Hearing Matters Podcast

Exploring Auditory Wellness with Dr. Larry Humes

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Dr. Larry Humes discusses the critical difference between hearing wellness (pure tone audiometric results) and the broader concept of auditory wellness which encompasses psychosocial health and speech comprehension abilities. This distinction explains why millions of Americans with normal audiograms still struggle with listening difficulties in everyday situations.

In this episode you'll learn: 

• Hearing wellness refers specifically to pure tone thresholds while auditory wellness includes comprehension and psychosocial factors

• 26 million Americans have normal hearing thresholds but experience significant listening difficulties

• Current audiometric categories (0-25dB as normal) may miss significant hearing difficulties that impact daily function

• Over-the-counter hearing aids address access and affordability but often lack the necessary support infrastructure

• The prevalence of hearing loss in children (15%) has remained stable despite concerns about earbuds and screen time

• Empowering individuals to manage their own auditory wellness requires better education and support tools

Connect with the Hearing Matters Podcast Team

Email: hearingmatterspodcast@gmail.com

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Speaker 1:

Thank you to our partners. Cycle, built for the entire hearing care practice. Redux, the best dryer, hands down Caption call by Sorenson. Life is calling CareCredit, here today to help more people hear tomorrow. Faderplugs the world's first custom adjustable earplug. Welcome back to another episode of the Hearing Matters Podcast. I'm founder and host Blaise Delfino and, as a friendly reminder, this podcast is separate from my work at Starkey.

Speaker 2:

Good afternoon. This is Dr Douglas Beck with the Hearing Matters Podcast, and this is my friend and my colleague, Dr Larry Humes. Larry, welcome to the Hearing Matters podcast so glad you're here. Let me do a little bit of an intro for those who may not be familiar and if you're not familiar, you probably have not been reading the audiology literature. After completing his PhD at Northwestern University, Dr Humes spent eight years on the faculty at Vanderbilt before joining the faculty at Indiana University, where he remains as distinguished professor emeritus. He has published over 185 articles in peer-reviewed journals and another 60 non-peer-reviewed articles, reviews, chapters and books. He's presented or been a co-presenter at over 380 presentations throughout the world. Professor Humes has received the Honors of the Association and the Kiwana Award for Lifetime Achievement in Publications from the American Speech-Language Hearing Association, the Juerger Career Award for Research in Audiology for the American Academy of Audiology, and presented the 2020 Carhartt Memorial Lecture at the Annual Meeting of the American Auditory Society. So, all of that said, Larry, it's a joy to have you here. Thank you for being here and looking forward to chatting with you today. Thanks, I'm looking forward to it too.

Speaker 2:

Let's start with some relatively easy stuff. What is hearing wellness? Can you define that for me?

Speaker 3:

Well, that's a good point right to start off with. So you referred to it as hearing wellness and the Consumer Technology Standards Association has actually defined hearing wellness and it is basically the pure tone average at 500, 1,000, 2,000, and 4,000. So the same metric that's used now by the World Health Organization. It's the better ear pure tone average of those four frequencies being less than 20 dB, you're considered to have good hearing wellness. I've been actually interested in a little bit broader concept that we refer to as auditory wellness and I'd be glad to distinguish between those two?

Speaker 2:

Yeah, I would love it if you do, because I think people often confuse hearing and listening, and this is a very, very important point for consumers, for patients, for professionals. Hearing is just perceiving or detecting sound. That's important, that's foundational, very, very cool. But you don't live there. You live with listening. That is the ability to comprehend sound, to make sense out of sound, to apply meaning to sound, and I think this gets to hearing wellness and auditory wellness as well. So, if you'd spend a few moments on that, I'd appreciate it.

Speaker 3:

Yeah, and it's not just listening or comprehending speech, as you suggested, but it's also auditory wellness, refers to psychosocial health, so it's beyond even speech. Is this more comprehensive measure? And hearing wellness? Pure tone, audiometry, basically, is a component of auditory wellness. Sure, and it's kind of as you were describing it. It's necessary, but not sufficient to achieve good auditory wellness, which is a much broader concept that cuts into other domains of everyday function that are important to people with hearing difficulties.

Speaker 2:

Yeah, I like that a lot and it harkens back to in 2019, I think you know Jeff Danhauer, obviously, and Jeff and I wrote a paper Journal of Otolaryngology ENT Research back in 2019. So six years ago and we said this, we said of the 335 million people in the USA, there's about 26 million six years ago, 26 million who had absolutely normal thresholds but they had hearing difficulty, listening difficulty, speech and noise complaints and unless the clinician, the audiologist, the ENT, the dispenser, unless they do extensive, you know best practices so speech and noise listening and communication assessments, things likeenser unless they do extensive, you know best practices so speech and noise listening and communication assessments, things like that they're not going to find these problems. They're invisible because they don't show up on peer channels.

