Diabetes and Hearing Loss: A Roundtable Discussion



Author: Brian Taylor, Au.D.; June M. McKoy, MD; Jeanette Flom and Sanreka R. Watley

The preponderance of medical literature suggests that hearing loss is more than twice as common in adults with diabetes compared to those who do not have the disease. According to one new study funded by the National Institutes of Health, 21% percent of the diabetics surveyed had hearing loss, compared to only 9% of non-diabetics. The relationship between hearing loss and diabetes presents a significant opportunity for audiologists to partner with family physicians and others in the care of the diabetic patient. Not only can audiologists evaluate the hearing of diabetic patients, they can provide comprehensive rehabilitation services when necessary. In addition, audiologists can play a role in helping patients with Type II diabetes maintain a healthy lifestyle. As the delivery of healthcare continues to rapidly evolve, audiologists that become an integral part of a primary care physician's “preventive care team” are likely to experience greater stature within their community and growth in their practice.

I recently convened a virtual panel of experts that examined several facets of care for patients with Type II diabetes. Let me briefly introduce the panel. June M. McKoy, MD is Associate Professor of Medicine at Northwestern University. Feinberg School of Medicine in Chicago. Dr. McKoy is part of a premier medical institution that delivers care to diabetic patients. Jeanette Flom is Executive Director of the Chicago/Northern Illinois area for the American Diabetes Association (ADA). She is the primary staff partner to the volunteer Community Leadership Board for the ADA. Her staff oversight responsibilities include community education, advocacy, and fundraising from events, foundations, individuals and corporate relations. She has primary responsibility for aligning the Chicago market with the national strategic plan for diabetes prevention and education, and exceeding annual fundraising targets. Sanreka R Watley is a physician education liaison at Northwestern University, Department of Communication Sciences and Disorders in Evanston, IL. Ms. Watley has extensive experience representing pharmaceutical companies.

Dr. Taylor: It’s been awhile since I took Introduction to Human Anatomy & Physiology. What is the underlying physiology of Type II diabetes and how might it cause hearing loss?

Dr. McKoy: To be brief, there are two basic underlying causes of Type II diabetes:
  • Decreased production of insulin from the beta cells within the pancreas in response to elevated blood glucose level
  • Impairment in glucose entry into the cell for energy use. In essence, even where insulin production and secretion are fine, a deficit exists in the binding of insulin to specific cellular receptors, thus negatively impacting glucose entry into cells
In terms of hearing loss, over time high blood glucose levels may lead to damage to the nerves and blood vessels of the inner ear. This results in sensorineural hearing loss.

Dr. Taylor: I’m sure it’s a lot more complicated than that, but our readers will appreciate the refresher. In your current caseload, what percentage of patients is diabetic or pre-diabetic?

Dr. McKoy: Currently, both those groups taken together is approximately 35 percent.

Dr. Taylor: We’ve heard that diabetes is an epidemic. Just how many people suffer from it? And, why is the number so high?

Ms. Flom: Diabetes is an epidemic. Each year the disease takes more than 300,000 lives- that’s more than AIDS and breast cancer combined! Today there are nearly 26 million American children and adults living with Diabetes and 79 million living with pre-diabetes. If current trends continue, as many as 1 in 3 American adults will have Type II diabetes by the year 2050.

The SEARCH for Diabetes in Youth study, funded by the Centers for Disease Control and Prevention and the National Institutes of Health, is assessing diabetes burden in children and youth younger than 20 years in five geographically dispersed populations that encompass the ethnic diversity of the United States.

SEARCH investigators found that, overall, the prevalence of Type II diabetes had increased 21 percent among American youth from 2001-2009, while Type I diabetes rose 23 percent. While the reasons for increase in Type I diabetes are unknown; researcher suggest some of the factors that are helping to lead in the increase in Type II diabetes have to do with lifestyle behaviors such healthy eating and being physically activate.

Dr. Taylor: Indeed, it sounds like a problem of epic proportions. Dr. McKoy, could you elaborate on some of the studies that have examined the relationship between hearing loss and diabetes? What are the general findings?

Dr. McKoy: Sure. The general study findings are that there is a relationship between hearing loss and diabetes. In 2008, Bainbridge and colleagues reported their findings from analysis of data from the National Health and Nutrition Examination Survey (1999-2004) in the Annals of Internal Medicine. They looked at data for 5140 non-institutionalized adults (20 to 69 years) who had audiometric testing. Hearing impairment was assessed over a range of frequencies and defined as mild or greater severity (pure tone average >25 decibels hearing level [dB HL]) and moderate or greater severity (pure tone average >40 dB HL). They found more prevalent hearing impairment among adults with diabetes that was independent of known risk factors for hearing impairment, such as noise exposure, ototoxic medication use, and smoking.

