June 13, 2025 • 22 mins
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
Instagram: @hearing_matters_podcast
Twitter: @hearing_mattas
Facebook: Hearing Matters Podcast
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:19):
Thank you to our partners.
Cycle, built for the entirehearing care practice.
Redux, the best dryer, handsdown Caption call by Sorenson.
Life is calling CareCredit,here today to help more people
hear tomorrow.
Faderplugs the world's firstcustom adjustable earplug.
(00:41):
Welcome back to another episodeof the Hearing Matters Podcast.
I'm founder and host BlaiseDelfino and, as a friendly
reminder, this podcast isseparate from my work at Starkey
.
Speaker 2 (00:56):
Good afternoon.
This is Dr Douglas Beck withthe Hearing Matters Podcast, and
this is my friend and mycolleague, Dr Larry Humes.
Larry, welcome to the HearingMatters podcast so glad you're
here.
Let me do a little bit of anintro for those who may not be
familiar and if you're notfamiliar, you probably have not
been reading the audiologyliterature.
After completing his PhD atNorthwestern University, Dr
(01:16):
Humes spent eight years on thefaculty at Vanderbilt before
joining the faculty at IndianaUniversity, where he remains as
distinguished professor emeritus.
He has published over 185articles in peer-reviewed
journals and another 60non-peer-reviewed articles,
reviews, chapters and books.
He's presented or been aco-presenter at over 380
presentations throughout theworld.
(01:37):
Professor Humes has receivedthe Honors of the Association
and the Kiwana Award forLifetime Achievement in
Publications from the AmericanSpeech-Language Hearing
Association, the Juerger CareerAward for Research in Audiology
for the American Academy ofAudiology, and presented the
2020 Carhartt Memorial Lectureat the Annual Meeting of the
American Auditory Society.
So, all of that said, Larry,it's a joy to have you here.
(01:59):
Thank you for being here andlooking forward to chatting with
you today.
Thanks, I'm looking forward toit too.
Let's start with some relativelyeasy stuff.
What is hearing wellness?
Can you define that for me?
Speaker 3 (02:11):
Well, that's a good point right to start off with.
So you referred to it ashearing wellness and the
Consumer Technology StandardsAssociation has actually defined
hearing wellness and it isbasically the pure tone average
at 500, 1,000, 2,000, and 4,000.
So the same metric that's usednow by the World Health
(02:32):
Organization.
It's the better ear pure toneaverage of those four
frequencies being less than 20dB, you're considered to have
good hearing wellness.
I've been actually interestedin a little bit broader concept
that we refer to as auditorywellness and I'd be glad to
distinguish between those two?
Speaker 2 (02:51):
Yeah, I would love it if you do, because I think
people often confuse hearing andlistening, and this is a very,
very important point forconsumers, for patients, for
professionals.
Hearing is just perceiving ordetecting sound.
That's important, that'sfoundational, very, very cool.
But you don't live there.
You live with listening.
That is the ability tocomprehend sound, to make sense
(03:12):
out of sound, to apply meaningto sound, and I think this gets
to hearing wellness and auditorywellness as well.
So, if you'd spend a fewmoments on that, I'd appreciate
it.
Speaker 3 (03:20):
Yeah, and it's not just listening or comprehending
speech, as you suggested, butit's also auditory wellness,
refers to psychosocial health,so it's beyond even speech.
Is this more comprehensivemeasure?
And hearing wellness?
Pure tone, audiometry,basically, is a component of
(03:51):
auditory wellness.
Sure, and it's kind of as youwere describing it.
It's necessary, but notsufficient to achieve good
auditory wellness, which is amuch broader concept that cuts
into other domains of everydayfunction that are important to
people with hearing difficulties.
Speaker 2 (04:09):
Yeah, I like that a lot and it harkens back to in
2019, I think you know JeffDanhauer, obviously, and Jeff
and I wrote a paper Journal ofOtolaryngology ENT Research back
in 2019.
So six years ago and we saidthis, we said of the 335 million
people in the USA, there'sabout 26 million six years ago,
26 million who had absolutelynormal thresholds but they had
(04:32):
hearing difficulty, listeningdifficulty, speech and noise
complaints and unless theclinician, the audiologist, the
ENT, the dispenser, unless theydo extensive, you know best
practices so speech and noiselistening and communication
assessments, things likeenserunless they do extensive, you
know best practices so speechand noise listening and
communication assessments,things like that they're not
going to find these problems.
They're invisible because theydon't show up on peer channels.
Speaker 3 (04:52):
No, that's exactly right.
That's the one of the mainpoints.
And when we looked at nationalepidemiological data from the
National Health and NutritionHanes Surveys and also the
National Health Interview Surveyand HIS, both are large,
regularly completedepidemiological surveys of
adults in the United States andthere clearly are millions of
(05:13):
people who especially in theHaynes data this is clear who
have audiometrically normalhearing so they would qualify by
the current definition ofhaving good hearing wellness as
implying that they don't needany help, but who self-report
that they have considerablehearing trouble.
