Sydney audiologist DR CELENE MCNEILL and Macquarie University Hearing postdoctoral Research Fellow and dietitian DR DIANA TANG discuss the potential role of diet and nutrition in hearing loss, ear health and ear disorders.

Food is increasingly being found to have a significant role in preventing, managing and helping to treat various conditions. Studies are also growing looking at what role nutrition may have in hearing and ear disorders.

Sydney audiologist Dr Celene McNeill says evidence indicates the relevance of diet and nutrition in preventing and treating ear disorders. She says lifestyle modifications including nutritionist referrals are relevant clinical tools in audiology, and suggests audiologists consider patients’ lifestyle and nutrition in the prevention and management of hearing and balance function.

Dietitian and Research Fellow Dr Diana Tang says Macquarie University Hearing research shows there may be an association between poor diet and increased risks of age-related hearing loss and tinnitus, with fish, zinc and iron being possible protectors. But she says overall data isn’t strong or consistent enough yet for audiologists to advise that good nutrition prevents or protects against hearing loss.

By Dr Celene McNeill PhD

Healthy Hearing & Balance Care, Bondi Junction, NSW

My interest in nutrition and health goes back a long way. I have always been intrigued by why we give so much faith to medication to treat illnesses while ignoring the effects of food in the body. I wonder if we would have more scientific evidence on the effects of food on our health if farmers funded medical research as much as pharmaceutical companies do.

The potential effect of poor diets as the root cause of some ear disorders is vastly neglected. We tend to accept that most diseases are caused by intrinsic and extrinsic factors while overlooking food consumption, or the lack of, as a contributor.

Western diets are mostly based on processed and ultra-processed foods that our bodies do not even recognise as nutrients. According to Watanabe¹ et al (2024), Australia comes second to the US for the highest consumption of ultra-processed foods in the world.

A study from 2019 (Jung²et al) showed that high levels of carbohydrates, cholesterol and fats in the diet affect hearing health. The researchers showed that a lack of vitamins A, B, C, D and/or E as well as minerals like zinc, magnesium, selenium, iron and iodine, increase the risk of hearing loss. An appropriate diet seems the best prevention as the body draws these nutrients from the foods we eat and not from the medicines we take.

A recent literature review on the effects of diet and lifestyle on audio-vestibular dysfunction (Chen³et al 2022) found 24 relevant publications on the topic. These studies showed compelling evidence on the effects of diet and nutrition in hearing, although there were not many references about the vestibular system. Research is still lacking in this field. Nevertheless, available evidence indicates the relevance of diet and nutrition to prevent and treat ear disorders as well as health conditions in general.

I had a personal experience after modifying my diet, following research on nutrition, with incredible results.  I had ongoing issues with one knee and shoulder which I could barely move. The prescribed treatment was cortisone injections to reduce inflammation but I did not want to proceed as I knew it was only a “band-aid” to give temporary relieve.

I also had gastroesophageal reflux disease and was prescribed a popular proton pump inhibitor which can deplete the body of vitamin B12, important for brain health.

Four years ago, I started researching foods that could be affecting my conditions and discovered evidence that dairy and gluten were the main culprits for inflammation affecting the joints. I removed dairy and gluten from my diet and started eating only real food such as fresh fruit, vegetables and meat.

In three months I became pain and reflux free, recovered full movement of my knee and shoulder and lost 15kg. My experience and research gave me the confidence to start discussing diet and nutrition with my patients in the audiology clinic.

Audiologists’ scope of practice encompasses prevention, assessment and rehabilitation of hearing and balance function. Patients of all ages from birth to the elderly seek our services as we are qualified to perform diagnostic tests to investigate the integrity of the auditory and vestibular pathway to help identify any lesion causing loss of function. ENTs and other specialists rely on our test results to diagnose and treat ear pathologies with medication and/surgeries, when available.

