-3860. Fax: 410-7044131. E-mail: [email protected]
mortalities [3]. According to the Organization for Economic Cooperation and Development [4], the top five countries with the highest percentage of obesity were the United States, Mexico, United Kingdom, Slovakia, Greece and Australia with obesity rates of 30.6%, 24.2%, 23%, 22.4%, 21.9% and 21.78%, respectively. When including persons who are overweight, an estimated 54% of the Australian population, for example, is considered to be obese or overweight [5]. Although some recent figures show a plateau in these prevalence rates [1], obesity still represents a major health epidemic. One of the primary reasons for the epidemic status is because of the increased risk for developing multiple health conditions associated with obesity, including diabetes, hypertension, high cholesterol, stroke, and certain cancers, among others [1]. In fact, obesity represents the leading
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cause of preventable death and is associated with an estimated 200,000 deaths per year in the United States [6]. Apart from the health-related consequences, obesity-related medical costs in the United States, for example, accounted for an estimated $147 billion dollars in 2008 [7]. Clearly, obesity represents a major healthcare problem that healthcare professionals will be increasingly exposed due to the number of comorbidities and concomitant disorders within this population. Because of this anticipated increased exposure, it is important that these professionals be aware that people who are obese have marked differences in muscle physiology, anatomy and respiration, among other areas. For example, respiratory muscles have been shown to work harder in obese patients compared to typical weight individuals [8], which has been associated with increased adiposity (additional lipids infiltrating the muscle mass) around the respiratory system [9]. Persons who are obese have also been shown to have differences in gas exchange rates, respiratory mechanics, breathing patterns, lung volumes, as well as other respiratory measures [10]. With regard to muscle physiology, greater fat infiltration into muscle and lower muscle mass, both of which may be found with persons who are obese, have been associated with a higher risk for loss of mobility, especially with increased age [11]. Additionally, in a large-scale study (n ¼ 2627) investigating the effects of aging and obesity on muscle function, Goodpaster et al. [12] found that muscle density and strength/ torque decreases as body mass index (BMI), total body fat and total percent fat increases [12]. Although numerous other studies exist and are not presented here, the overall consensus of this body of literature is that differences in muscle function, including respiratory, exist between people who are obese and their lean counterparts. The majority of these associations between obesity and differences in muscle strength, however, are typically derived from studies on upper and lower extremities and therefore it may not be appropriate to extrapolate these results to the muscles associated with speech and swallowing. There is evidence delineating the inherent differences between speech/swallow muscles and limb muscles both in composition and patterns of aging [13,14]. Rather than providing a full review of the literature (please see Ref. [13] for a thorough review of the speech motor system), a few key points are presented. First, the biomechanical and histological features of the speech/swallow muscles are different than the limb skeletal muscles [14]. For instance, laryngeal muscles have a different composition of myosin heavy chain fibers that produce shortening rates nearly double the rate of limb muscles [15]. In addition, the composition of muscle fibers in the tongue is different from the limbs, as well as other masticatory and orofacial muscles [16]. Second, muscles of deglutition and mastication may follow different aging patterns than limb muscles. For example, cross-sectional area of locomotive muscles begins to decline after the fifth decade whereas the cross-sectional area of lingual muscles has been shown to increase at 70 years [17]. Finally, the tongue provides arguably the best example of how difficult it is to generalize information from the limbs to the swallowing musculature. The tongue is a hydrostat, has no skeletal framework, and thus has unique biomechanical properties [18], especially in relation to the limbs. Given these significant differences in muscle composition and function between speech/swallow and limb muscles, and the marked differences between obese and thin muscle function, it is reasonable to suspect that differences exist in speech, swallowing and voice between persons who are obese and their lean counterparts. However, few studies have explored these potential differences. da Cunha et al. [19] compared vocal function in persons who are obese (n ¼ 45, BMI435) to normal-weight (n ¼ 45, BMI530) individuals using laryngoscopic examination
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(e.g. presence of hypertrophy), subjective ratings of voice quality and acoustic analysis (e.g. jitter, shimmer). Results showed significant differences in all three measures between the two groups. da Cunha et al. [19] attributed the differences in voice to increased vocal fold aperiodicity, increased presence of laryngopharyngeal reflux and increased respiratory difficulties in persons who are obese. In a similar study, Solomon et al. [9] investigated the effect of obesity on vocal function by using visual-perceptual (nasal endoscopy), acoustic and subjective ratings of voice quality, and aeromechanics in eight obese (BMI435) and eight age- and gender-matched non-obese (BMI530) individuals. Results in the Solomon et al.’s study [9] were in contrast to the da Cunha et al.’s study [19] in that no significant differences were found between the groups. Clearly, more research needs to be conducted to shed more light on the impact that obesity has on vocal function. With regard to swallowing, specific research exists on feeding and drinking patterns that suggests potential differences in the overall swallow may exist between these two groups. For instance, persons who are obese may eat faster, have longer overall meal durations, and have different drinking patterns than lean persons [20]. Furthermore, research conducted on eating differences in women who are obese and not obese showed that women who are obese spent less time chewing and more time drinking fluids [21]. Such differences in rate and volume may be considered prepharyngeal impairments [22] and an argument could be made that these prepharyngeal impairments or differences may ultimately place the obese individual at an increased risk for dysphagia. Other than data on feeding and drinking patterns, the authors are unaware of any research on the temporal or biomechanical characteristics of the swallow in persons who are obese. Again, considering the marked differences in muscle physiology, respiratory function and eating/drinking differences between persons who are obese and their thin counterparts, it is reasonable to suspect physiological and/or temporal differences in the stages of the swallow for persons who are obese. Perhaps the best example of the potential impact of obesity on the physiological function of the oropharyngeal region is obstructive sleep apnea syndrome (OSAS). It has been estimated that 30% of the obese population and 50–98% of the morbidly obese population have OSAS [23]. This is especially pertinent as persons with OSAS often present with ‘‘disproportionate anatomy’’, or increased size of the velum, uvula and base of tongue but a smaller mandible [24], and treatment may involve surgical resection of parts of these areas. Although there are different surgical techniques for treatment of OSAS (e.g. uvulopalatopharyngoplasty), existing research has not objectively addressed differences in swallowing, speech or taste pre-surgery and postsurgery but instead has used subjective means of determining differences [25–28]. More research is needed to compare the swallow (and speech) of persons who are obese and present with OSAS and their typical-weight counterparts to determine if objective differences exist. Even with all of the differences in muscle physiology, respiration, vocal tract anatomy and feeding/drinking styles between persons who are obese and persons who are not obese, one of the greatest difficulties in exploring this line of research is isolating the effects of obesity on swallowing function from the comorbidities associated with obesity. Research has been provided that in the least suggests a relationship between obesity and dysphagia (e.g. muscular weakness). However, this relationship may only be correlational and not causal [29–31]. If future research does indeed show a direct relationship, dysphagia may be identified as a risk factor for obesity. As a first step in attempting to better understand the potential differences in the swallow of persons who are obese, it is prudent
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to investigate the current impressions and knowledge of speechlanguage pathologists (SLPs) who routinely work with dysphagia in a healthcare setting. SLPs were targeted as it has been estimated that up to 61% of an SLP caseload consists of patients with dysphagia [32] and that nearly 90% of patients seen by an SLP in an acute care setting were diagnosed with dysphagia [33]. With rates of obesity on the rise around the world, SLPs are more than likely to encounter individuals from this population on their caseload. Thus, it is essential that SLPs, as well as other healthcare professionals, understand potential differences in the anatomy and physiology of the swallow in persons who are obese. Although future research should be expanded to include the relationship between obesity and dysphagia, the goal of this study was to provide preliminary descriptive data on the extent of knowledge and impressions of SLPs on the swallow of persons who are obese. This information may not directly benefit patients in a direct clinical manner, but it is a first step in understanding the knowledge base of those that assess, diagnose and treat dysphagia. If subsequent research shows that differences in the swallow do exist between persons who are obese and not obese, the results may provide a guide as to what continuing education may be needed for those working in this area.