Now, because it's anepidemiological study, they
(05:34):
don't delve into details aboutthe kinds of trouble they have,
but in a few follow-up questionsthey did document that the
kinds of difficultiesexperienced include difficulties
in social situations.
They're frustrated with theirdifficulties and they have
difficulties in noise, none ofwhich is a surprise, but it just
further documents that peoplethemselves perceive themselves
(05:58):
to have difficulties even whentheir audiogram qualifies as
being normal based on thecurrent hearing wellness
definition, which is basicallythe World Health Organization's
definition of normal.
So that's what kind of gaverise part of the impetus for
this notion of auditory wellness, that there's more involved and
that my colleagues and I feelthat self-report or perceived
(06:22):
measures are probably as or morevalid to quantify their
difficulties than the audiogram.
Speaker 2 (06:30):
Yeah, and this is such an important point because
and you mentioned NHANES inpassing, but I want to take this
right out of one of your papershere NHANES, for those who
don't know National Health andNutrition Exam Surveys and, as
you said, they do this every fewyears and it's been updated
quite a bit.
And the typical audiometricprofile was bilaterally
symmetric, sloping hearing loss,slight to mild loss, above
(06:50):
2,000.
Group data showed normalemittance measures, absence of
otoscopic abnormalities, exceptfor a little bit of wax.
But the conclusion and I lovethis you wrote tens of millions
of US adults have perceived orself-perceived we could say
right mild to moderate hearingtrouble, but have not pursued
assistance, either throughobtaining a hearing test or
(07:16):
acquiring prescription hearingaids.
And if you go to the GlobalBurden of Disease Study, which I
think came out in 2024 in Earand Hearing, they estimated
72.88 million people.
So let's round that up to 73.
73 million people in the USAhave hearing loss, that's one
out of five people.
And then I believe you'veestimated that about 85 to 90%
of adults who haveself-perceived mild to moderate
hearing loss don't seeamplification.
(07:37):
Am I saying that correctly?
Speaker 3 (07:39):
Yeah, and actually those who have yes, that's true,
because it's hard to tellNHANES measures their audiogram.
It doesn't mean they went tothe clinic to get that audiogram
.
But yeah, roughly 85% of thepeople with either
audiometrically defined need interms of they don't have good
hearing wellness or self-reportdefined mean meaning they report
(08:01):
that they're having hearingtrouble do not have not sought
an obtained hearing aids.
Speaker 2 (08:06):
And these numbers vary, you know, with whatever
study you read.
And a big part of this problemand the variation is that
audiologists, ents, hearing aiddispensers, in the USA we use 0
to 25 as normal and then 26 to40, mild, 41 to 70, moderate, 71
to 90, severe, 91 and aboveprofound.
That seems prettystraightforward but it's also
(08:26):
incorrect.
You know, when you go back to100 years ago Fletcher, I think
in 1929, said normal pure toneperception 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 15dB loss needs to be treated.
So give me your impression onthe variability in audiograms
and these categories ofconvenience that we use.
(08:48):
I mean, what should they be inyour opinion?
Speaker 3 (08:51):
Well, I think, broad brushstroke, the best overall
metric is the most recent oneadopted by the World Health
Organization, which is, in termsof just hearing loss detection.
It's better ear pure toneaverage for those four
frequencies.
That's an important part of it.
5, 1, 2 and 4.
Right, being better than 20 dBHL, so it's not 15.
(09:11):
And I agree.
So it's not 15.
And I agree, it's always.
It's been interesting to methat for some reason I actually
had a different publication thatlooked at this in kids and
adults.
But I've never quite understood.
I mean, I do because we'retalking about development of
speech and language but why isit more important for a child to
(09:32):
have better hearing than anadult?
So anyway, I think the rightanswer in terms of PTA and
trying to draw a simple linesomeplace is probably between 15
and 20.
But the problem with 20, I knowjust from having looked at that
is that it still averages fourfrequencies together and people
can have, for example,considerable hearing loss in
(09:54):
high frequencies and not bedetected.
Frequencies and not exceed thatlimit of 20.
And we went back and looked atseveral people who volunteered
for a study and 20% of them fellin the class that would be
considered normal hearingaudiometrically using that
definition 20 dB HL, not 25, but20.
Better ear those fourfrequencies and 80% of them.
(10:19):
If you looked at them by anaudiologist they'd say, oh yeah,
that person has enough highfrequency hearing loss to
consider hearing aids and so it.
Part of it is the metric andtrying to do use a single number
, but some of them were designedfor epidemiological purposes
where a whole yardstick worksbest in trying to come up with
the best, most valid measure todo that.
(10:40):
But that's different from whatwould be best for a clinician.
Speaker 2 (10:44):
Yeah, the point well taken.