At present, however, most ear disorders causing hearing loss and balance disturbances have no available medical cure, so patients rely on non-medical methods and techniques to improve their symptoms and quality of life.

Audiologists play an important role, providing counselling, technology and methods to manage hearing and balance disorders after any life-threatening pathologies have been properly investigated and treated by medical specialists.

The focus of audiological rehabilitation in Australia lies mostly on the provision of hearing aids and implants. Our university master’s degree training qualifies us to provide more than that. The Australian health funding model may be to blame for this situation, leaving patients with hearing and balance conditions without any further management or rehabilitation if hearing devices are not the solution for them.

Consider diet in assessment and management

Lifestyle modifications including nutrition, in my view, are relevant clinical tools in audiology. Nutrition is an integral part of health and that includes the ear. The foods in our diets potentially affect the prevention, causation and management of hearing and balance disorders.

Patients’ lifestyle and diets should be considered in their case history and part of the audiological assessment and management plan. Referrals to a doctor who practises integrative medicine or to a functional nutritionist might be as valuable as to an ENT and other specialists.

There is compelling evidence that diets high in sugar, fat, dairy, gluten, corn, soy, preservatives and heavy metals can cause insult to the ear causing symptoms of hearing loss, tinnitus and dizziness. It is important to refer patients for appropriate investigations using more integrative medical approaches.

Consideration of nutrition in the audiology clinic is not a new concept. In 2003, at a conference organised by the Australian Association of Audiologists in Private Practice (now Independent Audiologists Australia), late audiologist Dr William Tonisson suggested audiologists should offer nutrition advice to patients such as those with a high frequency hearing loss like in presbyacusis, stating it could be an early sign of heart disease.

Dr Tonisson suggested audiologists should discuss the benefits of low sugar and fat diets to prevent high frequency hearing losses and vascular diseases. His suggestion was not well received by peer audiologists on this occasion.

Years later, at an ACAud  (Australian College of Audiology) congress, South Australian audiologist Ms Kelly Korcec presented a case study of a patient with Ménière’s disease who had symptoms reversed by following a gluten-free diet. Again, the topic was not embraced by the audiology community.

A recent literature review (Chen³et al, 2022) found evidence that diet significantly impacts ear health and when the effects are negative, it causes symptoms like hearing loss, tinnitus and vestibular disturbances such as dizziness and vertigo. The effects of nutrition on ear health seem much stronger than accounted for.

Include nutrition and diet in patient history

Of course, audiologists are specialised in hearing and balance function, not nutrition,  but some knowledge on the topic should be a welcome addition to our toolkit. We already consider many probable causes of hearing and balance conditions in our assessments such as hereditary, medications, noise and toxic exposures. Diet and nutrition should also be part of the history taken.

Children referred to us for assessment of middle ear diseases, for example, may be identified with possible allergies and food intolerances as the root cause of their problems, with dairy usually being the main culprit. This should be reported to the referring source for further investigation. 

It is also common for children diagnosed with auditory processing disorders to have associated food intolerances and allergies. We can provide all the training and rehabilitation required to improve their processing skills, but the results may not be sustainable if we are not addressing the root cause. Reporting all identified potential causes of an audio-vestibular disorder and making appropriate referrals is part of our scope of practice and can only benefit our patients.

Diet resolving Ménière’s disease

In Ménière’s disease, my main topic of interest, there is increased evidence that some patients control their symptoms by changing their diet and lifestyle. There is no current cure for Ménière’s  and the aim of medical treatment is to manage symptoms, especially vertigo.

There is an arsenal of medications prescribed for this population attempting to reduce vertigo attacks, nausea and vomiting. But not many practitioners check patients’ diet and lifestyle. There is only emphasis on salt restriction for these patients even though there is no strong evidence that it works for most.

Diuretics are also widely prescribed for Ménière’s patients despite studies showing that increasing water intake has the same result with no negative side-effects. (Naganuma⁴ et al, 2006).

