Study Reveals The long-term negative effects of face coverings on ventilatory function

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These are very revealing excerpts from a professional university medical study conducted in Saudi Arabia in 2012, on the health effects of using of face coverings "niqab". The study used 38 young healthy non-smoking and non-obese women. 18 of them wore face coverings for 4 or more hours per day and the rest did not. Note that in many references the doctors compare the effects with those of face masks.

Wikipedia notes " A niqāb or niqaab (/nɪˈkɑːb/; Arabic: نِقاب‎ niqāb, "[face] veil"), also called a ruband, is a garment of clothing that covers the face, worn by some Muslim women as a part of a particular interpretation of hijab (modest dress)."

Below are excerpts. For the short version read only the parts in bold text. The most interesting parts I notated with 3 ### symbols .

You can download a PDF of the study here.

The long-term effect of  face coverings on ventilatory function (VF)

Effect of face veil on ventilatory function among Saudi adult females

Objective: The use of face veil called “niqab” by women to cover their faces at public places is a common practice in some Muslim communities. The long-term effect of niqab use on ventilatory function (VF) has not previously been reported. 

The aim of this cross-sectional study was to compare VF between niqab wearing and non-niqab wearing healthy Saudi females. Methodology: Thirty eight healthy adult Saudi females participated in this study. Nineteen subjects were regular niqab users and the other nineteen were either not using niqab at all or used it for less than one hour per day. Forced vital capacity (FVC), forced expiratory volume in one second (FEV1), FEV1/FVC (%), and maximal voluntary ventilation (MVV) were recorded using a digital spirometer.

Results: Mean values of FVC, FEV1, FEV1/FVC (%) and MVV for niqab wearers were significantly lower than the corresponding values for non-niqab wearers. 

Significant negative correlation was found between the FVC and FEV1 values and the number of hours of the use of face veil per day.

Conclusions: Long-term use of traditional niqab use can affect VF.  How to cite this article: Alghadir A, Aly F, Zafar H. Effect of face veil on ventilatory function among Saudi adult females. Pak J Med Sci 2012;28(1):71-74

Free and unobstructed airflow in the upper and lower respiratory tract during inspiration and ex- piration is a prerequisite for normal respiratory function. Any pathological or non-pathological condition that can compromise free airflow during respiratory cycle can result in hypoventilation with increased respiratory effort that can lead to physi- ological burden involving cardiovascular1-3 and temperature regulatory system,1 and can also cause psychological stresses.4

A large body of knowledge exists about possible mechanisms and short- and long-term physiological responses for different pathological airflow limiting conditions, involving the respiratory system endog- enously, such as obstructive sleep apnea,5 chronic obstructive pulmonary disease and asthma.6

How- ever, studies on physiological responses to external airflow limiting factors such as surgical and protective masks, are relatively few. Use of facemasks of different air permeability can cause changes in temperature and humidity in the microclimates of the facemasks, causing different effects on heart rate, thermal stress and perception of discomfort.7 It is also shown that 1-4 hours use of surgical masks during surgeries can result in decreased arterial oxygen saturation levels and increased pulse rate in surgeons.8###

In some Muslim communities, women use face veil called “niqab” to cover their faces at public places. The use of niqab is more common in Arab gulf countries, and in Saudi Arabia it is a cultural norm and a social obligation for Saudi women to wear niqab at public places. ### Due to the similarity in which the use of facial mask and niqab can interfere with the normal airflow during respiration, it can be reasonable to draw an analogy between the use of facial masks and niqab with regard to the physiological responses.

 However, to the best of our knowledge, no previous data on physiological impact for short- or long-term use of niqab on the VF is available. 

The spirometry data can help to study respiratory function and dysfunction in different condi- tions and diseases affecting the airflow in lungs during respiration,9 and can also provide informa- tion about breathing reserve and exercise tolerance to determine fitness levels of healthy subjects.10

###  For spirometry, the most commonly used parameters are vital capacity (VC), forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and maximal voluntary ventilation (MVV). The VC is the maximum volume of air that can be expelled from the lungs after a maximum inspiration, FVC is the volume of air that can forcibly be blown out after full inspiration, FEV1 is the maximum volume of air that can be forcibly blown out in the first sec- ond during the FVC manoeuvre, and MVV is the maximum volume of air that can be inhaled and ex- haled in one minute.11 

These VF values are gender dependent with lower values in females.12 We have previously shown that the parameters of VF tests in Saudi subjects are lower than the Caucasian reference values, and these gender related differences for Saudi adults is larger than corresponding differences in Caucasian population.13 ### Based on the analogy between the use of facial masks and niqab with regard to the physiological responses, it can be assumed that the long-term use of niqab can have an impact on the VF of its user. It is hypoth- esized that the VF values would be lower for face veil users than non-face veil users. The aim of this study was to compare VF values off face veil users and non-face veil users among healthy Saudi adult females.

MethodOLOGY Subjects: Thirty eight healthy Saudi females (aged 18-31 years; mean age 24) participated in this study. Nineteen subjects were regular niqab users (mini- mum of 3 years for 4 hours per day) (veil group), and nineteen subjects were either not using niqab at all or for less than one hour per day (non-veil group). Users of any tobacco products and obese subjects with body mass index (BMI) >25kg/m2 were excluded. General characteristics of subjects are shown in Table-I.

