INTRODUCTION
Physical activity (PA) is a fundamental and modifiable component of healthy aging 1.
Hearing impairment (HI) is a common condition at older ages. Several consequences of HI are hypothesized to be mediated by lower PA. However, whether older adults with HI have lower levels of PA is not well-understood.
METHODS
We conducted a systematic review of the association between HI and objectively measured PA among adults older than 50.
Using controlled vocabulary for HI and PA concepts, we conducted a literature search in Medline (Ovid), Embase, and Cochrane Library (supplemental materials).
The results were merged using EndNote (Clarivate Analytics) and imported into Covidence (Veritas Health Innovation). We followed a dual blinded review process for screening; a third reviewer resolved discrepancies. The final decision to include/exclude was based on the pre-specified criteria.
RESULTS
Of 1,127 unique studies; nine were selected by reviewers, and four were excluded after a full-text review (different outcome=3, different exposure=1), leaving five studies (Supplementary Materials S1).
The included studies (Table 1) had between 184 and 1,669 participants; all were cross-sectional and used the same data source—the National Health and Nutrition Examination Survey (NHANES) 2003–2006 cycle. One study included only participants with diabetes.
Table 1.
Characteristics, physical activity (PA) metrics, and findings of the included studies.
| Study | Study Population | Hearing Assessment (Pure-tone audiometry) |
Physical Activity Metric (Accelerometry-derived) |
Confounders | Findings |
|---|---|---|---|---|---|
| Gispen (2014)6 | N=706 NHANES 2005–06 participants, age 70+ |
HI categories: normal hearing, mild, and moderate or greater impairment |
Meeting PA guidelines (Inactive, 0 MVPA min/week; insufficiently active, 1–149 MVPA min/week; sufficiently active, ≥150 MVPA min/week) |
Age, sex, race, education, and income; cardiovascular disease (defined as history of coronary artery disease, congestive heart failure, angina pectoris, or myocardial infarction), hypertension, stroke, and smoking status | Mild hearing impairment not associated with PA category. Moderate hearing impairment associated with greater odds of being in the next lower PA category (OR=1.85 [ 95% CI:1.01 to 3.41]) but no longer in a model that included BMI (OR=1.70 [95% CI: 0.99 to 2.91]) |
| Choi (2016)7 |
N=1,669 NHANES 2005–06 participants, age 70+ |
1. HI categories: normal hearing, mild, and moderate or greater impairment 2. Normal hearing vs. any hearing impairment 3. BPTA, continuously |
Meeting PA guidelines (inactive, 0 MVPA min/week; insufficiently active, 1–149 MVPA min/week; sufficiently active, ≥150 MVPA min/week) |
Age, sex, race, education, income, hypertension, cardiovascular disease, stroke, and smoking status | Any hearing impairment, and moderate or greater impairment associated with greater odds of being in the next lower activity category (Any: OR=2.2 [95% CI: 1.1, 4.3], Moderate: OR=1.9 [95% CI: 1.0 to 3.4]) |
| Loprinzi (2013a)4 | N=1,445 NHANES 2003–06 participants, age 70+ |
HI categories: normal hearing vs. any hearing impairment |
Time spent in MVPA (minutes/day) | Age, BMI, race/ethnicity, sex, comorbidities, education, cotinine levels, c-reactive protein, valid accelerometry days, and wear time. | Hearing not associated with MVPA minutes: IRR 0.97 [95% CI: 0.88, 1.08] Significant interaction term (hearing impairment * vision impairment) |
| Loprinzi (2014)5 | N=184 NHANES 2003–06 with diabetes, mean age=58.5 |
HI categories: normal hearing, mild, and moderate or greater impairment |
Time spent in MVPA (minutes/day) | Age, BMI, race-ethnicity, sex, education, marital status, number of comorbidities, c-reactive protein, cotinine, homocysteine, HDL cholesterol, HbA1c, microalbuminuria, noise exposure, vision impairment | Mild hearing impairment associated with 0.07 [ 95% CI: 0.01, 0.60] times fewer MVPA minutes. Moderate or greater hearing impairment associated with 0.06 [95% CI: 0.01, 0.54] times fewer MVPA minutes |
| Loprinzi (2013b)8 | N=682, age 55+ and N=502, age 65+ |
HI categories: normal hearing, mild, and moderate or greater impairment |
Time spent sedentary (minutes/day) | Age, sex, race-ethnicity, poverty-to-income ratio, self-report arthritis and coronary heart disease, BMI, diabetes, hypertension, homocysteine, c-reactive protein, disability, wear time/day, days of wear | Normal hearing associated with fewer log-transformed sedentary minutes (β=−0.07 [95% CI: −0.12, −0.01]) only among participants ≥65 years |
Abbreviations: NHANES, National Health and Nutrition Examination Survey; WHO, World Health Organization; MVPA, moderate-vigorous physical activity; BMI, body mass index; HDL, high-density lipoprotein.