Materials and methods Participants Participants in this study were recruited by posting announcements on two popular listserves focused on dysphagia. The first was the American Speech-Language and Hearing Association (ASHA) special interest division (SID 13) and the second listserve was sponsored by the Dysphagia Resource Center (www.dysphagia.com). Instructions for both listserves were included in a cover letter that partially read (along with other information related to institutional review): I would greatly appreciate your participation in a research study that will look at SLPs’ knowledge and impressions of swallowing with people who are obese. This study is intended as a first step to learn more about the temporal and physiological characteristics of the obese swallow compared to non-obese swallow. To do this, you are being asked to complete a confidential questionnaire, which should take no more than 5 minutes of your time. There will be no follow-up contact as the survey will be confidential and anonymous. In an attempt to increase response rate, the announcement for the survey was released on both listserves twice with a 1-month interval. For the second posting, a line was added to the introduction that informed potential respondents that this posting was a duplicate of an earlier posting and to please only respond once. All respondents that accessed the survey during a 2-month time frame and either fully completed or responded to any of the items on the survey were included in the final analysis. The study was also approved by the Institutional Review Board at Towson University, Towson, MD. Survey Instrument The survey was modified from other surveys used in the literature to determine knowledge or impressions of SLPs on feeding tube placement [34], written language [35] and nonspeech oral motor exercises [26]. This survey was developed using questions focused on four primary areas: personal demographics, work experience, extent of knowledge of the obese swallow and impressions of the obese swallow. Questions on the survey were also developed with assistance from two SLPs in the Baltimore, MD, area and who
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were actively working in dysphagia in an acute and/or out-patient setting. The final version of the survey (see Appendix A) was posted on a website that specializes in web-based assessment (www.studentvoice.com). In addition to the multiple choice questions and Likert scales (strongly agree to strongly disagree), there was one open-ended question which asked: ‘‘Are there any other comments that you would like to share about swallowing and persons who are obese?’’ Although obesity is defined in adults by a BMI greater than or equal to 30 (weight divided by height [36]), it should be noted that the survey instrument did not provide a definition of obesity and that respondents were able to use their own working definition. The rationale being that SLPs would rarely have access to a person’s BMI and thus the authors wanted to be consistent and not provide a definition in the survey which may influence the results.
Results A total of 177 participants accessed the survey. Participant and workplace demographic information is displayed in Table 1. The majority of participants were female (91%) who worked full-time (86%) in a hospital or medical setting (96%) with adults (48%) and geriatrics (35%). Mean age of participants was 37.75 years and mean length of practice was 11.5 years. More than 90% of the Table 1. Survey responses to demographic data (total respondents ¼ 177). Participants Variable
Frequency Percentage
Age (yrs) Gender Female Male Work status Full-time Part-time Primary work setting School Hospital/medical Primary patient population Infants Children Adults Geriatrics CCC-SLP Yes No Length of practice Dysphagia education One graduate course Mix of graduate courses Clinical practicum Continuing education Receive education on obese swallow Yes No Treated people who were obese Yes No Treated obese for dysphagia Yes No Patients who were obese Infants Children Adults Geriatrics FEES/MBS Trained Yes No
M
SD
Range
37.75 10.28 22.0–72.0 161 14
90.9 7.9
152 24
85.8 13.6
5 169
2.8 95.5
14 21 155 114
4.6 6.9 51.0 37.5
142 26
80.2 14.7 11.51
121 39 143 151
26.6 8.6 31.5 33.3
1 173
0.6 99.4
164 10
94.2 5.7
142 6
95.9 4.0
20 29 140 102
13.3 19.3 93.3 68.0
127 29
80.9 18.5
9.73
0.083–45.0
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participants reported having treated people who are obese and 96% of the participants reported having treated people who are obese for dysphagia. Survey questions related to the knowledge and training of SLPs and obesity and dysphagia showed that 98% of the respondents either strongly agreed or agreed (67.5% strongly agreed, 30.5% agreed) to the statement ‘‘I feel that I have the appropriate training needed to treat swallowing disorders’’. Three participants (52%) responded with neutral or disagree. In addition, 71.4% of the respondents either strongly agreed or agreed (30.6% strongly agreed, 40.8% agreed) to the statement ‘‘I feel that I have the expertise to assess and treat people who are obese and have a swallowing disorder’’. Twenty-four percent of the respondents were neutral and 5% responded with disagree to this statement. Questions on the survey pertaining to the impressions of SLPs on people who are obese and the obese swallow are shown in Figure 1. When asked specific questions about the temporal and physiological characteristics of the swallow in persons who are obese, results showed less agreement. For instance, 44.6% of the respondents strongly agreed/agreed that the swallow of persons who are obese is the same as the swallow of persons who are not obese while 28% responded that they disagreed/strongly disagreed to this statement.
In addition to the Likert-type survey, participants were also provided the opportunity to provide general comments on swallowing and persons who are obese. A total of 58 respondents posted comments. These responses were analyzed using a method adopted from Creswell [37] and Moustakas [38] and used in the fluency and listener perception research [39,40]. Only those themes that had a minimum frequency count of four were included in the descriptive analysis. Specifically, participants responded to the question, ‘‘Are there any other comments that you would like to share about swallowing and persons who are obese?’’ Themes included (with the frequency count in parentheses): (a) patient size: people who are obese do not typically fit into MBS suites (n ¼ 8); (b) the prevalence of GERD and/or reflux in this population (n ¼ 6); (c) high rates of respiratory complications or shortness of breath (n ¼ 5); (d) difficulty palpating the patient’s swallow (n ¼ 5) and (e) the idea that dysphagia diagnoses are not directly correlated with obesity, but occur due to other medical contraindications (n ¼ 5).
Discussion This study provides descriptive information on the knowledge and impressions of SLPs on the swallow of persons who are obese. Overall, results indicate that nearly all SLPs who responded to the
SLPs Impressions of the Obese Swallow I feel that persons who are obese have the same overall swallow as people who aren’t obese I feel that persons who are obese have the same temporal characteristics (timing) as persons who aren’t obese
Survey Quesons
I feel that persons who are obese have the same strength characteristics as a person that is not obese
I feel that persons who are obese tend to become fatigued more easily Strongly Agree Agree
I feel that persons who are obese are more at risk for swallowing disorders
Neutral Disagree
I feel that persons who are obese are more at risk for swallowing disorders as they become older
Strongly Disagree
I feel that persons who are obese have a less coordinated swallow I feel that persons who are obese are more at risk for swallowing disorders regardless of general medical status
I feel that persons who are obese are more at risk for swallowing disorders due to medical comorbidities 0
10
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20
30 40 50 60 70 80 Number of Respondents
Figure 1. Survey results.