In January 2013, Horikawa and colleagues published the findings of a meta-analysis in the Journal of Clinical Endocrinology and Metabolism. The meta analysis included 13 eligible studies (1977-2011) examining the link between diabetes and hearing loss. There were 20,194 participants; 7,377 with diabetes and 12,817 persons without diabetes. They found that persons with diabetes were 2.15 times as likely as those without diabetes to have hearing loss. The authors concluded that the higher prevalence of hearing impairment in diabetic patients compared with non-diabetic patients was consistent regardless of age and other factors, such as a noisy environment.

Dr. Taylor: That’s great information that is very current. What further research is needed?

Dr. McKoy: Recent studies have utilized data based on patient self reports in terms of their diabetes diagnosis. Future studies need to be based on more objective data, such as hemoglobin A1C levels coupled with audiometric findings. Separation of patients into Type I and II diabetes in order to ascertain differences in underlying pathophysiology and hearing impairment is also needed.

Dr. Taylor: I know that the American Diabetes Association is a large organization. Just how broad a reach does it have and what role does the play with patients? Also, how can health care professionals, like audiologists utilize the ADA?

Ms. Flom: Because the American Diabetes Association is the authority on diabetes, we received millions of visits to www.diabetes.org. On an average three month period, the association receives about 3.7 million visits to our websites. In addition, 1-800-DIABETES, the association’s call center provides individuals with personal information on diabetes, as well as programs and events. Each year, more than 300,000 people contact us with questions and concerns, or to seek support or direction regarding diabetes and its management.

Here in Chicago, the association also provides direct access to diabetes education to more than 200,000 community members and partners annually through our programs and outreach events. Health care professionals such as audiologists can utilize the association in a number of ways such as volunteering to lead workshops in the community, participating in our outreach events and or encouraging your patients to get involved in our year round activities and programs.

Dr. Taylor: My guess is that in addition to taking medication or insulin, diabetics need to change some core lifestyle behaviors. Is that true? Once a patient has been diagnosed with Type II diabetes what role do you play?

Ms. Flom: While you cannot prevent Type I diabetes, research suggests maintaining a healthy diet combined with increased physical activity go a long way in preventing Type II diabetes. In addition, providing updated education on ways to better manage diabetes is critical to the heath of patients living with Type II diabetes.

That’s why each year the association helps to provide diabetes management education to thousands of community members through our highly successful outreach programs, such as Live EMPOWERED, Por Tu Familia. Each program employs an evidence-based, education model combined with offering resources that reflect the needs of the communities served. These impact programs continue to increase knowledge, change behaviors and improve individuals’ ability to better manage their diabetes.

Dr. Taylor: Let’s get Ms. Watley involved in the dialogue. One of the big challenges audiology practices face is raising the awareness of the negative consequences of hearing loss among the diabetic population. First, tell us your role in the Northwestern University clinic? Second, what are some tactics you rely on to raise awareness among the diabetic community in the area around Northwestern?

Ms. Watley: Currently, I work as a Physician Liaison for Northwestern University, educating primary care physicians, other providers, and patients and the medical community about the medical consequences of hearing loss and link between diabetes and hearing loss. My goal is to disseminate the growing body of outcome- based clinical research linking hearing loss and other medical conditions to the outside community.

When it comes to educating thought leaders and the public about diabetes, my goal is two-fold. My first goal is to educate physicians of the need to test the hearing of diabetic patients, since this group has twice the normal risk of hearing loss. My second goal is for those physicians to consider the possibility of diabetes in their hearing impaired patients.

To accomplish this change in the standard of care for both diabetic and hearing impaired patients our strategy is to partner with key thought leaders to “educate to obligate”. We’ve found educating endocrinologists is the key to the more frequent hearing testing of diabetes patients. The new standard of care should require that diabetics receive hearing testing on an annual basis (just as they currently receive testing for neuropathy and other major organ systems that negatively impact their quality of life.) Few people know that Northwestern University is the “Birthplace of Audiology.” We have always been pioneers in the profession. My goal now is to continue that tradition as we move into a new era in which the audiologist becomes a crucial member of the overall medical team.

Dr. Taylor: How might an audiologist become more actively involved in the preventive care of diabetic patients?

Ms. Watley: New healthcare reform laws will make audiologists that much more important to larger healthcare systems. Those systems will now be incentivized to control hearing loss to control later costs associated with the higher risk of diabetes, dementia, depression and a host of other conditions.

We have to be proactive as these changes take place. That means working now to require audiologists to become more involved with all patients who are at risk of hearing loss. It’s imperative that audiologists begin to build relationships with the medical community. We do that at Northwestern with an active physician education program. Our goal is to insert ourselves as early as possible in the progression of diabetic hearing loss. That way we can minimize the consequences of hearing loss and, perhaps, slow down its progression.