Hearing assessment
Audiometry was performed by trained NHANES examiners2. Hearing was defined by the speech-frequency (500, 1000, 2000, and 4000 Hz) pure-tone average of the better hearing ear and categorized into normal hearing (<25 dB HL), mild HI (25–39 dB HL), and moderate or greater HI (≥40 dB HL).
Physical activity assessment
PA was assessed, for seven consecutive days, using a hip-worn accelerometer (AM-7164, Actigraph, Pensacola, FL.), only removed during sleep and water-based activities. PA was summarized into counts per minute (CPM).
Studies calculated the time spent at different activity intensities, using predefined CPM thresholds: sedentary (<100), light (100– 2,019), moderate (2,020–5,998), and vigorous (≥5,999)3.
Two studies used moderate and vigorous (MVPA) minutes per day as an integer variable for their outcome; two studies used MVPA minutes to categorize participants into inactive (0 MVPA minutes/week), insufficiently active (1–149 MVPA minutes/week), and sufficiently active (≥150 MVPA minutes/week)1. Finally, one study used log-transformed sedentary minutes.
Findings
The studies’ findings are summarized in Table 1
Time spent in MVPA
One study4 investigated the association between hearing and vision impairments and time spent in MVPA. Neither mild nor moderate or greater HI were associated with PA.
Another study5 investigated the association between HI and MVPA minutes among participants with diabetes. Mild and moderate or greater HI were associated with fewer MVPA minutes vs. normal hearing.
Meeting the physical activity guidelines
Of the two studies that used this metric, one6 found increased odds of being in the next lower activity group (e.g., inactive vs. insufficiently active) for those with moderate or greater HI vs. normal hearing. However, after BMI adjustment, the association was no longer significant. The second study7 also found increased odds of being in the next lower PA group for those with moderate or greater HI, vs. normal hearing. Both studies found no significant association between mild HI and PA.
Sedentary time
The last study used log-transformed sedentary minutes (LTSM)8 and found that participants aged >65 years with normal hearing engaged in 0.07 (95% CI: −0.12, −0.01) fewer LTSM per day .
DISCUSSION
Five studies analyzed the association of HI with objectively measured PA, all using NHANES data. The studies suggest that older adults with HI, particularly moderate or greater, may have lower PA levels and spend more time sedentary. However, two studies found no statistically significant associations4,6. Moreover, the PA metrics used in these studies have limitations. First, the validity of the CPM thresholds to classify PA intensities for older adults is unknown. Second, MVPA may be unattainable in the study population due to limited functional status. Third, using only MVPA minutes ignores differences in light intensity activity—the most common form of PA among older adults. Finally, emerging research suggests that novel PA metrics such as total PA volume, diurnal patterns, and fragmentation of activity may provide more discriminatory power in older populations than traditional PA measures9. A study published after our search was completed investigated the association between HI and these novel PA metrics, finding that HI was associated with lower total PA volume and more PA fragmentation10.
Conclusion
Five studies investigated the association between HI and objectively measured PA in NHANES. Overall, hearing impairment was associated with lower levels of PA. The analyses and interpretation of some accelerometry metrics had limitations. Studies that use novel accelerometry-derived PA metrics are warranted.
Supplementary Material
Supplementary Material S1: Systematic literature search strategy for hearing impairment and objectively measured physical activity
ACKNOWLEDGEMENTS
We thank Lori Rosman, MLS from the Johns Hopkins Welch Medical Library for her guidance and support in the development of our search strategy.
DISCLOSURES AND FUNDING:
Pablo-Martinez Amezcua and Jonathan J. Suen were supported by the Cochlear Center for Hearing and Public Health. J.J. Suen is also supported by the National Institute on Aging grant F31 AG071353.
Jennifer A. Schrack is supported by the National Institute on Aging grant R01 AG061786
Jennifer A. Deal is supported by the National Institute on Aging grant K01 AG054693
Sponsor’s role
The authors’ sponsors had no role in the design, methods, data collection, analysis, or preparation of the paper.
Footnotes
Conflict of Interest
Frank R. Lin is a consultant to Frequency Therapeutics, received speaker honoraria from Caption Call, and director of the Cochlear Center for Hearing and Public Health—a public health research center funded in part by a philanthropic gift from Cochlear Ltd to the Johns Hopkins Bloomberg School of Public Health.
All other authors have nothing additional to disclose.
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Supplementary Materials
Supplementary Material S1: Systematic literature search strategy for hearing impairment and objectively measured physical activity