90 100
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survey treat persons who are obese for dysphagia; there is little consensus as to how the obese swallow compares to the normal swallow; there is little consensus as to the characteristics of the obese swallow; and finally, the majority of respondents agreed that persons who are obese are more at risk for dysphagia due to other reasons. It is interesting to note that although nearly all SLPs have treated someone who is obese for dysphagia, only a small percentage (0.6%) reported having received any specific education on the obese swallow. Despite a lack of education on this specific topic and minimal agreement as to the characteristics of the obese swallow, a large proportion (71.4%) of respondents agreed or strongly agreed that they have the appropriate knowledge to assess and treat people who are obese and have a swallowing disorder. Specific information related to the knowledge and impressions of SLPs on the obese swallow is presented below. Knowledge of SLPs on the obese swallow The survey showed that SLPs primarily received their dysphagia education through a graduate course, clinical practicum, and continuing education. Considering the dearth of information on the obese swallow, it was no surprise that nearly all of the SLPs reported not having received any specific education on the swallow of persons who are obese. Since 71% of the respondents stated that they feel comfortable assessing and treating someone who is obese for dysphagia, it may be possible that the SLPs in this study are relying on clinical experience, rather than from information in textbooks and existing research. If this were true though, it stands to reason that it would be reflected in the comments by SLPs (i.e. group comparisons based on clinical experience). However, none of the comments were related to this. With regard to coursework on dysphagia, there is no mention of obesity in the recommended curriculum (e.g. abnormal swallowing/etiology and conditions) for a graduate dysphagia course as directed by the ASHA [41] and the authors are unaware of any continuing education courses on dysphagia that include obesity as a primary or even secondary content area. All of this lack of education and absence of research on the obese swallow is in glaring contrast to the population that the responding SLPs serve. Recall that nearly all SLPs stated that they treat people who are obese and that nearly all have treated persons who are obese for dysphagia. Considering the incidence of obesity in our society and the epidemic that it has become, this discrepancy should prompt future research to begin determining if there are differences in the swallow of persons who are obese and whether or not these differences are attributed to concomitant disorders or solely a result of the obesity. It may ultimately be that obesity, in and of itself, be considered a risk factor for dysphagia due to inherent differences in muscle physiology, respiration and/or vocal tract anatomy. This potential shift in thinking may be analogous to views on the elderly swallow. Research has clearly shown that the swallow of older individuals is distinct from that of younger persons [42,43] across numerous parameters. In fact, research suggests that aging itself is associated with reduced operating reserve of the swallow [44]. The same shift may have also begun in the area of vocal function and obesity. Prior to studies by da Cunha et al. [19] and Solomon et al. [9], the author is unaware of any published research on vocal function by BMI or even overall weight. In addition, currently, there is an increased interest in OSAS and due to the increased prevalence of persons with OSAS being obese, it may provide an opportunity to investigate the baseline functions (e.g. voice, taste and swallow) of persons who are obese. These findings could ultimately provide a basis for future investigations to address the question: Is there a difference
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in the swallow of persons who are obese? In fact, two newly published studies have reported that obesity is associated with adolescent sensorineural hearing loss [45] and decreased volume of gray matter in children [46]. Such findings should provide the opportunity for other fields to determine if differences also exist in other areas. Understanding these potential differences could be an important factor in treating a person who is obese for dysphagia, as well as other disorders, and determining potential risk factors. Impressions of SLPs on the swallow of persons who are obese Results of this survey suggest two themes with regard to SLPs beliefs on swallowing and obesity. First, there is not a consensus among SLPs on the comparison of the swallow of persons who are obese with those who are not obese. This finding is consistent with the paucity of information on the obese swallow but also alarming, given the incidence of obesity in our society as well as the high percentage of SLPs in this study reporting that they have treated people who are obese for dysphagia. Although there was not an overall consensus of the swallow of persons who are obese, two themes did emerge. First, when asked directly if there is a difference between the swallow of persons who are obese and non-obese, results were primarily skewed to the positive (42% strongly agree/agree) rather than the negative (28% strongly disagree/disagree). However, Figure 1 shows that when asked specifically about physiologic or temporal differences, responses were more evenly (i.e. temporal characteristics) or more negatively distributed (i.e. strength characteristics). One possible explanation for this difference may be that SLPs believe that the swallow of persons who are obese is inherently different, although this belief is not borne out with the questions on the survey. The issue of fatigue may also play a role here as 70% of SLPs felt that people who are obese become fatigued more easily. Additional research is warranted to shed light on this potential theme. The second theme that emerged is a majority of SLPs reported people who are obese are more at risk for swallowing disorders. However, it is very important to note though that the SLPs believed that this increased risk is not due to the obesity itself but due to other concomitant factors associated with the obesity. This theme was evidenced by survey questions on the nature of the swallowing disorder. Nearly all respondents replied that people who are obese are more at risk for dysphagia but that this is due to other concomitant disorders or aging. As noted above, there are significant differences between the swallow of young and elderly persons [42] and SLPs most likely receive education on those differences as part of their graduate training (dysphagia course content) or through continuing education. It may be that those healthcare professionals working with dysphagia in a medical setting have more experience with and more awareness of dysphagia associated with aging, respiratory problems, cardiac problems, etc. Specifically, many of those comorbidities are associated with obesity. Thus, that may form the basis of SLP impressions. If future research does show a distinct swallowing profile for persons who are obese that is associated with increased dysphagia or aspiration, then efforts will need to be made to educate healthcare professionals on this shift in thinking. Limitations The primary limitation of this study was the verbiage that was used in selecting questions could have been misleading or misinterpreted. Specifically, three of the survey questions used a comparison between persons who are obese relative to persons who are not obese (e.g. I feel that persons who are obese have the same strength characteristics as a person who is not obese).
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Other questions did not include the comparison (e.g. I feel that persons who are obese have a less coordinated swallow). Additionally, there were questions that were intended to target swallowing function between the two populations but as written, could have been interpreted to relate to overall function (e.g. I feel that persons who are obese have the same strength characteristics as a person who is not obese). A case could be made that a person’s overall function is related to a specific function, for example, overall muscular weakness will be associated weakness in the swallow. However, this was not explicitly stated. As a result of these potential problems with the wording of the survey, results should be interpreted with caution. An additional limitation is that a definition of ‘‘obesity’’ was not provided to survey respondents. Even though BMI may be the most commonly used reference point to determine obesity, it may not be the best indicator or measure of obesity [46,47]. Until there is a consensus as to the best way to represent obesity, it was decided to let the respondents determine their own definition of obesity and not provide a definition or reference point. Similar to other web-based survey studies [35], this study also had several other limitations related to the design. First, the survey was administered via the internet, which immediately restricts participation to those SLPs that use and can navigate the internet. Second, since the word obesity was in the title of the survey, it may be possible that some SLPs who are sensitive to the concept of obesity may not have accessed or completed the survey, thus creating a biased sample from the onset. Third, since geographic location was not collected in the personal demographics, a crosssectional representation cannot be verified. It is possible that responding SLPs were from select geographic areas thus, again providing a limited or even biased sample. Fourth, by using the survey, only those SLPs that chose to respond to the survey were included. This may have created a biased sample in that these respondents were more motivated for some reason compared to other SLPs that did not respond to the survey. Finally, since this study had a sample size of 177, it may be difficult to generalize the results to all SLPs working in dysphagia. Apart from these limitations, since the purpose of this study was only to provide preliminary insight into a topic that is not yet explored in the literature or discussed in clinical settings, the authors hope that the current data will be used as a starting point for future research.
Conclusion Results of this study suggest that there is not a consensus of SLPs impressions of the swallowing characteristics for persons who are obese relative to non-obese individuals, but that persons who are obese are at an increased risk for dysphagia as a result of concomitant disorders associated with obesity. These two findings highlight the need for initial research into the swallow of persons who are obese in hopes of shedding light on the relationship between obesity and dysphagia. Given the high percentage of SLPs in this study that reportedly assess and treat patients who are obese for dysphagia and the increasing worldwide epidemic that obesity has become, investigating and delineating the swallow of persons who are obese should be a priority. In addition to understanding the basic swallowing characteristics of persons who are obese, future research should also address the efficacy of various therapeutic interventions on persons who are obese.