Physician liaisons, like me, are likely to play a larger role in bridging audiology to other healthcare providers. Audiologist must also be willing to step out of the box and join non-traditional industry associations such as American Diabetes Associations, Endocrinology Associations, and local Certified Diabetes Educators. Partnering with these organizations that support patient education will show industry commitment. Relationship building will lead to greater awareness and patient referrals.

Dr. Taylor: Tell us about some of the initiatives you are working on at NU and how an audiologist might translate into common practice.

Ms. Watley: Besides reaching out to the physician community at Northwestern, we’re also stepping outside the box to join nontraditional industry associations such as American Diabetes Associations, Endocrinology Associations, and local Certified Diabetes Educators. Partnering with these organizations supports patient education, reinforces our commitment, and ultimately leads to greater awareness and patient referrals.

In addition, we’re cautiously investigating new arrangements with traditional health insurance entities. As audiologists work more closely with the medical community (and develop closer relationships to larger healthcare systems), our financial structure is likely to change. At Northwestern, we’re already marketing our tradition of excellence to the rest of the medical community. We have to let them know going in that they are dealing with a cutting-edge, top-tier facility.

These are lessons that, I think, apply to many audiology practices. Healthcare reform is stressful, but the good thing is that it finally puts audiologists where they should be....on the front lines of medical care. The goal is to stay ahead of these changes and to maintain as much control as possible over both patient care and revenue streams.

What motivates me is the belief that ultimately patients will benefit as audiologists become more involved, and at an earlier stage, in their care. What’s more, as patients benefit our profession will benefit as well. As George Merck (founder of Merck) said, “Take care of the patient and the profits will follow.”

Dr. Taylor: What other insights could you share with audiologists?

Ms. Watley: Identify 5 to 10 family medical practices within your area and provide them with the evidence demonstrating the relationship between diabetes and hearing loss. This information comes directly out of the medical literature, some of which Dr. McKoy cited earlier. We summarize it, so that it is easier for the physician and staff to digest. Readers can contact me directly if they want more information about the specific educational material we use. Also, it can take up to seven direct face-to-face encounters with a physician or staff before they begin to refer diabetic patients to you.

As you know, Brian, it is the relationship that really counts. Of course, we try to educate physicians about several other disease states with a higher than average incidence of hearing loss, but those topics are probably best covered in another round table.

Dr. Taylor: This is great information. I want to add that Ms. Watley and Northwestern University have the start of what appears to be an effective template for success. I also wanted to close our virtual roundtable discussion by mentioning that Dr. Kathy Dowd, a private practice audiologist in North Carolina, along with several students from Salus University, provided hearing screenings and literature at the recently concluded annual meeting of the American Association of Diabetes Educators. Their goal was to raise awareness among this group on the important role audiology can play with their patients.    

June M. McKoy, MD MPH JD*MBA is an Associate Professor of Medicine at Northwestern University Feinberg School of Medicine in Chicago, IL. She can be contacted at j-mckoy@northwestern.edu.

Jeanette Flom is Executive Director of the Chicago/Northern Illinois area for the American Diabetes Association.

Sanreka R Watley is a physician liaison at Northwestern University School of Communication, The Roxelyn and Richard Pepper Department of Communication Sciences and Disorders, in Evanston, IL. She can be contacted at sanreka.watley@northwestern.edu.

Brian Taylor, Au.D. is Editor of Audiology Practices. He can be reached at brian.taylor@unitron.com.
The Silent Epidemic Requires a Loud Voice from You
Author: Kathryn R. Dowd, Au.D.

The preceding roundtable discussion from a panel of experts on the topic of diabetes is a call to action for audiologists. The panel provides a compelling reason for the partnership between audiologists and medical professionals directly involved with the diagnosis and on-going care of patients with Type II diabetes. Recently, I had the privilege of leading a group of dedicated future audiologists on a project to further this relationship. On August 7-9, 2013 the Academy of Doctors of Audiology (ADA), along with a grant from Unitron, sponsored a booth at the American Association of Diabetes Educators (AADE) to raise awareness of the link between diabetes and hearing loss. AADE is an organization of more than 13,000 members including certified diabetes educators, pharmacists, registered dietitians, nurse practitioners, physician assistants and registered nurses. Over 5,000 members and exhibitors attended their recent conference in Philadelphia, PA.

The Academy of Doctors of Audiology booth supplied AADE members with a CD containing research and screening tools that diabetes educators can use immediately with their patients. Many diabetes educators heard of the link between hearing loss and diabetes for the first time during the conference. Joanne Rinker, CDE, RD and National Diabetes Educator of 2013 presented a session at the conference about hearing loss, diabetes and depression.