Epidemiologic studies arestudies of large groups of
people that tell you things likeaverages, standard deviations,
how common something is, butthat is not necessarily at all
reflective of the patientsitting in front of you, and so
it's very important to look atepidemiological data as group
data and it may or may notinfluence your diagnosis or
(11:05):
treatment of the patient.
Let's talk a little bit aboutyou know, in October of 22, the
FDA approved over-the-counterhearing aids and I know you've
published quite a few studieslooking at over-the-counter
hearing aids, and I know you'vepublished quite a few studies
looking at over-the-counter andthe results and the predictions,
and I wonder if you can give mean overview statement.
October 2022, the FDA says,okay, we're going to go with
(11:26):
over-the-counter hearing aidsbecause access and affordability
, which were the two primaryimpediments they said we need to
overcome that.
So I've always thought thatmade very, very good sense to me
.
Access and affordability arevery important, but I have some
thoughts on that.
But before we get to mine, Iwant to get your thoughts on it.
Speaker 3 (11:43):
Yeah, no, I think it's an important starting point
access and affordability, andaccess means that.
So some people say, well,aren't those the same thing?
And they're not.
Access is how easy it is to getto the help you want.
And we've looked at studieswhere people have been
identified and screening and nowthere are several studies that
(12:06):
then track those people over thenext several weeks to year and
see the drop off of the numberof people.
And it's not the expense,because several of these studies
were done in the VA.
It's not the expense of thedevice for the services.
It's the inconvenience of going,setting up the appointment,
going there, getting there, andso that's a different kind of
accessibility issue, andover-the-counter in forms of
(12:30):
direct-to-consumer devices canskip a lot of those barriers.
Unfortunately, I'd beenadvocating for many years.
While I was working on thewhole validation of the
self-fitting processes, I wasadvocating for people to start
recognizing that if this happens, it would potentially be worse
(12:53):
if you dump devices that we knowcan be fit and can provide good
benefit but you don't provideany help.
And so people have known, evenin the conventional hearing aid,
prescription hearing aids andconventional delivery systems,
that people need help in theinitial stages of adjusting to
hearing aids.
(13:14):
And then to go to where you canbuy these devices yourself to
not consider the support thatwas needed is, I think the
assumption was well, it's thisdevice you need to make
accessible and affordable.
End of story.
It's not, it's the device isthe starting point, and then you
need to figure out how to alsomake affordable and accessible
(13:38):
support available to the peoplewho make that choose that
pathway.
Basically, yeah.
Speaker 2 (13:43):
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 Medicarealready covers comprehensive
audiometric evaluations.
92557 is the CPT code, and whatmany of us had said is why
(14:06):
don't we, instead of dealing somuch with OTC in particular, why
don't we do this?
Why don't we say that the stepone in obtaining an OTC is you
have to get an audiometricevaluation by a licensed hearing
healthcare professional.
That person would test you,advise you, counsel you and then
you buy whatever the heck youwant.
Obviously, they didn't choosethat route, but we thought it
was very important to suggestthat for exactly the same reason
, because hearing aids are notintuitive.
(14:26):
It's not just a matter of makingit louder.
What most people actually wantis for it to be clearer, not
louder.
In general, you know, adults,people with presbycusis,
age-related issues they wantthings clearer, and so when we
talk about OTC, I think it'svery important that the products
do make things clearer, notjust louder, because if we make
(14:46):
it just louder, the number onecomplaint of all patients with
hearing loss or self-perceivedhearing 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 necessarilyimproved the signal-to-noise
ratio, and we can't reallyexpect it to be clearer when all
we've done is make it louder.
Speaker 3 (15:03):
Yeah, I agree.
So in comments, just about themodel that you had suggested.
I think that still has thisaccessibility barrier in that
you're saying they need to go toan audiologist and get their
hearing tested and then they'llget the counseling and
expectations and other, and thenthey can choose whatever device
they want.
(15:23):
But I think that's why only 15%with trouble have purchased
hearing aids.
Yeah, that's a fair point.
First step, and what I've beentrying to do in part of the
auditory wellness approach, istrying to empower the person to
manage their own auditorywellness.
That takes a lot ofinfrastructure to support.
They have to be knowledgeableabout the importance of hearing,
(15:44):
why hearing matters as a plugfor the program and the consumer
needs to know that.
The consumer needs to beinformed and have tools
available to go through thisprocess.
It's a daunting process becausepeople have never been
empowered to do this before, andmany of them.
When we've looked at follow-upsurveys of people who have been
(16:06):
in some of our clinical trials,it's clear that one of the
limitations to their uptake anduse of the devices is their lack
of confidence in making goodchoices, because they've never
had to do that.
It was always a professionaltelling them this is what you
need, this is best for you, andso, anyway, I think it's a part
of this whole need forinformation and education and
(16:30):
empowering people with hearingdifficulties to manage their own
auditory wellness.