Acknowledgements The authors would like to express their gratitude to all of the respondents for providing their impressions and sharing their thoughts and knowledge. The authors also thank Heather Starmer and Kim Webster from the Department of Otolaryngology-Head
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and Neck Surgery at Johns Hopkins Medical Institute for their invaluable assistance in developing and modifying the survey and Nancy Pearl Solomon for her editorial assistance on a previous version of the manuscript.
Declarations of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Portions of this study were presented at the 2011 ASHA annual convention, San Diego, CA.
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21. Adams N, Ferguson J, Stunkard AJ, Stewart A. The eating behavior of obese and nonobese women. Behav Res Ther 1978;16: 225–32. 22. Leopold NA, Kagel MC. Prepharyngeal dysphagia in Parkinson’s disease. Dysphagia 1996;11:14–22. 23. Pillar G, Shehadeh N. Abdominal fat and sleep apnea: the chicken or the egg? Diabetes Care 2008;31:S303–9. 24. Aragon SB. Surgical management for snoring and sleep apnea. Dent Clin North Am 2001;45:867–79. 25. Li H, Wang P, Hsu C, et al. Same stage palatopharyngeal and hypopharyngeal surgery for severe obstructive sleep apnea. Acta Otolaryngology 2004;124:820–6. 26. Stuck B, Maurer J, Ho¨rmann K. Tongue base reduction with radiofrequency tissue ablation: preliminary results after two treatment sessions. Sleep Breath 2000;4:155–62. 27. Andsberg U, Jessen M. Eight years of follow-up: uvulopalatopharyngoplasty combined with midline glossectomy as a treatment for obstructive sleep apnea syndrome. Acta Otolaryngol 2000;S43: 175–8. 28. Hora F, Na´polis LM, Daltro C. Clinical, anthropometric and upper airway anatomic characteristics of obese patients with obstructive sleep apnea. Respiration 2007;74:517–24. 29. Eslick GD, Talley NJ. Dysphagia: epidemiology, risk factors and impact on quality of life – a population-based study. Aliment Pharmacol Ther 2008;27:971–9. 30. Tibbling L, Gustafsson B. Dysphagia and its consequences in the elderly. Dysphagia 1991;6:200–2. 31. Jia H, Lubetkin EI. The impact of obesity on health-related qualityof-life in the general adult US population. J Public Health (Oxf) 2005;27:156–64. 32. American Speech-Language-Hearing Association. 2009. 2009 Membership survey summary report: Number and type of responses. Rockville (MD): ASHA. 33. American Speech-Language-Hearing Association. 2011. National outcomes measurement system: adults in healthcare–Acute hospital national data report, 2011. Rockville (MD): National Center for Evidence-Based Practice in Communication Disorders. 34. Sharp H, Shega J. Feeding tube placement in patients with advanced dementia: the beliefs and practice patterns of speech-language pathologists. Am J Speech-Lang Pat 2009;18:222–30. 35. Fallon K, Katz L. Providing written language services in the schools: the time is now. Lang Speech Hear Serv 2011;42:3–17. 36. National Institutes of Health. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults – the evidence report. Obes Res 6(Suppl 2) 1998;51S–209S. 37. Creswell, JW. Qualitative inquiry and research design: choosing among five traditions. Thousand Oaks (CA): Sage; 1998. 38. Moustakas, CE. Phenomenological research methods. Thousand Oaks, (CA): Sage; 1994. 39. Panico J, Healey E, Brouwer K, Susca M. Listener perceptions of stuttering across two presentation modes: a quantitative and qualitative approach. J Fluency Disord 2005;30:65–85. 40. Susca M, Healey EC. Perceptions of simulated stuttering and fluency. J Speech Lang Hear Res 2001;44:61–72. 41. American Speech-Language-Hearing Association. 2007. Graduate curriculum on swallowing and swallowing disorders (Adult and pediatric dysphagia) [Technical report] 2007. Available from: http:// www.asha.org/policy/TR2007–00280.htm. 42. Logemann J, Pauloski B, Rademaker A, et al. Temporal and biomechanical characteristics of oropharyngeal swallow in younger and older men. J Speech Lang Hear Res 2000;4:1264–74. 43. Butler S, Stuart A, Castell D, et al. Effects of age, gender, bolus condition, viscosity, and volume on pharyngeal and upper esophageal sphincter pressure and temporal measurements during swallowing. J Speech Lang Hear Res 2009;52:240–53. 44. Robbins J, Levine R, Wood J, et al. Age effects on lingual pressure generation as a risk factor for dysphagia. J Gerontol A Biol Sci Med Sci 1995;50A:M257–62. 45. Lalwani A, Katz K, Liu Y, et al. Obesity is associated with sensoineural hearing loss in adolescents. Laryngoscope 2013;123: 3178–84. 46. Alosco M, Stanek K, Galioto R, et al. Body mass index and brain structure in healthy children and adolescents. Int J Neurosci 2014; 124:49–55. 47. Hughes V. The big fat truth. Nature 2013;497:428–30.
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Appendix A Survey Questionnaire: Obesity and Dysphagia Background information: (1) My work status is (a) Full time (b) Part time (c) I prefer not to respond (2) I was born in the year __________. (3) I am a __________. (a) Female (b) Male (c) I prefer not to respond (4) My primary work setting is (a) School (b) Hospital/medical (c) I prefer not to respond (5) I primarily work with (circle all that apply) (a) infants (b) children (c) adults (d) geriatrics (e) I prefer not to respond (6) I have my CCC-SLP (a) Yes (b) No (c) I prefer not to respond (7) I have been practicing Speech-Language Pathology for _____ years. (8) I have been working with individuals with dysphagia for ______ years. (9) Where did you receive your education on dysphagia (please mark all that apply)? (a) Dedicated course on dysphagia in graduate school (b) Mixture of courses in graduate school (c) Clinical practicum (d) Continuing education opportunities (e) I prefer not to respond (10) If you circled any responses in the above question (#9), did you receive any education on the swallow of people who are obese? (a) Yes If so, which classes? _________________________ (b) No (c) I prefer not to respond (11) Have you every treated someone that you would consider to be obese? (a) Yes (b) No (c) I prefer not to respond (12) If you answered Yes to the above question (#11), did you treat the person(s) for dysphagia? Please leave blank if you answered No to the above question. (a) Yes (b) No (c) I prefer not to respond (13) Approximately how many people that were obese would you say that you have treated as a Speech-Language Pathologist? (a) 0–10 (b) 11–20 (c) 21–30 (d) 31–40 (e) 41–50 (f) 450 (g) I prefer not to respond (14) Of those persons that you treated that were obese, please indicate what percent fell into the following categories: (a) Infant _______% (b) Children _______% (c) Adults ________% (d) Geriatrics _______% (e) I prefer not to respond (15) Do you have specialty training in FEES or VFSS/MBS? (a) Yes (b) No
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(c) I prefer not to respond (16) Are there any other comments that you would like to share about swallowing and persons who are obese?