The big question from most of the AADE members who came to ADA’s booth was “Why am I just now hearing about this?” The answer may lie in the fact that the National Institute of Deafness and Communication Disorders (NIDCD), the National Institute of Health (NIH) agency that sponsors research on hearing, does not have a budget for education. NIDCD research findings are not disseminated to other government and national agencies like CDC or the American Diabetes Association for public education and policy making. In contrast, the National Eye Institute (NEI) has an education budget and can immediately translate new research findings into educational materials for all national and government agencies for immediate policy updates and new standards of care.

So, the gentleman who stood in front of the Academy’s booth with his mouth open in disbelief and who said with incredulity, “ What is this?!? Where did this come from? Why is this the first time I am hearing about this?” was typical of many responses of AADE members who visited the ADA booth. The gentleman was a writer and now has the ADA material in hand.
Three Salus University students at the ADA booth during the recent AADE conference


The Academy has put valuable information in the hands of direct service providers to patients with diabetes. The educators said they would use the screening forms with their patients in education classes. We stressed finding a local audiologist as a referral resource for screening failures and helped the educators find an audiologist on ADA’s website.

ADA members need to strike while the iron is hot. What can ADA members do now to continue the momentum from the AADE conference?
  1. Contact your local diabetes educator groups and offer to present on diabetes and hearing loss. Please contact me at the e-mail below for a list of diabetes educators who attended this conference that might be in your area.
  2. Go to your state diabetes agency and request that they add hearing screening to their state strategic plan for diabetes education. North Carolina is the sole state with this directive.
  3. Add a Diabetes Management webpage to your website and use ADA information for patients and healthcare providers to view and download. Offer a Diabetes Management program in your practice.
  4. Attend the session regarding Chronic Disease Management at the ADA conference this fall in Bonita Springs FL.
A special thanks to the Salus University students who volunteered at the ADA booth! These students are the voices for the future of audiology. They provided important campaigning for audiology causes at the AADE conference. Kathryn R. Dowd, Au.D is in private practice at Hearing Solution Center, 135 S Sharon Amity Road, Suite 208, Charlotte, NC 28211. Dr. Dowd can be contacted at kdowd@carolina.rr.com.
Diabetes and Hearing Loss: 5 Facts You Need to Know
  1. There is a proven link between diabetes and hearing loss in adults over the age of 60.

    The same microvascular changes which often lead to nephropathy and retinopathy in diabetic patients, can lead to damage to the microstructures of the cochlea. One recent peer reviewed survey1 indicates that 21% of diabetics had hearing loss, compared to 9% of non-diabetic adults. For diabetic patients over the age of 60, the prevalence of high frequency hearing loss rose to 54%, compared to 32% of non-diabetic adults of similar age.

  2. Diabetic patients should have their hearing screened when identified with diabetes. Given the relationship between diabetes and hearing loss, patients who are identified as diabetic should have their hearing screened by a licensed audiologist. Earlier identification of hearing loss often leads to more successful remediation strategies and better patient outcomes.

  3. Diabetic patients may have a progressive hearing loss.

    It is possible that diabetic patients can have normal or near-normal hearing at the time of the initial identification of diabetes, only to suffer from a progressive form of sensorineural hearing loss.2 Therefore; diabetic patients should have their hearing screened annually.

  4. Hearing loss of adult onset often contributes to social isolation, cognitive loss and depression. Studies indicate that adults with mild to moderate-severe hearing loss are more likely to suffer the effects of social isolation and withdrawal, including depression, cognitive deficits. 3,4

  5. Auditory rehabilitation, including hearing aids may help.

    A peer-reviewed study conducted by the National Council on Aging of over 2000 participants with hearing loss provides evidence of the benefits of hearing aids, including improved overall health, better interpersonal relationships and a reduction in frustration, anxiety and depression. An audiologist is trained to provide a comprehensive solution to hearing impaired, including the provision of hearing aids, if necessary.5 The evidence suggests diabetic patients need to have their hearing screened annually. Please consider referring your diabetic patients to your local audiologist for a hearing screening and any necessary follow-up.
References
1 Bainbridge, K. et al (2008) Diabetes and hearing impairment in the US: Audiometric evidence from the national health and nutrition examination survey, 1999 to 2004. Annals of Medicine. 149, 1, 1-10.

2 Hendricks, J. et al (2006). Progressive sensorineural hearing impairment in maternally inherited diabetes mellitus and deafness (MIDD). Otology Neurotology.27, 6, 802-808.

3 Mulrow, C. et al (1990). Quality-of-life changes and hearing impairment. A randomized trial Annals of Internal Medicine. 113, 3, 188-194.

4 Lin F. et al (2011). Hearing loss prevalence and risk factors among older adults in the United States. Journal of Gerontology. 66A, 5, 582-590.

5 The consequences of untreated hearing loss in adults. May, 1999. National Council on Aging: White paper. This information was provided by the Academy of Doctors of Audiology to be shared with diabetes educators, physicians and other medical professionals.