Recent research by ENT surgeon and neuroscientist, Professor Jose Antonio Lopez-Escamez and his team at the Kolling Institute, Sydney University and Granada University, Spain, confirms that Ménière’s symptoms are caused by inflammation in the inner ear (Frejo⁵ et al, 2024).

These findings endorse a case study published in 2013 of a patient who had all symptoms resolved after following a gluten-free diet. The inflammatory properties of gluten, researchers concluded, were responsible for inner ear inflammation leading to symptoms of fluctuating ear fullness, tinnitus, hearing loss and vertigo  (Di Berardino⁶ et al). In my clinical practice I  have come across similar results.

Unfortunately, the current approach to address inflammation in ear diseases is to use anti-inflammatory drugs without considering the possible effects of patients’ diets that could be increasing inflammation in the first place. I am not disregarding the utility of pharmaceutical drugs to alleviate acute symptoms but appropriate diet and nutrition should also be part of any treatment.

In September 2024 I attended a conference in Brazil organised by the Fundacao Otorrinolaringologia (FORL) or Brazilian Otolaryngology Foundation. Endocrinologist Dr Delane Goldbach delivered a session on culinary medicine, describing the positive outcomes of reducing high levels of glycaemic and lipid index in a group of sick patients after teaching them “cooking skills” instead of prescribing medication.

Many in the study group also experienced tinnitus and dizziness due to their metabolic disorder and had these symptoms resolved by her approach. Dr Goldbach’s treatment methods included educating patients on healthy food habits such as how to read and interpret food labels as well as preparing and cooking meals.

The genetic profile of individuals is also an important consideration when it comes to the effects of food and nutrition; what affects one person may not affect the other and it is not one size fits all. Current developments in genetic research mean we will be able to provide individualised treatments for each patient’s genomic profile. The influences of epigenetics such as the food we eat and the environment we live in will also play an important role.

It seems unlikely that conventional western medicine in Australia will embrace such approach any time soon, for various reasons. In the meantime, audiologists could start looking outside the box to include patient’s lifestyle and nutrition for the prevention and management of hearing and balance function for the benefit of their patients. A good starting point would be a search of literature on the topic of nutrition and its impact on human health. 

*References for Dr McNeill’s article are further below at the bottom of the entire article.

More research needed but fish, iron, zinc look       promising for hearing loss, tinnitus

By Dr Diana Tang, PhD, MNutriDiet, Research Fellow, Macquarie University Hearing, NSW

The Macquarie University Hearing team looked at longitudinal data from a cohort of Australians aged 50 and over and found there may be an association between hearing health and specific dietary factors.

Our study¹ was the first longitudinal study to explore associative links between dietary intakes of iron and zinc and prevalence and incidence of tinnitus in an older adult population.

The evidence indicated higher intakes of zinc and iron were associated with significantly lower risk of developing tinnitus over 10 years. As there are no other studies like this in Australia, more research is needed to confirm the accuracy of our findings especially because the amounts of iron and zinc found to be protective against tinnitus exceed current dietary recommendations.

We need to be sure about these benefits before providing recommendations to consume higher nutrient intakes to patients. We also need to keep in mind that our findings are based on data collected in the 1990s to 2000s among a mostly Caucasian cohort of adults who were consuming a more western-style diet. This may not reflect current Australian demographic or eating patterns.

Looking at  the same cohort² we also found that those with lower diet quality had twice the likelihood of having concurrent hearing and vision loss (dual sensory impairment). Poor nutrition could have a role in concurrent, age-related hearing and vision impairment due to the importance of diet in healthy ageing.

For vision impairment, there is evidence from high quality research to support the link between nutrition and age-related macular degeneration (AMD). This includes a large clinical trial³ evaluating effectiveness of nutritional supplements in preventing or slowing progression of AMD.  Further investigation⁴ found only participants with lower intakes of lutein and zeaxanthin from their diet significantly benefited from these supplements. Those with higher dietary intakes of lutein and zeaxanthin did not gain further benefit, suggesting supplements and food have the same impact.