Knowledge and preparedness: Please use the following scale to rate the statements below:
Strongly Agree I feel that I have the appropriate training needed to treat swallowing disorders. I feel that I have the expertise to assess and treat people who are obese and have a swallowing disorder. I feel persons who are obese have the same overall swallow as people that aren’t obese. I feel that persons who are obese have the same temporal characteristics (timing) as people that aren’t obese. I feel that persons who are obese have the same strength characteristics as a person that is not obese. I feel that persons who are obese tend to become fatigued more easily. I feel that persons who are obese are more at risk for swallowing disorders. I feel that persons who are obese are more at risk for swallowing disorders as they become older. I feel that persons who are obese have a less coordinated swallow. I feel that persons who are obese are more at risk for swallowing disorders regardless of general medical status. I feel that persons who are obese are more at risk for swallowing disorders due to medical co morbidities.
Agree
Neutral
Disagree
Strongly Disagree
Prefer not to respond
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REHABILITATION IN PRACTICE
Current knowledge and impressions of speech-language pathologists of the swallow of persons who are obese Paul M. Evitts1, Michelle Kopf2, and Megan Kauffman3 1
Department of Audiology, Speech-Language Pathology, and Deaf Studies, Towson University, Towson, MD, USA, 2Department of Speech-Language Pathology, Hershey Medical Center, Hershey PA, USA, and 3Department of Speech-Language Pathology, Kennedy Krieger Institute, Baltimore MD, USA Abstract
Keywords
Purpose: The overall goal of this study was to provide insight on the topic of dysphagia in the obese population. More specifically, the purpose of this study was to obtain preliminary descriptive data on the knowledge and impressions of speech-language pathologists (SLPs) working in the field of dysphagia on the swallow of persons who are obese. Methods: One hundred seventy-seven SLPs responded to a web-based survey that was posted on two popular listserves that serve the dysphagia community. Results: Descriptive results showed that nearly all SLPs have assessed and treated patients who are obese for dysphagia, that there is little consensus as to how the obese swallow compares to the normal swallow, and that there is a consensus that dysphagia observed in the obese population is most likely related to other concomitant disorders. Conclusions: Results provide preliminary insight into the knowledge and impressions of SLPs working with dysphagia and highlight the need for future research to determine (1) if there is an increased incidence of dysphagia in the obese population, and (2) if obesity itself constitutes a risk factor for dysphagia or if any dysphagia observed in this population is related to other comorbidities.
Deglutition, deglutition disorders, dysphagia, obesity, swallowing muscles History Received 18 October 2013 Revised 27 February 2014 Accepted 5 March 2014 Published online 26 March 2014
ä Implications for Rehabilitation
Many healthcare professionals (i.e. speech-language pathologists [SLPs]) assess, diagnose and treat individuals for swallowing disorders who are obese in the absence of research or evidence-based medicine on the impact of obesity on the swallow or the impact of obesity on dysphagia rehabilitation (e.g. swallowing exercises). Results of this study suggest that: there is not a consensus among SLPs on the swallowing characteristics of persons who are obese; that persons who are obese are more at risk for swallowing disorders; and that the increased risk of dysphagia may be related to concomitant disorders and not the presence of obesity itself. Clinicians who work with dysphagia need to understand the impact of obesity on the swallow and on dysphagia rehabilitation with persons who are obese. Future research should focus on establishing estimates of swallowing function in persons who are obese. This information can provide a foundation for efficacy studies of various therapy techniques (e.g. exercises) and ultimately can assist with goal setting and intervention planning.
Introduction Obesity is a major public health problem and has been recognized as a worldwide epidemic [1]. In 2005, nearly 1.6 billion adults and 20 million children were considered to be overweight [2]. It is estimated that by 2015, approximately 2.3 billion adults will be overweight and more than 700 million adults will be obese [2]. In addition, obesity-related deaths outnumber all other preventable deaths in the United States except for tobacco-related
Address for correspondence: Paul M. Evitts, Department of Audiology, Speech-Language Pathology & Deaf Studies, 8000 York Road, Towson University, Towson, MD 21252, USA. Tel: 410-704-3860. Fax: 410-7044131. E-mail: [email protected]
mortalities [3]. According to the Organization for Economic Cooperation and Development [4], the top five countries with the highest percentage of obesity were the United States, Mexico, United Kingdom, Slovakia, Greece and Australia with obesity rates of 30.6%, 24.2%, 23%, 22.4%, 21.9% and 21.78%, respectively. When including persons who are overweight, an estimated 54% of the Australian population, for example, is considered to be obese or overweight [5]. Although some recent figures show a plateau in these prevalence rates [1], obesity still represents a major health epidemic. One of the primary reasons for the epidemic status is because of the increased risk for developing multiple health conditions associated with obesity, including diabetes, hypertension, high cholesterol, stroke, and certain cancers, among others [1]. In fact, obesity represents the leading
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cause of preventable death and is associated with an estimated 200,000 deaths per year in the United States [6]. Apart from the health-related consequences, obesity-related medical costs in the United States, for example, accounted for an estimated $147 billion dollars in 2008 [7]. Clearly, obesity represents a major healthcare problem that healthcare professionals will be increasingly exposed due to the number of comorbidities and concomitant disorders within this population. Because of this anticipated increased exposure, it is important that these professionals be aware that people who are obese have marked differences in muscle physiology, anatomy and respiration, among other areas. For example, respiratory muscles have been shown to work harder in obese patients compared to typical weight individuals [8], which has been associated with increased adiposity (additional lipids infiltrating the muscle mass) around the respiratory system [9]. Persons who are obese have also been shown to have differences in gas exchange rates, respiratory mechanics, breathing patterns, lung volumes, as well as other respiratory measures [10]. With regard to muscle physiology, greater fat infiltration into muscle and lower muscle mass, both of which may be found with persons who are obese, have been associated with a higher risk for loss of mobility, especially with increased age [11]. Additionally, in a large-scale study (n ¼ 2627) investigating the effects of aging and obesity on muscle function, Goodpaster et al. [12] found that muscle density and strength/ torque decreases as body mass index (BMI), total body fat and total percent fat increases [12]. Although numerous other studies exist and are not presented here, the overall consensus of this body of literature is that differences in muscle function, including respiratory, exist between people who are obese and their lean counterparts. The majority of these associations between obesity and differences in muscle strength, however, are typically derived from studies on upper and lower extremities and therefore it may not be appropriate to extrapolate these results to the muscles associated with speech and swallowing. There is evidence delineating the inherent differences between speech/swallow muscles and limb muscles both in composition and patterns of aging [13,14]. Rather than providing a full review of the literature (please see Ref. [13] for a thorough review of the speech motor system), a few key points are presented. First, the biomechanical and histological features of the speech/swallow muscles are different than the limb skeletal muscles [14]. For instance, laryngeal muscles have a different composition of myosin heavy chain fibers that produce shortening rates nearly double the rate of limb muscles [15]. In addition, the composition of muscle fibers in the tongue is different from the limbs, as well as other masticatory and orofacial muscles [16]. Second, muscles of deglutition and mastication may follow different aging patterns than limb muscles. For example, cross-sectional area of locomotive muscles begins to decline after the fifth decade whereas the cross-sectional area of lingual muscles has been shown to increase at 70 years [17]. Finally, the tongue provides arguably the best example of how difficult it is to generalize information from the limbs to the swallowing musculature. The tongue is a hydrostat, has no skeletal framework, and thus has unique biomechanical properties [18], especially in relation to the limbs. Given these significant differences in muscle composition and function between speech/swallow and limb muscles, and the marked differences between obese and thin muscle function, it is reasonable to suspect that differences exist in speech, swallowing and voice between persons who are obese and their lean counterparts. However, few studies have explored these potential differences. da Cunha et al. [19] compared vocal function in persons who are obese (n ¼ 45, BMI435) to normal-weight (n ¼ 45, BMI530) individuals using laryngoscopic examination