Speaker 3:

No, that's exactly right. That's the one of the main points.

Speaker 3:

And when we looked at national epidemiological data from the National Health and Nutrition Hanes Surveys and also the National Health Interview Survey and HIS, both are large, regularly completed epidemiological surveys of adults in the United States and there clearly are millions of people who especially in the Haynes data this is clear who have audiometrically normal hearing so they would qualify by the current definition of having good hearing wellness as implying that they don't need any help, but who self-report that they have considerable hearing trouble.

Speaker 3:

Now, because it's an epidemiological study, they don't delve into details about the kinds of trouble they have, but in a few follow-up questions they did document that the kinds of difficulties experienced include difficulties in social situations. They're frustrated with their difficulties and they have difficulties in noise, none of which is a surprise, but it just further documents that people themselves perceive themselves to have difficulties even when their audiogram qualifies as being normal based on the current hearing wellness definition, which is basically the World Health Organization's definition of normal. So that's what kind of gave rise part of the impetus for this notion of auditory wellness, that there's more involved and that my colleagues and I feel that self-report or perceived measures are probably as or more valid to quantify their difficulties than the audiogram.

Speaker 2:

Yeah, and this is such an important point because and you mentioned NHANES in passing, but I want to take this right out of one of your papers here NHANES, for those who don't know National Health and Nutrition Exam Surveys and, as you said, they do this every few years and it's been updated quite a bit.

Speaker 2:

And the typical audiometric profile was bilaterally symmetric, sloping hearing loss, slight to mild loss, above 2,000. Group data showed normal emittance measures, absence of otoscopic abnormalities, except for a little bit of wax. But the conclusion and I love this you wrote tens of millions of US adults have perceived or self-perceived we could say right mild to moderate hearing trouble, but have not pursued assistance, either through obtaining a hearing test or acquiring prescription hearing aids. And if you go to the Global Burden of Disease Study, which I think came out in 2024 in Ear and Hearing, they estimated 72.88 million people. So let's round that up to 73. 73 million people in the USA have hearing loss, that's one out of five people. And then I believe you've estimated that about 85 to 90% of adults who have self-perceived mild to moderate hearing loss don't see amplification. Am I saying that correctly?

Speaker 3:

Yeah, and actually those who have yes, that's true, because it's hard to tell NHANES measures their audiogram. It doesn't mean they went to the clinic to get that audiogram. But yeah, roughly 85% of the people with either audiometrically defined need in terms of they don't have good hearing wellness or self-report defined mean meaning they report that they're having hearing trouble do not have not sought an obtained hearing aids.

Speaker 2:

And these numbers vary, you know, with whatever study you read. And a big part of this problem and the variation is that audiologists, ents, hearing aid dispensers, in the USA we use 0 to 25 as normal and then 26 to 40, mild, 41 to 70, moderate, 71 to 90, severe, 91 and above profound. That seems pretty straightforward but it's also incorrect. You know, when you go back to 100 years ago Fletcher, I think in 1929, said normal pure tone perception in adults was 0 to 15. And Miriam Downs, you know, gosh, 40 or 50 years ago, miriam used to say any child with a 15 dB loss needs to be treated. So give me your impression on the variability in audiograms and these categories of convenience that we use. I mean, what should they be in your opinion?

Speaker 3:

Well, I think, broad brushstroke, the best overall metric is the most recent one adopted by the World Health Organization, which is, in terms of just hearing loss detection.

Speaker 3:

It's better ear pure tone average for those four frequencies. That's an important part of it. 5, 1, 2 and 4. Right, being better than 20 dB HL, so it's not 15. And I agree. So it's not 15. And I agree, it's always. It's been interesting to me that for some reason I actually had a different publication that looked at this in kids and adults. But I've never quite understood. I mean, I do because we're talking about development of speech and language but why is it more important for a child to have better hearing than an adult? So anyway, I think the right answer in terms of PTA and trying to draw a simple line someplace is probably between 15 and 20. But the problem with 20, I know just from having looked at that is that it still averages four frequencies together and people can have, for example, considerable hearing loss in high frequencies and not be detected.

Speaker 3:

Frequencies and not exceed that limit of 20. And we went back and looked at several people who volunteered for a study and 20% of them fell in the class that would be considered normal hearing audiometrically using that definition 20 dB HL, not 25, but 20. Better ear those four frequencies and 80% of them. If you looked at them by an audiologist they'd say, oh yeah, that person has enough high frequency hearing loss to consider hearing aids and so it. Part of it is the metric and trying to do use a single number, but some of them were designed for epidemiological purposes where a whole yardstick works best in trying to come up with the best, most valid measure to do that.