If I may, I'll tell you.
Speaker 2 (16:37):
I was vice president of academic sciences at a major
hearing aid company for 18 yearsand when I left, otc was
happening and quite a few of themanufacturers of OTC sent me
products and said Doug, whereare 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 ofthem I think there were eight of
them because they were terrible.
(16:57):
They were awful and what youdid is you picked a really good
one, and so that's great andthat one makes sense.
I won't say the manufacturer'sname, but they were about $1,700
for a pair.
Most OTC patients are willing tospend $200 or $300 a pair,
according to the researchliterature, and so we still have
this huge disconnect betweenthe better OTCs.
(17:18):
In fact, consumer Reports inJanuary 2025 looked at premium
OTC products, much like the onethat you guys used in your study
, and they said you know, theyrange from about $1,800 to
$2,800 a pair, and so when wetalk about access and
affordability, it's still reallyexpensive, and I always thought
that the primary issue was notprice.
(17:39):
I really did, and I know peoplewill criticize that, but I go
back to the Mike Valente AminAmlani study 2017, 2018, in
American Academy ofOtolaryngology, head and neck
surgery.
And they said you know, the USAis the most expensive place to
buy hearing aids.
That's a fact, seems to be afact.
And then they said you know, ifyou look at countries like the
EU the UK, sweden, norway,denmark, canada, new Zealand,
(18:02):
australia you look at placeswhere hearing aids are free the
uptake is 60% of people say no,I'm good, you know so.
Even when they're free, peopledon't really want them and I
think the main thing about thatis not so much access and
affordability as it is the formfactor.
You know, people just don'twant to be that guy wearing a
hearing aid in general and Ithink it's terrible and it's
(18:22):
cruel and it's rude and peopleshouldn't feel like that.
But hearing aid stigma is ahuge part of this whole
discussion and you know, if youcould just go to WebMD and you
put in hearing aid stigma,you'll find you know 10 or 15
very current last two or threeyears articles saying that most
people are going to shy awayfrom it because of the way it
looks.
Speaker 3 (18:41):
I agree it's a big factor issue for the person with
hearing difficulties toovercome and I think some cases
the form factor forover-the-counter devices was
modeled after earbuds.
That are common in youngeradults and seen more frequently,
(19:03):
much more visible.
But I think the uptake of thatform factor and some of the
acoustical issues, includingfeedback and things that were
occurring occlusion pushedpeople away from that and it
seems like at least my take onthe current over-the-counter
good quality over-the-counterdevices seem to be more like
(19:23):
conventional Rick.
Speaker 2 (19:25):
Larry, before I let you go, I want to talk about
children, and I want to speakspecifically about things like
AirPods and other in-ear devices, the fact that they're looking
at screens all day long, thefact that they will wear
headsets to amplify theirscreens, and things like that.
I have not seen a huge changein hearing loss in children.
(19:45):
One of the papers you publishedin Asher Wire a while ago was
audiograms and prevalence ofhearing loss in children.
One of the papers you publishedin ASHA Wire a while ago was
audiograms and prevalence ofhearing loss in US children,
adolescents 6 to 19.
That was in the Journal ofSpeech-Language Hearing from
ASHA and you said about 15% ofkids have hearing loss and I
think that's pretty much whatI've always known for the last
40 years In your experience.
Is that correct or am I missingsomething?
Speaker 3 (20:06):
That's correct, and I don't think there's evidence of
increased prevalence of hearingloss.
And in this case there is somevariation across the years for
epidemiological data in terms ofhow they defined hearing loss.
But when you use the sameyardstick, really, the numbers
today are no greater, ifanything, maybe slightly less
than earlier estimates, but notnoticeably.
(20:28):
So yeah, I don't see the causefor alarm.
I think there's potentialbecause it's possible now.
So all the evaluation of noiseexposure would focus more on
industrial or occupational noise, and the parameters were kind
of an eight-hour day and theseare the doses, the levels that
(20:48):
you can be exposed to for thatperiod of time, and it's
possible, depending upon thechild and the use, to actually
have high levels for much longerthan that.
And so that's where I thinksome of the alarm or concern has
been.
But I at least.
In the epidemiological data itdoesn't seem to be the case that
there's a much higherprevalence of hearing loss in
(21:10):
that age range.
Speaker 2 (21:12):
All right.
Well, listen, it's an honor totalk to you, dr Humes.
I've been following your careerloosely for many, many years.
Last time, I think, you and Iwere on stage together, 2015, at
the.
Speaker 3 (21:20):
American Academy of Audiology.
Speaker 2 (21:22):
And we were discussing cognition, audition
and amplification and that was10 years ago.
So, listen, I am veryappreciative of being here on
the Hearing Matters podcast andI value your knowledge and your
ability to explain very complexthings very simply.
That's a gift and I'm so gladthat we had the time together.
Speaker 3 (21:40):
Well, thanks, doug.