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(e.g. presence of hypertrophy), subjective ratings of voice quality and acoustic analysis (e.g. jitter, shimmer). Results showed significant differences in all three measures between the two groups. da Cunha et al. [19] attributed the differences in voice to increased vocal fold aperiodicity, increased presence of laryngopharyngeal reflux and increased respiratory difficulties in persons who are obese. In a similar study, Solomon et al. [9] investigated the effect of obesity on vocal function by using visual-perceptual (nasal endoscopy), acoustic and subjective ratings of voice quality, and aeromechanics in eight obese (BMI435) and eight age- and gender-matched non-obese (BMI530) individuals. Results in the Solomon et al.’s study [9] were in contrast to the da Cunha et al.’s study [19] in that no significant differences were found between the groups. Clearly, more research needs to be conducted to shed more light on the impact that obesity has on vocal function. With regard to swallowing, specific research exists on feeding and drinking patterns that suggests potential differences in the overall swallow may exist between these two groups. For instance, persons who are obese may eat faster, have longer overall meal durations, and have different drinking patterns than lean persons [20]. Furthermore, research conducted on eating differences in women who are obese and not obese showed that women who are obese spent less time chewing and more time drinking fluids [21]. Such differences in rate and volume may be considered prepharyngeal impairments [22] and an argument could be made that these prepharyngeal impairments or differences may ultimately place the obese individual at an increased risk for dysphagia. Other than data on feeding and drinking patterns, the authors are unaware of any research on the temporal or biomechanical characteristics of the swallow in persons who are obese. Again, considering the marked differences in muscle physiology, respiratory function and eating/drinking differences between persons who are obese and their thin counterparts, it is reasonable to suspect physiological and/or temporal differences in the stages of the swallow for persons who are obese. Perhaps the best example of the potential impact of obesity on the physiological function of the oropharyngeal region is obstructive sleep apnea syndrome (OSAS). It has been estimated that 30% of the obese population and 50–98% of the morbidly obese population have OSAS [23]. This is especially pertinent as persons with OSAS often present with ‘‘disproportionate anatomy’’, or increased size of the velum, uvula and base of tongue but a smaller mandible [24], and treatment may involve surgical resection of parts of these areas. Although there are different surgical techniques for treatment of OSAS (e.g. uvulopalatopharyngoplasty), existing research has not objectively addressed differences in swallowing, speech or taste pre-surgery and postsurgery but instead has used subjective means of determining differences [25–28]. More research is needed to compare the swallow (and speech) of persons who are obese and present with OSAS and their typical-weight counterparts to determine if objective differences exist. Even with all of the differences in muscle physiology, respiration, vocal tract anatomy and feeding/drinking styles between persons who are obese and persons who are not obese, one of the greatest difficulties in exploring this line of research is isolating the effects of obesity on swallowing function from the comorbidities associated with obesity. Research has been provided that in the least suggests a relationship between obesity and dysphagia (e.g. muscular weakness). However, this relationship may only be correlational and not causal [29–31]. If future research does indeed show a direct relationship, dysphagia may be identified as a risk factor for obesity. As a first step in attempting to better understand the potential differences in the swallow of persons who are obese, it is prudent
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to investigate the current impressions and knowledge of speechlanguage pathologists (SLPs) who routinely work with dysphagia in a healthcare setting. SLPs were targeted as it has been estimated that up to 61% of an SLP caseload consists of patients with dysphagia [32] and that nearly 90% of patients seen by an SLP in an acute care setting were diagnosed with dysphagia [33]. With rates of obesity on the rise around the world, SLPs are more than likely to encounter individuals from this population on their caseload. Thus, it is essential that SLPs, as well as other healthcare professionals, understand potential differences in the anatomy and physiology of the swallow in persons who are obese. Although future research should be expanded to include the relationship between obesity and dysphagia, the goal of this study was to provide preliminary descriptive data on the extent of knowledge and impressions of SLPs on the swallow of persons who are obese. This information may not directly benefit patients in a direct clinical manner, but it is a first step in understanding the knowledge base of those that assess, diagnose and treat dysphagia. If subsequent research shows that differences in the swallow do exist between persons who are obese and not obese, the results may provide a guide as to what continuing education may be needed for those working in this area.
Materials and methods Participants Participants in this study were recruited by posting announcements on two popular listserves focused on dysphagia. The first was the American Speech-Language and Hearing Association (ASHA) special interest division (SID 13) and the second listserve was sponsored by the Dysphagia Resource Center (www.dysphagia.com). Instructions for both listserves were included in a cover letter that partially read (along with other information related to institutional review): I would greatly appreciate your participation in a research study that will look at SLPs’ knowledge and impressions of swallowing with people who are obese. This study is intended as a first step to learn more about the temporal and physiological characteristics of the obese swallow compared to non-obese swallow. To do this, you are being asked to complete a confidential questionnaire, which should take no more than 5 minutes of your time. There will be no follow-up contact as the survey will be confidential and anonymous. In an attempt to increase response rate, the announcement for the survey was released on both listserves twice with a 1-month interval. For the second posting, a line was added to the introduction that informed potential respondents that this posting was a duplicate of an earlier posting and to please only respond once. All respondents that accessed the survey during a 2-month time frame and either fully completed or responded to any of the items on the survey were included in the final analysis. The study was also approved by the Institutional Review Board at Towson University, Towson, MD. Survey Instrument The survey was modified from other surveys used in the literature to determine knowledge or impressions of SLPs on feeding tube placement [34], written language [35] and nonspeech oral motor exercises [26]. This survey was developed using questions focused on four primary areas: personal demographics, work experience, extent of knowledge of the obese swallow and impressions of the obese swallow. Questions on the survey were also developed with assistance from two SLPs in the Baltimore, MD, area and who
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were actively working in dysphagia in an acute and/or out-patient setting. The final version of the survey (see Appendix A) was posted on a website that specializes in web-based assessment (www.studentvoice.com). In addition to the multiple choice questions and Likert scales (strongly agree to strongly disagree), there was one open-ended question which asked: ‘‘Are there any other comments that you would like to share about swallowing and persons who are obese?’’ Although obesity is defined in adults by a BMI greater than or equal to 30 (weight divided by height [36]), it should be noted that the survey instrument did not provide a definition of obesity and that respondents were able to use their own working definition. The rationale being that SLPs would rarely have access to a person’s BMI and thus the authors wanted to be consistent and not provide a definition in the survey which may influence the results.