Speaker 3:

But that's different from what would be best for a clinician.

Speaker 2:

Yeah, the point well taken.

Speaker 2:

Epidemiologic studies are studies of large groups of people that tell you things like averages, standard deviations, how common something is, but that is not necessarily at all reflective of the patient sitting in front of you, and so it's very important to look at epidemiological data as group data and it may or may not influence your diagnosis or treatment of the patient. Let's talk a little bit about you know, in October of 22, the FDA approved over-the-counter hearing aids and I know you've published quite a few studies looking at over-the-counter hearing aids, and I know you've published quite a few studies looking at over-the-counter and the results and the predictions, and I wonder if you can give me an overview statement. October 2022, the FDA says, okay, we're going to go with over-the-counter hearing aids because access and affordability, which were the two primary impediments they said we need to overcome that. So I've always thought that made very, very good sense to me. Access and affordability are very important, but I have some thoughts on that. But before we get to mine, I want to get your thoughts on it.

Speaker 3:

Yeah, no, I think it's an important starting point access and affordability, and access means that. So some people say, well, aren't those the same thing? And they're not. Access is how easy it is to get to the help you want.

Speaker 3:

And we've looked at studies where people have been identified and screening and now there are several studies that then track those people over the next several weeks to year and see the drop off of the number of people. And it's not the expense, because several of these studies were done in the VA. It's not the expense of the device for the services.

Speaker 3:

It's the inconvenience of going, setting up the appointment, going there, getting there, and so that's a different kind of accessibility issue, and over-the-counter in forms of direct-to-consumer devices can skip a lot of those barriers.

Speaker 3:

Unfortunately, I'd been advocating for many years. While I was working on the whole validation of the self-fitting processes, I was advocating for people to start recognizing that if this happens, it would potentially be worse if you dump devices that we know can be fit and can provide good benefit but you don't provide any help. And so people have known, even in the conventional hearing aid, prescription hearing aids and conventional delivery systems, that people need help in the initial stages of adjusting to hearing aids. And then to go to where you can buy these devices yourself to not consider the support that was needed is, I think the assumption was well, it's this device you need to make accessible and affordable. End of story. It's not, it's the device is the starting point, and then you need to figure out how to also make affordable and accessible support available to the people who make that choose that pathway. Basically, yeah.

Speaker 2:

And I can tell you I was at a lot of those FDA and FTC hearings back in 2016, 2017, and quite a number of us had suggested this. You know, because Medicare already covers comprehensive audiometric evaluations. 92557 is the CPT code, and what many of us had said is why don't we, instead of dealing so much with OTC in particular, why don't we do this? Why don't we say that the step one in obtaining an OTC is you have to get an audiometric evaluation by a licensed hearing healthcare professional. That person would test you, advise you, counsel you and then you buy whatever the heck you want. Obviously, they didn't choose that route, but we thought it was very important to suggest that for exactly the same reason, because hearing aids are not intuitive.

Speaker 2:

It's not just a matter of making it louder. What most people actually want is for it to be clearer, not louder. In general, you know, adults, people with presbycusis, age-related issues they want things clearer, and so when we talk about OTC, I think it's very important that the products do make things clearer, not just louder, because if we make it just louder, the number one complaint of all patients with hearing loss or self-perceived hearing loss is the inability to understand speech and noise. If we make everything louder, we're going to make the speech and the noise louder. We have not necessarily improved the signal-to-noise ratio, and we can't really expect it to be clearer when all we've done is make it louder.

Speaker 3:

Yeah, I agree. So in comments, just about the model that you had suggested. I think that still has this accessibility barrier in that you're saying they need to go to an audiologist and get their hearing tested and then they'll get the counseling and expectations and other, and then they can choose whatever device they want. But I think that's why only 15% with trouble have purchased hearing aids.

Speaker 3:

Yeah, that's a fair point. First step, and what I've been trying to do in part of the auditory wellness approach, is trying to empower the person to manage their own auditory wellness. That takes a lot of infrastructure to support. They have to be knowledgeable about the importance of hearing, why hearing matters as a plug for the program and the consumer needs to know that. The consumer needs to be informed and have tools available to go through this process. It's a daunting process because people have never been empowered to do this before, and many of them. When we've looked at follow-up surveys of people who have been in some of our clinical trials, it's clear that one of the limitations to their uptake and use of the devices is their lack of confidence in making good choices, because they've never had to do that. It was always a professional telling them this is what you need, this is best for you, and so, anyway, I think it's a part of this whole need for information and education and empowering people with hearing difficulties to manage their own auditory wellness. If I may, I'll tell you.

