---
title: "Midlife hearing decline and health links in the Busselton Healthy Ageing Study"
id: "plos-one-14-change-in-hearing-loss-and-its-association-with-general-health-in-a-community"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-14-change-in-hearing-loss-and-its-association-with-general-health-in-a-community"
content_type: "clinical_feed_article"
specialty: "General"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0360651"
published_at: "2026-10-15T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Midlife hearing decline and health links in the Busselton Healthy Ageing Study
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-14-change-in-hearing-loss-and-its-association-with-general-health-in-a-community
- **Specialty:** [General](https://medichelpline.com/clinical-feed/general.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0360651)
- **Published At:** 2026-10-15T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- Population-based longitudinal cohort of middle-aged adults (baseline age 45–70 years) from the **Busselton Healthy Ageing Study**, with audiometry at baseline (T0) and six-year follow-up (T1). 3596 participants had reliable audiometric data at both visits. - Objective hearing metrics: better-ear four-frequency pure tone average (**4FPTA**, 0.5–4 kHz) and high-frequency PTA (**HFPTA**, 4 & 8 kHz); WHO thresholds used to classify impairment. - Over six years the prevalence of mild-or-greater hearing loss rose from 14% to 26% by **4FPTA** and from 53% to 71% by **HFPTA**; thresholds worsened at all ages but more at higher frequencies and in men. - Linear mixed models identified multiple baseline correlates of faster threshold deterioration after adjustment for age and sex: older age, male sex, higher BMI, current smoking, tinnitus, chronic ear infection, noisy workplace exposure (especially when hearing protection was inconsistent or absent), hypertension and pre-diabetes. - Audiometry used automated AMTAS procedures with built-in quality grading; only tests rated “good” or “fair” at both time points were analysed. Demographic and health covariates came from T0; only hearing was measured at T1. - The investigators noted that hearing decline in midlife appears shaped by both demographic factors and broader metabolic and environmental health profiles, indicating potential targets for further research and intervention trials. - Data access is restricted; de-identified datasets can be requested through the Busselton Population Medical Research Institute following ethics approval and a data access agreement. - The study was approved by The University of Western Australia Human Research Ethics Committee; funding sources included state and federal grants and private donations, with no declared competing interests. - The source did not report specific intervention or treatment effects, nor did it report detailed temporal changes in non-hearing health measures between T0 and T1 for the cohort in this article. - Remaining questions documented by the authors include the causal pathways linking metabolic health, environmental exposures and hearing trajectories, and the need for further research to clarify these complex relationships.
## Clinical Analysis & Structured Key Points
Change in hearing loss and its association with general health in a community-based longitudinal study of middle-aged individuals: The Busselton healthy ageing study | PLOS One Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click here . Article Authors Metrics Comments Media Coverage Peer Review Reader Comments Figures Figures Abstract Introduction With the ageing of the global population, disabling hearing loss is a major health concern. While age and sex are established determinants, the relation between general and environmental health factors and the progression of hearing loss remains incompletely understood, particularly in middle-aged adults. Methods We used data from the Busselton Healthy Ageing Study (BHAS) , a population-based cohort in Western Australia. Adults aged 45–70 years at baseline (2010–2015) underwent audiometric testing and health assessments with a six-year follow-up. The better-ear four-frequency Pure Tone Averages for 0.5-4kHZ (4FPTA) and for high frequencies (4 & 8 kHz) (HFPTA) were calculated. Hearing loss was classified according to WHO criteria. Demographic, ear-related, general health, and environmental factors were analysed and their association with change in hearing thresholds using linear mixed models. Results 3596 participants with reliable audiometry at baseline and follow-up were included (mean baseline age 57.9 years, 55% female). Over 6 years follow-up, the prevalence of mild-or-greater hearing loss increased from 14% to 26% (4FPTA) and from 53% to 71% (HFPTA). Thresholds worsened across all age categories, with greater deterioration in men and at higher frequencies. In univariate models, older age, male sex, higher BMI, smoking, tinnitus, chronic ear infection, noisy workplace exposure (particularly with inconsistent or absent hearing protection), hypertension and pre-diabetes were significantly associated with faster hearing decline after adjustments for age and sex. Conclusions In this longitudinal population-based study of middle-aged Western Australians we demonstrated that hearing thresholds significantly declined over a six-year period with greater deterioration in men and at higher frequencies. Findings suggest that hearing loss progression in midlife is shaped not only by age and sex, but also by broader metabolic and environmental health profiles. These outcomes highlight the need for future research to further clarify the complex interplay between metabolic health, environmental exposures, and hearing outcomes. Citation: Smit AL, Eikelboom RH, Mao Y, Hunter M, Atlas MD, Swanepoel DW, et al. (2026) Change in hearing loss and its association with general health in a community-based longitudinal study of middle-aged individuals: The Busselton healthy ageing study. PLoS One 21(10): e0360651. https://doi.org/10.1371/journal.pone.0360651 Editor: Gauri Mankekar, LSU Health Shreveport, UNITED STATES OF AMERICA Received: January 19, 2026; Accepted: September 29, 2026; Published: October 15, 2026 Copyright: © 2026 Smit et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: Data from the Busselton Health Study are restricted due to ethical and privacy requirements. De-identified datasets may be accessed by external researchers through the Busselton Population Medical Research Institute (BPMRI) following ethics approval and a Data Access Agreement. For access requests, visit https://bpmri.org.au/research/database-access.html or contact kevin.murray@uwa.edu.au . Funding: Grants from the Government of Western Australia (Department of Jobs, Tourism, Science and Innovation), the Commonwealth Government (Department of Health), the City of Busselton and from private donations to the Busselton Population Medical Research Institute. In-kind support: The Western Australian Country Health Service, Pathwest, Abbott, Stallergenes, Resmed, Wesnes