Results A total of 177 participants accessed the survey. Participant and workplace demographic information is displayed in Table 1. The majority of participants were female (91%) who worked full-time (86%) in a hospital or medical setting (96%) with adults (48%) and geriatrics (35%). Mean age of participants was 37.75 years and mean length of practice was 11.5 years. More than 90% of the Table 1. Survey responses to demographic data (total respondents ¼ 177). Participants Variable
Frequency Percentage
Age (yrs) Gender Female Male Work status Full-time Part-time Primary work setting School Hospital/medical Primary patient population Infants Children Adults Geriatrics CCC-SLP Yes No Length of practice Dysphagia education One graduate course Mix of graduate courses Clinical practicum Continuing education Receive education on obese swallow Yes No Treated people who were obese Yes No Treated obese for dysphagia Yes No Patients who were obese Infants Children Adults Geriatrics FEES/MBS Trained Yes No
M
SD
Range
37.75 10.28 22.0–72.0 161 14
90.9 7.9
152 24
85.8 13.6
5 169
2.8 95.5
14 21 155 114
4.6 6.9 51.0 37.5
142 26
80.2 14.7 11.51
121 39 143 151
26.6 8.6 31.5 33.3
1 173
0.6 99.4
164 10
94.2 5.7
142 6
95.9 4.0
20 29 140 102
13.3 19.3 93.3 68.0
127 29
80.9 18.5
9.73
0.083–45.0
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participants reported having treated people who are obese and 96% of the participants reported having treated people who are obese for dysphagia. Survey questions related to the knowledge and training of SLPs and obesity and dysphagia showed that 98% of the respondents either strongly agreed or agreed (67.5% strongly agreed, 30.5% agreed) to the statement ‘‘I feel that I have the appropriate training needed to treat swallowing disorders’’. Three participants (52%) responded with neutral or disagree. In addition, 71.4% of the respondents either strongly agreed or agreed (30.6% strongly agreed, 40.8% agreed) to the statement ‘‘I feel that I have the expertise to assess and treat people who are obese and have a swallowing disorder’’. Twenty-four percent of the respondents were neutral and 5% responded with disagree to this statement. Questions on the survey pertaining to the impressions of SLPs on people who are obese and the obese swallow are shown in Figure 1. When asked specific questions about the temporal and physiological characteristics of the swallow in persons who are obese, results showed less agreement. For instance, 44.6% of the respondents strongly agreed/agreed that the swallow of persons who are obese is the same as the swallow of persons who are not obese while 28% responded that they disagreed/strongly disagreed to this statement.
In addition to the Likert-type survey, participants were also provided the opportunity to provide general comments on swallowing and persons who are obese. A total of 58 respondents posted comments. These responses were analyzed using a method adopted from Creswell [37] and Moustakas [38] and used in the fluency and listener perception research [39,40]. Only those themes that had a minimum frequency count of four were included in the descriptive analysis. Specifically, participants responded to the question, ‘‘Are there any other comments that you would like to share about swallowing and persons who are obese?’’ Themes included (with the frequency count in parentheses): (a) patient size: people who are obese do not typically fit into MBS suites (n ¼ 8); (b) the prevalence of GERD and/or reflux in this population (n ¼ 6); (c) high rates of respiratory complications or shortness of breath (n ¼ 5); (d) difficulty palpating the patient’s swallow (n ¼ 5) and (e) the idea that dysphagia diagnoses are not directly correlated with obesity, but occur due to other medical contraindications (n ¼ 5).
Discussion This study provides descriptive information on the knowledge and impressions of SLPs on the swallow of persons who are obese. Overall, results indicate that nearly all SLPs who responded to the
SLPs Impressions of the Obese Swallow I feel that persons who are obese have the same overall swallow as people who aren’t obese I feel that persons who are obese have the same temporal characteristics (timing) as persons who aren’t obese
Survey Quesons
I feel that persons who are obese have the same strength characteristics as a person that is not obese
I feel that persons who are obese tend to become fatigued more easily Strongly Agree Agree
I feel that persons who are obese are more at risk for swallowing disorders
Neutral Disagree
I feel that persons who are obese are more at risk for swallowing disorders as they become older
Strongly Disagree
I feel that persons who are obese have a less coordinated swallow I feel that persons who are obese are more at risk for swallowing disorders regardless of general medical status
I feel that persons who are obese are more at risk for swallowing disorders due to medical comorbidities 0
10
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20
30 40 50 60 70 80 Number of Respondents
Figure 1. Survey results.
90 100
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survey treat persons who are obese for dysphagia; there is little consensus as to how the obese swallow compares to the normal swallow; there is little consensus as to the characteristics of the obese swallow; and finally, the majority of respondents agreed that persons who are obese are more at risk for dysphagia due to other reasons. It is interesting to note that although nearly all SLPs have treated someone who is obese for dysphagia, only a small percentage (0.6%) reported having received any specific education on the obese swallow. Despite a lack of education on this specific topic and minimal agreement as to the characteristics of the obese swallow, a large proportion (71.4%) of respondents agreed or strongly agreed that they have the appropriate knowledge to assess and treat people who are obese and have a swallowing disorder. Specific information related to the knowledge and impressions of SLPs on the obese swallow is presented below. Knowledge of SLPs on the obese swallow The survey showed that SLPs primarily received their dysphagia education through a graduate course, clinical practicum, and continuing education. Considering the dearth of information on the obese swallow, it was no surprise that nearly all of the SLPs reported not having received any specific education on the swallow of persons who are obese. Since 71% of the respondents stated that they feel comfortable assessing and treating someone who is obese for dysphagia, it may be possible that the SLPs in this study are relying on clinical experience, rather than from information in textbooks and existing research. If this were true though, it stands to reason that it would be reflected in the comments by SLPs (i.e. group comparisons based on clinical experience). However, none of the comments were related to this. With regard to coursework on dysphagia, there is no mention of obesity in the recommended curriculum (e.g. abnormal swallowing/etiology and conditions) for a graduate dysphagia course as directed by the ASHA [41] and the authors are unaware of any continuing education courses on dysphagia that include obesity as a primary or even secondary content area. All of this lack of education and absence of research on the obese swallow is in glaring contrast to the population that the responding SLPs serve. Recall that nearly all SLPs stated that they treat people who are obese and that nearly all have treated persons who are obese for dysphagia. Considering the incidence of obesity in our society and the epidemic that it has become, this discrepancy should prompt future research to begin determining if there are differences in the swallow of persons who are obese and whether or not these differences are attributed to concomitant disorders or solely a result of the obesity. It may ultimately be that obesity, in and of itself, be considered a risk factor for dysphagia due to inherent differences in muscle physiology, respiration and/or vocal tract anatomy. This potential shift in thinking may be analogous to views on the elderly swallow. Research has clearly shown that the swallow of older individuals is distinct from that of younger persons [42,43] across numerous parameters. In fact, research suggests that aging itself is associated with reduced operating reserve of the swallow [44]. The same shift may have also begun in the area of vocal function and obesity. Prior to studies by da Cunha et al. [19] and Solomon et al. [9], the author is unaware of any published research on vocal function by BMI or even overall weight. In addition, currently, there is an increased interest in OSAS and due to the increased prevalence of persons with OSAS being obese, it may provide an opportunity to investigate the baseline functions (e.g. voice, taste and swallow) of persons who are obese. These findings could ultimately provide a basis for future investigations to address the question: Is there a difference
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in the swallow of persons who are obese? In fact, two newly published studies have reported that obesity is associated with adolescent sensorineural hearing loss [45] and decreased volume of gray matter in children [46]. Such findings should provide the opportunity for other fields to determine if differences also exist in other areas. Understanding these potential differences could be an important factor in treating a person who is obese for dysphagia, as well as other disorders, and determining potential risk factors. Impressions of SLPs on the swallow of persons who are obese Results of this survey suggest two themes with regard to SLPs beliefs on swallowing and obesity. First, there is not a consensus among SLPs on the comparison of the swallow of persons who are obese with those who are not obese. This finding is consistent with the paucity of information on the obese swallow but also alarming, given the incidence of obesity in our society as well as the high percentage of SLPs in this study reporting that they have treated people who are obese for dysphagia. Although there was not an overall consensus of the swallow of persons who are obese, two themes did emerge. First, when asked directly if there is a difference between the swallow of persons who are obese and non-obese, results were primarily skewed to the positive (42% strongly agree/agree) rather than the negative (28% strongly disagree/disagree). However, Figure 1 shows that when asked specifically about physiologic or temporal differences, responses were more evenly (i.e. temporal characteristics) or more negatively distributed (i.e. strength characteristics). One possible explanation for this difference may be that SLPs believe that the swallow of persons who are obese is inherently different, although this belief is not borne out with the questions on the survey. The issue of fatigue may also play a role here as 70% of SLPs felt that people who are obese become fatigued more easily. Additional research is warranted to shed light on this potential theme. The second theme that emerged is a majority of SLPs reported people who are obese are more at risk for swallowing disorders. However, it is very important to note though that the SLPs believed that this increased risk is not due to the obesity itself but due to other concomitant factors associated with the obesity. This theme was evidenced by survey questions on the nature of the swallowing disorder. Nearly all respondents replied that people who are obese are more at risk for dysphagia but that this is due to other concomitant disorders or aging. As noted above, there are significant differences between the swallow of young and elderly persons [42] and SLPs most likely receive education on those differences as part of their graduate training (dysphagia course content) or through continuing education. It may be that those healthcare professionals working with dysphagia in a medical setting have more experience with and more awareness of dysphagia associated with aging, respiratory problems, cardiac problems, etc. Specifically, many of those comorbidities are associated with obesity. Thus, that may form the basis of SLP impressions. If future research does show a distinct swallowing profile for persons who are obese that is associated with increased dysphagia or aspiration, then efforts will need to be made to educate healthcare professionals on this shift in thinking. Limitations The primary limitation of this study was the verbiage that was used in selecting questions could have been misleading or misinterpreted. Specifically, three of the survey questions used a comparison between persons who are obese relative to persons who are not obese (e.g. I feel that persons who are obese have the same strength characteristics as a person who is not obese).