I appreciate the opportunityand the best wishes for
continued success for you.
Thank you, larry, you too.
Thank you to our partners.
Cycle, built for the entirehearing care practice.
Redux, the best dryer, handsdown Caption call by Sorenson.
Life is calling CareCredit,here today to help more people
hear tomorrow.
Faderplugs the world's firstcustom adjustable earplug.
(00:41):
Welcome back to another episodeof the Hearing Matters Podcast.
I'm founder and host BlaiseDelfino and, as a friendly
reminder, this podcast isseparate from my work at Starkey
.
Speaker 2 (00:56):
Good afternoon.
This is Dr Douglas Beck withthe Hearing Matters Podcast, and
this is my friend and mycolleague, Dr Larry Humes.
Larry, welcome to the HearingMatters podcast so glad you're
here.
Let me do a little bit of anintro for those who may not be
familiar and if you're notfamiliar, you probably have not
been reading the audiologyliterature.
After completing his PhD atNorthwestern University, Dr
(01:16):
Humes spent eight years on thefaculty at Vanderbilt before
joining the faculty at IndianaUniversity, where he remains as
distinguished professor emeritus.
He has published over 185articles in peer-reviewed
journals and another 60non-peer-reviewed articles,
reviews, chapters and books.
He's presented or been aco-presenter at over 380
presentations throughout theworld.
(01:37):
Professor Humes has receivedthe Honors of the Association
and the Kiwana Award forLifetime Achievement in
Publications from the AmericanSpeech-Language Hearing
Association, the Juerger CareerAward for Research in Audiology
for the American Academy ofAudiology, and presented the
2020 Carhartt Memorial Lectureat the Annual Meeting of the
American Auditory Society.
So, all of that said, Larry,it's a joy to have you here.
(01:59):
Thank you for being here andlooking forward to chatting with
you today.
Thanks, I'm looking forward toit too.
Let's start with some relativelyeasy stuff.
What is hearing wellness?
Can you define that for me?
Speaker 3 (02:11):
Well, that's a good point right to start off with.
So you referred to it ashearing wellness and the
Consumer Technology StandardsAssociation has actually defined
hearing wellness and it isbasically the pure tone average
at 500, 1,000, 2,000, and 4,000.
So the same metric that's usednow by the World Health
(02:32):
Organization.
It's the better ear pure toneaverage of those four
frequencies being less than 20dB, you're considered to have
good hearing wellness.
I've been actually interestedin a little bit broader concept
that we refer to as auditorywellness and I'd be glad to
distinguish between those two?
Speaker 2 (02:51):
Yeah, I would love it if you do, because I think
people often confuse hearing andlistening, and this is a very,
very important point forconsumers, for patients, for
professionals.
Hearing is just perceiving ordetecting sound.
That's important, that'sfoundational, very, very cool.
But you don't live there.
You live with listening.
That is the ability tocomprehend sound, to make sense
(03:12):
out of sound, to apply meaningto sound, and I think this gets
to hearing wellness and auditorywellness as well.
So, if you'd spend a fewmoments on that, I'd appreciate
it.
Speaker 3 (03:20):
Yeah, and it's not just listening or comprehending
speech, as you suggested, butit's also auditory wellness,
refers to psychosocial health,so it's beyond even speech.
Is this more comprehensivemeasure?
And hearing wellness?
Pure tone, audiometry,basically, is a component of
(03:51):
auditory wellness.
Sure, and it's kind of as youwere describing it.
It's necessary, but notsufficient to achieve good
auditory wellness, which is amuch broader concept that cuts
into other domains of everydayfunction that are important to
people with hearing difficulties.
Speaker 2 (04:09):
Yeah, I like that a lot and it harkens back to in
2019, I think you know JeffDanhauer, obviously, and Jeff
and I wrote a paper Journal ofOtolaryngology ENT Research back
in 2019.
So six years ago and we saidthis, we said of the 335 million
people in the USA, there'sabout 26 million six years ago,
26 million who had absolutelynormal thresholds but they had
(04:32):
hearing difficulty, listeningdifficulty, speech and noise
complaints and unless theclinician, the audiologist, the
ENT, the dispenser, unless theydo extensive, you know best
practices so speech and noiselistening and communication
assessments, things likeenserunless they do extensive, you
know best practices so speechand noise listening and
communication assessments,things like that they're not
going to find these problems.
They're invisible because theydon't show up on peer channels.
Speaker 3 (04:52):
No, that's exactly right.
That's the one of the mainpoints.
And when we looked at nationalepidemiological data from the
National Health and NutritionHanes Surveys and also the
National Health Interview Surveyand HIS, both are large,
regularly completedepidemiological surveys of
adults in the United States andthere clearly are millions of
(05:13):
people who especially in theHaynes data this is clear who
have audiometrically normalhearing so they would qualify by
the current definition ofhaving good hearing wellness as
implying that they don't needany help, but who self-report
that they have considerablehearing trouble.