Fish intake reduced risk of hearing loss

A third study⁵ from our group showed higher intakes of omega-3 fatty acids and regular intake of fish reduced the risk of age-related hearing loss. The benefits of fish intake and omega 3 fatty acids for hearing health were significant.

A key finding was participants who had two or more servings of fish per week compared with participants who had less than one serving weekly significantly reduced their risk of developing hearing loss by 42% after five years. However, our study is the only study globally to report on this link and more research is encouraged to confirm our findings.

The research we have conducted so far suggests more food-focused research is needed. As nutrients obtained through the diet are more potent than supplements and the influence of the food matrix unknown, single-nutrient solutions like supplements may not be the answer as they are more typically linked to relative deficiencies such as those arising from restrictions of certain foods or food groups or due to physiological changes in the body.

Possible mechanisms

Although the pathophysiology of hearing loss and tinnitus are unknown, it’s hypothesised that good vascular health and adequate blood flow to the cochlea supports good hearing health.

Iron⁶ is known to play an important role in oxygen circulation with poor circulation to the inner ear increasing susceptibility to ischaemic damage resulting in impaired inner ear functioning.

In a similar way, omega 3 fatty acids and fish intake have been shown⁷ to prevent heart disease through various biological actions such as hypolipidaemic properties, triglyceride lowering, and anti-inflammatory and anti-atherothrombotic properties.

Higher intakes compared to lower intakes may contribute to better heart health and thus hearing health.

It is hypothesised⁸ that zinc is involved in cochlear pathology and the synapses of the auditory system. Zinc plays a key role in various cellular processes and pathways and has antioxidant and anti-inflammatory properties. Lower intakes of zinc may therefore increase the susceptibility of the auditory system to the effects of inflammation, leading to tinnitus.

The data we analysed was collected in the 1990s to the early 2000s from older Australians living in the Blue Mountains area of Sydney. It has given us insights into a potential association between hearing health and some dietary factors, but we need more large Australian studies to back up these findings.

Ear Health Survey and diet

Our team, in collaboration with the Westmead Institute for Medical Research, UNSW Sydney, The Brien Holden Foundation and The George Institute for Global Health, is wrapping up the Australian Eye and Ear Health Survey.

Hearing health and nutrition data has been collected along with other information in Aboriginal and Torres Strait Islander people aged 40 years and over, and non-Indigenous Australians aged 50 years and over.

With analyses underway, it will be interesting to see what current data will tell us about links between hearing health and nutrition and how it compares to what we know so far.

Based on the limited data we have, research evidence isn’t strong or consistent enough for audiologists to provide specific nutrition advice or recommendations that are guaranteed to prevent or protect against hearing loss.

A scoping review published in 2021 identified 22 studies related to hearing health and nutrition. However, when they broke down the evidence by individual dietary components or nutrients, most only had evidence from one or two studies or from data coming from cross-sectional studies which are lower quality.

Until there is more concrete evidence about the role of specific nutrients in hearing health, it is important to acknowledge what we do know; that is, a healthy diet is an important contributor to healthy ageing.

As a large proportion of hearing loss is age-related, a healthy and balanced diet would be beneficial for the overall health of most of the population. Anyone who has other health conditions or concerns should speak to their GP or dietitian for more specific advice relevant to their needs and circumstances. 

*References for Dr McNeill’s article:

1. Watanabe J, Nieto J, Suarez-Dieguez T and Silva M (2024) Influence of culinary skills in the dietetic pattern: ultra-processed food consumption and Mediterranean diet adherence. An integrative review. In Nutrition.

2. Jung S, Kim S and Yeo S (2019). Association of Nutrition Factors with Hearing Loss. In Nutrients.

3. Chen H-L, Tan C, Wu C and Liu T (2022). Effects of Diet and Lifestyle on Audio-Vestibular Dysfunctions in the Elderly:  a literature review. In Nutrients.