Measurements and Procedures: This study was performed at the Cardiopulmonary Laboratory, CAMS, King Saud University. 

The investigation was approved by the Ethics committee of Rehabilitation Research Chair, King Saud University. All subjects gave their informed consent to be part of the study. The VF tests were conducted in accordance with ‘Guidelines for Standardization of Spirometry’14 using a portable spirometer Pony Fx (COSMED, Rome, Italy). 

 for healthy  face veil and non-face veil using Saudi women

The Pearson product moment correlation coefficient test was used to test the presence of any linear relationship between the number of hours of veil use per day and the values of VF parameters. ... The values for all parameters were significantly lower in veil group than the non- veil group.

### Correlation statistics revealed significant negative relationship between number of hours of wearing face veil per day and FVC...

Discussion To the best of our knowledge, this is the first study on the effect of niqab use on the ventilatory function. ###The present results show that VF values (FVC, FEV1, FEV1/FVC (%) and MVV) for niqab wearing females were significantly lower than the corre- sponding values for non-niqab wearing females. In fact, the FVC, FEV1 and MVV values were approxi- mately 30% lower, and the FEV1/FVC (%) was 9% lower for niqab wearing females. The data also show a significant negative correlation between the dura- tion of niqab use and the FVC and FEV1 values.

### It is reasonable to believe that any condition, pathological or otherwise, which can interfere with the free airflow in the respiratory system or adequate expansion of lungs and chest wall, can result in insufficient ventilation or excessive work of respiratory muscles to maintain required ventilation. Previous studies show that different conditions limiting chest expansion during respiration, such as obesity, scoliosis or use of bullet proof vests, body armour and heavy backpacks can reduce FVC and FEV1, without affecting the FVC/ FEV1 ratio.16-18  These results indicate a proportionate  reduction in FEV1 and FVC values. However, ### our present results show that FEV1/FVC% value for niqab wearing females was significantly lower than the non-niqab wearing females. This indicates that with long-term use of niqab, the FEV1 was relatively reduced more than the FVC.


### A few previous studies on the use of facial masks7,8 only reported short-term physiological responses (heart rate, thermal stress and oxygen saturation). Thus, our present data add new knowledge on the effect of long-term use of niqab on VF.

It has been reported that with increased physical activity the temperature in the facemask microclimate increases,7,19 causing increase in thermal sen- sations of the whole body 20, which decreases work endurance.21 The temperature of air entering the facemask during inspiration corresponds to thermal stimulus to the skin under mask and affects heat exchange from the respiratory tract, reducing breathing comfort sensation.22 Decrease in blood oxygenation level among surgeons has also been reported following the use of surgical masks during surgery lasting 1 to 4 hours,8 and long duration use of facemasks by medical emergency staff has been related to extreme stress.23

### Taken together, it is reasonable to believe that the short-term physiological responses to the use of niqab maybe similar to those previously described for different kinds of facial masks. It can be argued that unlike the facial masks, the niqab is usually not very tightly applied to the face, and thus the thermal and circulatory changes that occur when wearing a surgical mask may not be applicable.

### However, in comparison to the facial masks that cover mainly the nose and mouth, the niqab used by Saudi women covers the whole face except the eyes and is thus maybe capable of causing facial mask like short-term physiological responses. In fact, in- creased breathing discomfort during summer is a common complaint among our niqab wearing sub- jects corroborating previous studies.19,22 

No data is available on the air and moisture permeability of the layers of fabric used in making the niqab. ### It has been reported that use of two different kinds of facemasks with 95% and 96% filtration efficiency, can result in different mean heart rate, microclimate temperature, humidity and skin temperature under facemask, together with perceived discomfort, fa- tigue and breathing resistance.7

In light of these pre- vious findings, it is reasonable to speculate that the present result of lower VF values in veil group than non-veil group, is not only due to direct airway re- sistance caused by niqab, but increase in microcli- mate temperature, humidity and skin temperature inside the niqab can be contributing factors.  In addition, it is a possibility that part of the exhaled carbon dioxide may also be trapped inside the niqab, lead- ing to some shortage of oxygen causing an increase in heart rate via sympathetic nervous system.24

### Furthermore, the use of niqab in presence of known sedentary life style of Saudi females probably does not require extra respiratory effort to overcome physiological responses to the use of niqab, as these ladies may adapt to shallow breathing patterns with higher heart rate. Prolonged reduction of pulmonary ventilation during the use of niqab for several hours may result in lowering the tidal volume, which may induce insufficient oxygenation and inadequate carbon dioxide elimination. This affects gas exchange15 and thus can cause some de- gree of hypoxia, which may lead to different musculoskeletal pain disorders and reduction in endurance levels. We can also speculate that the regular use of niqab by Saudi women can probably be one of the reasons of higher prevalence of fibromyalgia and cervicobrachialgia among Saudi females.25 The present results of lower VF values in veil group than non-veil group, merit further investigations where different physiological responses, blood oxygen saturation levels and subjective perception of discomfort should be investigated during different levels of physical activity with niqab made of differ- ent air and moisture permeability.