Now, because it's anepidemiological study, they
(05:34):
don't delve into details aboutthe kinds of trouble they have,
but in a few follow-up questionsthey did document that the
kinds of difficultiesexperienced include difficulties
in social situations.
They're frustrated with theirdifficulties and they have
difficulties in noise, none ofwhich is a surprise, but it just
further documents that peoplethemselves perceive themselves
(05:58):
to have difficulties even whentheir audiogram qualifies as
being normal based on thecurrent hearing wellness
definition, which is basicallythe World Health Organization's
definition of normal.
So that's what kind of gaverise part of the impetus for
this notion of auditory wellness, that there's more involved and
that my colleagues and I feelthat self-report or perceived
(06:22):
measures are probably as or morevalid to quantify their
difficulties than the audiogram.
Speaker 2 (06:30):
Yeah, and this is such an important point because
and you mentioned NHANES inpassing, but I want to take this
right out of one of your papershere NHANES, for those who
don't know National Health andNutrition Exam Surveys and, as
you said, they do this every fewyears and it's been updated
quite a bit.
And the typical audiometricprofile was bilaterally
symmetric, sloping hearing loss,slight to mild loss, above
(06:50):
2,000.
Group data showed normalemittance measures, absence of
otoscopic abnormalities, exceptfor a little bit of wax.
But the conclusion and I lovethis you wrote tens of millions
of US adults have perceived orself-perceived we could say
right mild to moderate hearingtrouble, but have not pursued
assistance, either throughobtaining a hearing test or
(07:16):
acquiring prescription hearingaids.
And if you go to the GlobalBurden of Disease Study, which I
think came out in 2024 in Earand Hearing, they estimated
72.88 million people.
So let's round that up to 73.
73 million people in the USAhave hearing loss, that's one
out of five people.
And then I believe you'veestimated that about 85 to 90%
of adults who haveself-perceived mild to moderate
hearing loss don't seeamplification.
(07:37):
Am I saying that correctly?
Speaker 3 (07:39):
Yeah, and actually those who have yes, that's true,
because it's hard to tellNHANES measures their audiogram.
It doesn't mean they went tothe clinic to get that audiogram
.
But yeah, roughly 85% of thepeople with either
audiometrically defined need interms of they don't have good
hearing wellness or self-reportdefined mean meaning they report
(08:01):
that they're having hearingtrouble do not have not sought
an obtained hearing aids.
Speaker 2 (08:06):
And these numbers vary, you know, with whatever
study you read.
And a big part of this problemand the variation is that
audiologists, ents, hearing aiddispensers, in the USA we use 0
to 25 as normal and then 26 to40, mild, 41 to 70, moderate, 71
to 90, severe, 91 and aboveprofound.
That seems prettystraightforward but it's also
(08:26):
incorrect.
You know, when you go back to100 years ago Fletcher, I think
in 1929, said normal pure toneperception 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 15dB loss needs to be treated.
So give me your impression onthe variability in audiograms
and these categories ofconvenience that we use.
(08:48):
I mean, what should they be inyour opinion?
Speaker 3 (08:51):
Well, I think, broad brushstroke, the best overall
metric is the most recent oneadopted by the World Health
Organization, which is, in termsof just hearing loss detection.
It's better ear pure toneaverage for those four
frequencies.
That's an important part of it.
5, 1, 2 and 4.
Right, being better than 20 dBHL, so it's not 15.
(09:11):
And I agree.
So it's not 15.
And I agree, it's always.
It's been interesting to methat for some reason I actually
had a different publication thatlooked at this in kids and
adults.
But I've never quite understood.
I mean, I do because we'retalking about development of
speech and language but why isit more important for a child to
(09:32):
have better hearing than anadult?
So anyway, I think the rightanswer in terms of PTA and
trying to draw a simple linesomeplace is probably between 15
and 20.
But the problem with 20, I knowjust from having looked at that
is that it still averages fourfrequencies together and people
can have, for example,considerable hearing loss in
(09:54):
high frequencies and not bedetected.
Frequencies and not exceed thatlimit of 20.
And we went back and looked atseveral people who volunteered
for a study and 20% of them fellin the class that would be
considered normal hearingaudiometrically using that
definition 20 dB HL, not 25, but20.
Better ear those fourfrequencies and 80% of them.
(10:19):
If you looked at them by anaudiologist they'd say, oh yeah,
that person has enough highfrequency hearing loss to
consider hearing aids and so it.
Part of it is the metric andtrying to do use a single number
, but some of them were designedfor epidemiological purposes
where a whole yardstick worksbest in trying to come up with
the best, most valid measure todo that.
(10:40):
But that's different from whatwould be best for a clinician.
Speaker 2 (10:44):
Yeah, the point well taken.