4. Naganuma H, Kawahara K, Tokumasu K, Okamoto M. (2006). Water may cure patients with Meniere’s disease. In Laryngoscope.

5. Frejo L et al (2024) Allergy and autoinflammation drive persistent systemic inflammatory responses in Meniere Disease.  In Clin Immunol.

6. Di Berardino F, Flipponi E, Alpini D, Cesarini A (2013) Meniere’s disease gluten sensitivity- Recovery after a gluten-free diet. In Am J ORL.

*References for Dr Tang’s article:

1. Tang D, Shekhawat GS, Burlutsky G, Mitchell P, Gopinath B. The Association between Dietary Intakes of Vitamins and Minerals with Tinnitus. Nutrients. 2024 Aug 2;16(15):2535.
   

2. Gopinath B, Schneider J, Flood VM, McMahon CM, Burlutsky G, Leeder SR, Mitchell P. Association between diet quality with concurrent vision and hearing impairment in older adults. J Nutr Health Aging. 2014 Mar;18(3):251-6.

3. Age-Related Eye Disease Study Research Group. A Randomized, Placebo-Controlled, Clinical Trial of High-Dose Supplementation With Vitamins C and E, Beta Carotene, and Zinc for Age-Related Macular Degeneration and Vision Loss: AREDS Report No. 8. Arch Ophthalmol. 2001;119(10):1417–1436. doi:10.1001/archopht.119.10.1417.

4. Age-Related Eye Disease Study 2 Research Group. Lutein + zeaxanthin and omega-3 fatty acids for age-related macular degeneration: the Age-Related Eye Disease Study 2 (AREDS2) randomized clinical trial. JAMA. 2013 May 15;309(19):2005-15. doi: 10.1001/jama.2013.4997. Erratum in: JAMA. 2013 Jul 10;310(2):208. PMID: 23644932.

5. Gopinath B, Flood VM, Rochtchina E, McMahon CM, Mitchell P. Consumption of omega-3 fatty acids and fish and risk of age-related hearing loss. Am J Clin Nutr. 2010 Aug;92(2):416-21. doi: 10.3945/ajcn.2010.29370. Epub 2010 Jun 9. PMID: 20534742.

6. Schieffer, K.M.; Chuang, C.H.; Connor, J.; Pawelczyk, J.A.; Sekhar, D.L. Iron Deficiency Anemia is Associated with Hearing Loss in the Adult Population. JAMA Otolaryngol. Head. Neck Surg. 2017, 143, 350. AND Sunwoo, W.; Lee, D.Y.; Lee, J.Y.; Lee, M.; Kang, Y.; Park, M.H.; Kim, Y.H. Characteristics of tinnitus found in anemia patients and analysis of population-based survey. Auris Nasus Larynx 2018, 45, 1152–1158.

7. Connor WE. Importance of n-3 fatty acids in health and disease. Am J Clin Nutr. 2000 Jan;71(1 Suppl):171S-5S. doi: 10.1093/ajcn/71.1.171S. PMID: 10617967.

8. Person, O.C.; Puga, M.E.; da Silva, E.M.; Torloni, M.R. Zinc supplementation for tinnitus. Cochrane Database Syst. Rev. 2016, 2016, CD009832.

9. Jarosz, M.; Olbert, M.; Wyszogrodzka, G.; Młyniec, K.; Librowski, T. Antioxidant and anti-inflammatory effects of zinc. Zinc-dependent NF-κB signaling. Inflammopharmacology 2017, 25, 11–24.

10. Rodrigo L, Campos-Asensio C, Rodríguez MÁ, Crespo I, Olmedillas H. Role of nutrition in the development and prevention of age-related hearing loss: A scoping review. J Formos Med Assoc. 2021 Jan;120(1 Pt 1):107-120. doi: 10.1016/j.jfma.2020.05.011. Epub 2020 May 28. PMID: 32473863.