### In conclusion, our data show that there are differences in VF tests among niqab and non-niqab wearing Saudi adult females, where values for niqab users are lower than the values for those who do not use niqab. Further studies are required to investigate the effect of different fabric materials with different air and moisture permeability that can safely be used for niqab with minimal effect on ventilatory function. 

REFERENCES 1. Laird IS, Goldsmith R, Pack RJ, Vitalis A. The effect on heart rate and facial skin temperature of wearing respiratory protection at work. Ann Occup Hyg 2002;46(2):143-8. 2. Seliga R, Bhattacharya A, Succop P, Wickstrom R, Smith D, Willeke K. Effect of work load and respirator wear on postural stability, heart rate, and perceived exertion. Am Ind Hyg Assoc J 1991;52(10):417-22. 3. Lange JH. Health effects of respirator use at low airborne concentrations. Med Hypotheses 2000;54(6):1005-7. 4. Morgan WP. Psychological problems associated with the wearing of industrial respirators: a review. Am Ind Hyg Assoc J 1983;44(9):671–6. 5. Szymanowska K, Piatkowska A, Nowicka A, Cofta S, Wierzchowiecki M. Heart rate turbulence in patients with obstructive sleep apnea syndrome. Cardiol J 2008;15(5):441-5. 6. Boulet LP, Turcotte H, Hudon C, Carrier G, Maltais F. Clinical, physiological and radiological features of asthma with incomplete reversibility of airflow obstruction compared with those of COPD. Can Respir J 1998;5(4):270-7. 7. Li Y, Tokura H, Guo YP, Wong AS, Wong T, Chung J, et al. Effects of wearing N95 and surgical facemasks on heart rate, thermal stress and subjective sensations. Int Arch Occup Environ Health 2005;78(6):501-9. 8. Beder A, Buyukkocak U, Sabuncuoglu H, Keskil ZA, Keskil S. Preliminary report on surgical mask induced deoxygenation during major surgery. Neurocirugia 2008;19(2):121-6. 9. Hayes D Jr, Kraman SS. The physiologic basis of spirometry. Respir Care 2009;54(12):1717-26. 10. Guenette JA, Witt JD, McKenzie DC, Road JD, Sheel AW. Respiratory mechanics during exercise in endurance-trained men and women. J Physiol 2007;581(Pt3):1309-22. 11. Pierce R. Spirometry: an essential clinical measurement. Aust Fam Physician 2005;34(7):535-9. 12. Ostrowski S, Barud W. Factors influencing lung function: are the predicted values for spirometry reliable enough? J Physiol Pharmacol 2006;57(Suppl 4):263-71. 13. Alghadir A, Aly F. Ventilatory function among healthy young Saudi adults: a comparison with Caucasian reference values. Asian Biomed 2011;5(1):157-161 14. Standardization of Spirometry, 1994 Update. American Thoracic Society. Am J Respir Crit Care Med 1995;152(3):1107-36. 15. Pellegrino R, Viegi G, Brusasco V, Crapo RO, Burgos F, Casaburi R, et al. Interpretative strategies for lung function tests. Eur Respir J 2005;26(5):948-68. 16. Coast JR, Baronas JL, Morris C, Willeford KS. The effect of football shoulder pads on pulmonary function. J Sports Sci Med 2005;4:367-71 17. Legg SJ. Influence of body armour on pulmonary function. Ergonomics 1988;31(3):349-53. 18. Muza S, Latzka W, Epstein Y, Pandolf K. Load carriage induced alterations of pulmonary function. Int J Ind Ergonomics 1989;3(3):221-27. 19. Hayashi C, Tokura H. The effects of two kinds of mask (with or without exhaust valve) on clothing microclimates inside the mask in participants wearing protective clothing for spraying pesticides. Int Arch Occup Environ Health 2004;77(1):73-8. 20. Nielsen R, Berglund LG, Gwosdow AR, DuBois AB. Thermal sensation of the body as influenced by the thermal microclimate in a face mask. Ergonomics 1987;30(12):1689-703. 21. White MK, Hodous TK, Vercruyssen M. Effects of thermal environment and chemical protective clothing on work tolerance, physiological responses, and subjective ratings. Ergonomics 1991;349(4):445-57. 22. Meyer JP, Héry M, Herrault J, Hubert G, François D, Hecht G, et al. Field study of subjective assessment of negative pressure half-masks. Influence of the work conditions on comfort and efficiency. Appl Ergon 1997;28(5-6):331-8. 23. Farquharson C, Baguley K. Responding to the severe acute respiratory syndrome (SARS) outbreak: lessons learned in a Toronto emergency department. J Emerg Nurs 2003;29(3):222-8. 24. Ganong WF. Review of Medical Physiology. Appleton and Lange. Stamford. 1997: 565–566. 25. Kaki AM. Pain clinic experience in a teaching hospital in Western, Saudi Arabia. Relationship of patient’s age and gender to various types of pain. Saudi Med J 2006;27(12):1882-6.

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