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Other questions did not include the comparison (e.g. I feel that persons who are obese have a less coordinated swallow). Additionally, there were questions that were intended to target swallowing function between the two populations but as written, could have been interpreted to relate to overall function (e.g. I feel that persons who are obese have the same strength characteristics as a person who is not obese). A case could be made that a person’s overall function is related to a specific function, for example, overall muscular weakness will be associated weakness in the swallow. However, this was not explicitly stated. As a result of these potential problems with the wording of the survey, results should be interpreted with caution. An additional limitation is that a definition of ‘‘obesity’’ was not provided to survey respondents. Even though BMI may be the most commonly used reference point to determine obesity, it may not be the best indicator or measure of obesity [46,47]. Until there is a consensus as to the best way to represent obesity, it was decided to let the respondents determine their own definition of obesity and not provide a definition or reference point. Similar to other web-based survey studies [35], this study also had several other limitations related to the design. First, the survey was administered via the internet, which immediately restricts participation to those SLPs that use and can navigate the internet. Second, since the word obesity was in the title of the survey, it may be possible that some SLPs who are sensitive to the concept of obesity may not have accessed or completed the survey, thus creating a biased sample from the onset. Third, since geographic location was not collected in the personal demographics, a crosssectional representation cannot be verified. It is possible that responding SLPs were from select geographic areas thus, again providing a limited or even biased sample. Fourth, by using the survey, only those SLPs that chose to respond to the survey were included. This may have created a biased sample in that these respondents were more motivated for some reason compared to other SLPs that did not respond to the survey. Finally, since this study had a sample size of 177, it may be difficult to generalize the results to all SLPs working in dysphagia. Apart from these limitations, since the purpose of this study was only to provide preliminary insight into a topic that is not yet explored in the literature or discussed in clinical settings, the authors hope that the current data will be used as a starting point for future research.
Conclusion Results of this study suggest that there is not a consensus of SLPs impressions of the swallowing characteristics for persons who are obese relative to non-obese individuals, but that persons who are obese are at an increased risk for dysphagia as a result of concomitant disorders associated with obesity. These two findings highlight the need for initial research into the swallow of persons who are obese in hopes of shedding light on the relationship between obesity and dysphagia. Given the high percentage of SLPs in this study that reportedly assess and treat patients who are obese for dysphagia and the increasing worldwide epidemic that obesity has become, investigating and delineating the swallow of persons who are obese should be a priority. In addition to understanding the basic swallowing characteristics of persons who are obese, future research should also address the efficacy of various therapeutic interventions on persons who are obese.
Acknowledgements The authors would like to express their gratitude to all of the respondents for providing their impressions and sharing their thoughts and knowledge. The authors also thank Heather Starmer and Kim Webster from the Department of Otolaryngology-Head
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and Neck Surgery at Johns Hopkins Medical Institute for their invaluable assistance in developing and modifying the survey and Nancy Pearl Solomon for her editorial assistance on a previous version of the manuscript.
Declarations of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Portions of this study were presented at the 2011 ASHA annual convention, San Diego, CA.
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Appendix A Survey Questionnaire: Obesity and Dysphagia Background information: (1) My work status is (a) Full time (b) Part time (c) I prefer not to respond (2) I was born in the year __________. (3) I am a __________. (a) Female (b) Male (c) I prefer not to respond (4) My primary work setting is (a) School (b) Hospital/medical (c) I prefer not to respond (5) I primarily work with (circle all that apply) (a) infants (b) children (c) adults (d) geriatrics (e) I prefer not to respond (6) I have my CCC-SLP (a) Yes (b) No (c) I prefer not to respond (7) I have been practicing Speech-Language Pathology for _____ years. (8) I have been working with individuals with dysphagia for ______ years. (9) Where did you receive your education on dysphagia (please mark all that apply)? (a) Dedicated course on dysphagia in graduate school (b) Mixture of courses in graduate school (c) Clinical practicum (d) Continuing education opportunities (e) I prefer not to respond (10) If you circled any responses in the above question (#9), did you receive any education on the swallow of people who are obese? (a) Yes If so, which classes? _________________________ (b) No (c) I prefer not to respond (11) Have you every treated someone that you would consider to be obese? (a) Yes (b) No (c) I prefer not to respond (12) If you answered Yes to the above question (#11), did you treat the person(s) for dysphagia? Please leave blank if you answered No to the above question. (a) Yes (b) No (c) I prefer not to respond (13) Approximately how many people that were obese would you say that you have treated as a Speech-Language Pathologist? (a) 0–10 (b) 11–20 (c) 21–30 (d) 31–40 (e) 41–50 (f) 450 (g) I prefer not to respond (14) Of those persons that you treated that were obese, please indicate what percent fell into the following categories: (a) Infant _______% (b) Children _______% (c) Adults ________% (d) Geriatrics _______% (e) I prefer not to respond (15) Do you have specialty training in FEES or VFSS/MBS? (a) Yes (b) No
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(c) I prefer not to respond (16) Are there any other comments that you would like to share about swallowing and persons who are obese?
Knowledge and preparedness: Please use the following scale to rate the statements below:
Strongly Agree I feel that I have the appropriate training needed to treat swallowing disorders. I feel that I have the expertise to assess and treat people who are obese and have a swallowing disorder. I feel persons who are obese have the same overall swallow as people that aren’t obese. I feel that persons who are obese have the same temporal characteristics (timing) as people that aren’t obese. I feel that persons who are obese have the same strength characteristics as a person that is not obese. I feel that persons who are obese tend to become fatigued more easily. I feel that persons who are obese are more at risk for swallowing disorders. I feel that persons who are obese are more at risk for swallowing disorders as they become older. I feel that persons who are obese have a less coordinated swallow. I feel that persons who are obese are more at risk for swallowing disorders regardless of general medical status. I feel that persons who are obese are more at risk for swallowing disorders due to medical co morbidities.
Agree
Neutral
Disagree
Strongly Disagree
Prefer not to respond
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