Epidemiologic studies arestudies of large groups of
people that tell you things likeaverages, standard deviations,
how common something is, butthat is not necessarily at all
reflective of the patientsitting in front of you, and so
it's very important to look atepidemiological data as group
data and it may or may notinfluence your diagnosis or
(11:05):
treatment of the patient.
Let's talk a little bit aboutyou know, in October of 22, the
FDA approved over-the-counterhearing aids and I know you've
published quite a few studieslooking at over-the-counter
hearing aids, and I know you'vepublished quite a few studies
looking at over-the-counter andthe results and the predictions,
and I wonder if you can give mean overview statement.
October 2022, the FDA says,okay, we're going to go with
(11:26):
over-the-counter hearing aidsbecause access and affordability
, which were the two primaryimpediments they said we need to
overcome that.
So I've always thought thatmade very, very good sense to me
.
Access and affordability arevery important, but I have some
thoughts on that.
But before we get to mine, Iwant to get your thoughts on it.
Speaker 3 (11:43):
Yeah, no, I think it's an important starting point
access and affordability, andaccess means that.
So some people say, well,aren't those the same thing?
And they're not.
Access is how easy it is to getto the help you want.
And we've looked at studieswhere people have been
identified and screening and nowthere are several studies that
(12:06):
then track those people over thenext several weeks to year and
see the drop off of the numberof people.
And it's not the expense,because several of these studies
were done in the VA.
It's not the expense of thedevice for the services.
It's the inconvenience of going,setting up the appointment,
going there, getting there, andso that's a different kind of
accessibility issue, andover-the-counter in forms of
(12:30):
direct-to-consumer devices canskip a lot of those barriers.
Unfortunately, I'd beenadvocating for many years.
While I was working on thewhole validation of the
self-fitting processes, I wasadvocating for people to start
recognizing that if this happens, it would potentially be worse
(12:53):
if you dump devices that we knowcan be fit and can provide good
benefit but you don't provideany help.
And so people have known, evenin the conventional hearing aid,
prescription hearing aids andconventional delivery systems,
that people need help in theinitial stages of adjusting to
hearing aids.
(13:14):
And then to go to where you canbuy these devices yourself to
not consider the support thatwas needed is, I think the
assumption was well, it's thisdevice you need to make
accessible and affordable.
End of story.
It's not, it's the device isthe starting point, and then you
need to figure out how to alsomake affordable and accessible
(13:38):
support available to the peoplewho make that choose that
pathway.
Basically, yeah.
Speaker 2 (13:43):
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 Medicarealready covers comprehensive
audiometric evaluations.
92557 is the CPT code, and whatmany of us had said is why
(14:06):
don't we, instead of dealing somuch with OTC in particular, why
don't we do this?
Why don't we say that the stepone in obtaining an OTC is you
have to get an audiometricevaluation by a licensed hearing
healthcare professional.
That person would test you,advise you, counsel you and then
you buy whatever the heck youwant.
Obviously, they didn't choosethat route, but we thought it
was very important to suggestthat for exactly the same reason
, because hearing aids are notintuitive.
(14:26):
It's not just a matter of makingit louder.
What most people actually wantis for it to be clearer, not
louder.
In general, you know, adults,people with presbycusis,
age-related issues they wantthings clearer, and so when we
talk about OTC, I think it'svery important that the products
do make things clearer, notjust louder, because if we make
(14:46):
it just louder, the number onecomplaint of all patients with
hearing loss or self-perceivedhearing 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 necessarilyimproved the signal-to-noise
ratio, and we can't reallyexpect it to be clearer when all
we've done is make it louder.
Speaker 3 (15:03):
Yeah, I agree.
So in comments, just about themodel that you had suggested.
I think that still has thisaccessibility barrier in that
you're saying they need to go toan audiologist and get their
hearing tested and then they'llget the counseling and
expectations and other, and thenthey can choose whatever device
they want.
(15:23):
But I think that's why only 15%with trouble have purchased
hearing aids.
Yeah, that's a fair point.
First step, and what I've beentrying to do in part of the
auditory wellness approach, istrying to empower the person to
manage their own auditorywellness.
That takes a lot ofinfrastructure to support.
They have to be knowledgeableabout the importance of hearing,
(15:44):
why hearing matters as a plugfor the program and the consumer
needs to know that.
The consumer needs to beinformed and have tools
available to go through thisprocess.
It's a daunting process becausepeople have never been
empowered to do this before, andmany of them.
When we've looked at follow-upsurveys of people who have been
(16:06):
in some of our clinical trials,it's clear that one of the
limitations to their uptake anduse of the devices is their lack
of confidence in making goodchoices, because they've never
had to do that.
It was always a professionaltelling them this is what you
need, this is best for you, andso, anyway, I think it's a part
of this whole need forinformation and education and
(16:30):
empowering people with hearingdifficulties to manage their own
auditory wellness.
If I may, I'll tell you.