Speaker 2:

I was vice president of academic sciences at a major hearing aid company for 18 years and when I left, otc was happening and quite a few of the manufacturers of OTC sent me products and said Doug, where are these? Be a spokesperson? I said, well, send it to me, let me see what it is. And I didn't say yes to any of them I think there were eight of them because they were terrible. They were awful and what you did is you picked a really good one, and so that's great and that one makes sense. I won't say the manufacturer's name, but they were about $1,700 for a pair.

Speaker 2:

Most OTC patients are willing to spend $200 or $300 a pair, according to the research literature, and so we still have this huge disconnect between the better OTCs. In fact, consumer Reports in January 2025 looked at premium OTC products, much like the one that you guys used in your study, and they said you know, they range from about $1,800 to $2,800 a pair, and so when we talk about access and affordability, it's still really expensive, and I always thought that the primary issue was not price. I really did, and I know people will criticize that, but I go back to the Mike Valente Amin Amlani study 2017, 2018, in American Academy of Otolaryngology, head and neck surgery. And they said you know, the USA is the most expensive place to buy hearing aids. That's a fact, seems to be a fact.

Speaker 2:

And then they said you know, if you look at countries like the EU the UK, sweden, norway, denmark, canada, new Zealand, australia you look at places where hearing aids are free the uptake is 60% of people say no, I'm good, you know so. Even when they're free, people don't really want them and I think the main thing about that is not so much access and affordability as it is the form factor. You know, people just don't want to be that guy wearing a hearing aid in general and I think it's terrible and it's cruel and it's rude and people shouldn't feel like that. But hearing aid stigma is a huge part of this whole discussion and you know, if you could just go to WebMD and you put in hearing aid stigma, you'll find you know 10 or 15 very current last two or three years articles saying that most people are going to shy away from it because of the way it looks.

Speaker 3:

I agree it's a big factor issue for the person with hearing difficulties to overcome and I think some cases the form factor for over-the-counter devices was modeled after earbuds. That are common in younger adults and seen more frequently, much more visible. But I think the uptake of that form factor and some of the acoustical issues, including feedback and things that were occurring occlusion pushed people away from that and it seems like at least my take on the current over-the-counter good quality over-the-counter devices seem to be more like conventional Rick.

Speaker 2:

Larry, before I let you go, I want to talk about children, and I want to speak specifically about things like AirPods and other in-ear devices, the fact that they're looking at screens all day long, the fact that they will wear headsets to amplify their screens, and things like that. I have not seen a huge change in hearing loss in children. One of the papers you published in Asher Wire a while ago was audiograms and prevalence of hearing loss in children. One of the papers you published in ASHA Wire a while ago was audiograms and prevalence of hearing loss in US children, adolescents 6 to 19. That was in the Journal of Speech-Language Hearing from ASHA and you said about 15% of kids have hearing loss and I think that's pretty much what I've always known for the last 40 years In your experience. Is that correct or am I missing something?

Speaker 3:

That's correct, and I don't think there's evidence of increased prevalence of hearing loss. And in this case there is some variation across the years for epidemiological data in terms of how they defined hearing loss. But when you use the same yardstick, really, the numbers today are no greater, if anything, maybe slightly less than earlier estimates, but not noticeably. So yeah, I don't see the cause for alarm. I think there's potential because it's possible now. So all the evaluation of noise exposure would focus more on industrial or occupational noise, and the parameters were kind of an eight-hour day and these are the doses, the levels that you can be exposed to for that period of time, and it's possible, depending upon the child and the use, to actually have high levels for much longer than that. And so that's where I think some of the alarm or concern has been. But I at least. In the epidemiological data it doesn't seem to be the case that there's a much higher prevalence of hearing loss in that age range.

Speaker 2:

All right. Well, listen, it's an honor to talk to you, dr Humes. I've been following your career loosely for many, many years. Last time, I think, you and I were on stage together, 2015, at the.

Speaker 3:

American Academy of Audiology.

Speaker 2:

And we were discussing cognition, audition and amplification and that was 10 years ago. So, listen, I am very appreciative of being here on the Hearing Matters podcast and I value your knowledge and your ability to explain very complex things very simply. That's a gift and I'm so glad that we had the time together.

Speaker 3:

Well, thanks, doug. I appreciate the opportunity and the best wishes for continued success for you. Thank you, larry, you too.

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Blaise M. Delfino, M.S. - HIS

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