Speaker 2 (16:37):
I was vice president of academic sciences at a major
hearing aid company for 18 yearsand when I left, otc was
happening and quite a few of themanufacturers of OTC sent me
products and said Doug, whereare 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 ofthem I think there were eight of
them because they were terrible.
(16:57):
They were awful and what youdid is you picked a really good
one, and so that's great andthat one makes sense.
I won't say the manufacturer'sname, but they were about $1,700
for a pair.
Most OTC patients are willing tospend $200 or $300 a pair,
according to the researchliterature, and so we still have
this huge disconnect betweenthe better OTCs.
(17:18):
In fact, consumer Reports inJanuary 2025 looked at premium
OTC products, much like the onethat you guys used in your study
, and they said you know, theyrange from about $1,800 to
$2,800 a pair, and so when wetalk about access and
affordability, it's still reallyexpensive, and I always thought
that the primary issue was notprice.
(17:39):
I really did, and I know peoplewill criticize that, but I go
back to the Mike Valente AminAmlani study 2017, 2018, in
American Academy ofOtolaryngology, head and neck
surgery.
And they said you know, the USAis the most expensive place to
buy hearing aids.
That's a fact, seems to be afact.
And then they said you know, ifyou look at countries like the
EU the UK, sweden, norway,denmark, canada, new Zealand,
(18:02):
australia you look at placeswhere hearing aids are free the
uptake is 60% of people say no,I'm good, you know so.
Even when they're free, peopledon't really want them and I
think the main thing about thatis not so much access and
affordability as it is the formfactor.
You know, people just don'twant to be that guy wearing a
hearing aid in general and Ithink it's terrible and it's
(18:22):
cruel and it's rude and peopleshouldn't feel like that.
But hearing aid stigma is ahuge part of this whole
discussion and you know, if youcould just go to WebMD and you
put in hearing aid stigma,you'll find you know 10 or 15
very current last two or threeyears articles saying that most
people are going to shy awayfrom it because of the way it
looks.
Speaker 3 (18:41):
I agree it's a big factor issue for the person with
hearing difficulties toovercome and I think some cases
the form factor forover-the-counter devices was
modeled after earbuds.
That are common in youngeradults and seen more frequently,
(19:03):
much more visible.
But I think the uptake of thatform factor and some of the
acoustical issues, includingfeedback and things that were
occurring occlusion pushedpeople away from that and it
seems like at least my take onthe current over-the-counter
good quality over-the-counterdevices seem to be more like
(19:23):
conventional Rick.
Speaker 2 (19:25):
Larry, before I let you go, I want to talk about
children, and I want to speakspecifically about things like
AirPods and other in-ear devices, the fact that they're looking
at screens all day long, thefact that they will wear
headsets to amplify theirscreens, and things like that.
I have not seen a huge changein hearing loss in children.
(19:45):
One of the papers you publishedin Asher Wire a while ago was
audiograms and prevalence ofhearing loss in children.
One of the papers you publishedin ASHA Wire a while ago was
audiograms and prevalence ofhearing loss in US children,
adolescents 6 to 19.
That was in the Journal ofSpeech-Language Hearing from
ASHA and you said about 15% ofkids have hearing loss and I
think that's pretty much whatI've always known for the last
40 years In your experience.
Is that correct or am I missingsomething?
Speaker 3 (20:06):
That's correct, and I don't think there's evidence of
increased prevalence of hearingloss.
And in this case there is somevariation across the years for
epidemiological data in terms ofhow they defined hearing loss.
But when you use the sameyardstick, really, the numbers
today are no greater, ifanything, maybe slightly less
than earlier estimates, but notnoticeably.
(20:28):
So yeah, I don't see the causefor alarm.
I think there's potentialbecause it's possible now.
So all the evaluation of noiseexposure would focus more on
industrial or occupational noise, and the parameters were kind
of an eight-hour day and theseare the doses, the levels that
(20:48):
you can be exposed to for thatperiod of time, and it's
possible, depending upon thechild and the use, to actually
have high levels for much longerthan that.
And so that's where I thinksome of the alarm or concern has
been.
But I at least.
In the epidemiological data itdoesn't seem to be the case that
there's a much higherprevalence of hearing loss in
(21:10):
that age range.
Speaker 2 (21:12):
All right.
Well, listen, it's an honor totalk to you, dr Humes.
I've been following your careerloosely for many, many years.
Last time, I think, you and Iwere on stage together, 2015, at
the.
Speaker 3 (21:20):
American Academy of Audiology.
Speaker 2 (21:22):
And we were discussing cognition, audition
and amplification and that was10 years ago.
So, listen, I am veryappreciative of being here on
the Hearing Matters podcast andI value your knowledge and your
ability to explain very complexthings very simply.
That's a gift and I'm so gladthat we had the time together.
Speaker 3 (21:40):
Well, thanks, doug.
I appreciate the opportunityand the best wishes for
continued success for you.
Thank you, larry, you too.
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