Cognition LTD and BD Biosciences. All funding bodies had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. Competing interests: The authors have declared that no competing interests exist. Introduction With the rise and ageing of the global population, the increasing numbers of individuals living with disabling hearing loss is considered one of the most important global health problems according to the WHO [ 1 ]. Hearing loss can have a major impact on daily life by disturbing communicative abilities but is also implicated in social isolation, depression, cognitive decline and dementia [ 2 ]. Identifying and understanding factors that contribute to the onset and progression of hearing loss in middle-aged adults could influence patient counseling, rehabilitation and possible treatment of the underlying condition The prevalence of hearing loss increases significantly with age and even accelerates with age [ 3 – 5 ]. Furthermore, different patterns of hearing deterioration can be seen between males and females [ 6 ]. Currently, underlying mechanisms of hearing loss across age are only partly understood. Besides physiological degeneration of the inner ear structures, health-related factors as well as environmental and genetical factors have their effect on hearing deterioration over time [ 7 , 8 ]. To date, most studies focusing on the identification and quantification of factors contributing to age-related hearing loss have been based on cross-sectional studies, and findings have been inconsistent. This can be explained by the differences in measures of risk factors (e.g., based on self-reported medical history of hypertension in contrast to objective blood pressures measures of hypertension), hearing outcomes (e.g., subjective assessment of hearing handicap versus objective assessment of hearing levels by pure tone audiometry), study setting (e.g., visitors to ear clinics versus population studies) and/or characteristics of the participants (e.g., age range). Instead, longitudinal studies allow assessment of temporal relationships and are therefore better suited to determine whether potential risk factors precede changes in hearing. Additionally, population studies can contribute to determining which factors are involved in the etiology of hearing loss. This knowledge could contribute to identifying potentially modifiable factors, which in turn may help to reduce or delay age-related hearing loss and its broader impact on society. Only a few longitudinal studies have investigated the association between demographics, health-related, and environmental risk factors and objectively measured changes in hearing levels over time in population-based settings. Demographic factors were studied in the EHLS (the Epidemiology of Hearing Loss Study, USA as a follow-up study on the Beaver Dam Eye study) with a follow-up up to 15 years. In addition to older age being a risk factor for both the incidence and progression of hearing loss, male sex and indicators of lower socioeconomic status were also found to be associated with a higher incidence of hearing loss, even after adjusting for age [ 9 – 11 ]. A history of noisy occupation was not found to be associated [ 10 ]. In a longitudinal analysis of 1436 adults aged 18–89 + years from a US community-based cohort, average hearing thresholds declined by 0.83 dB per year (95% CI 0.79–0.86), with females (versus males) showed higher rates of threshold change in higher frequencies but less decline per year in lower frequencies [ 12 ]. A Dutch population-based cohort, with a follow-up of 12 years, also found that higher age and male gender were significantly associated with poorer baseline hearing thresholds and faster deterioration of hearing loss [ 13 ]. An Australian population study, with a follow-up period of 11 years, also found that men had higher baseline hearing thresholds, but women experienced faster rates of decline in hearing for mid- to high-range frequencies [ 6 ]. These findings were not confirmed in a Dutch population study with a shorter follow up period (4 years), in which higher age was associated with worse hearing thresholds at baseline, but there was no statistical evidence that the tested determinants such as sex, age and education level were associated with progression of hearing loss (Rigters et al. 2018). Several other population-based studies have examined the association between cardiovascular risk factors and the progression of hearing loss over time using combinations of medical history taking and objective measures to assess the cardiovascular determinants. In a recent study, as part of the Canadian Longitudinal Study of Ageing, hypertension and the general cardiovascular risk profile score were associated with greater loss of hearing over the 3-year follow-up period for both sexes [ 14 ]. In addition, smoking in males and obesity in females were associated with faster rates of hearing decline over 3-year follow-up [ 14 ]. In a Dutch population-based cohort study with a follow-up of 12 years it was found that a large waist circumference was also associated with hearing deterioration over time in participants aged 24–42 years, but not in older age groups [ 13 ]. In the same study cardiovascular disease (CVD) was associated with faster hearing deterioration, but the effect was small and was found only in middle-aged (43–62 years) adults whereas obesity was associated with faster hearing loss in older adults only (age 63–81 years). These findings were not disaggregated by sex. Fifteen-year follow-up data from the EHLS concluded that current smoking, waist circumference and poorly controlled diabetes mellitus were associated with greater risk of incident hearing loss. Former smokers and people with better-controlled diabetes mellitus were not at greater risk [ 9 ]. In other population based longitudinal studies, smoking and diabetes [ 15 ], a history of stroke or diabetes [ 6 ], CVD [ 16 ] and persistent hypertension compared to normotension [ 17 ] were not confirmed to be associated with a change in hearing over time. Besides tobacco smoking, other lifestyle factor s such as alcohol consumption have scarcely been studied; Rigters et al found no association between alcohol consumption and the 4-year progression of hearing loss [ 15 ]. To clarify which factors contribute to hearing deterioration in midlife, using objective measures of hearing and health-related factors, this study investigates the trajectory of hearing thresholds over time, and secondly assesses associations between demographic, health-related and environmental characteristics and the progression of hearing loss in a population-based sample of middle-aged men and women. Materials and methods This study is reported according to the STROBE statement (see S1 Checklist ) [ 18 ]. Study sample and recruitment process This study used data from the Busselton Healthy Ageing Study (BHAS), which commenced in 2010 with the aim to identify the cumulative effects of multimorbidity that impacts on healthy aging. The BHAS includes detailed assessments of physical function, cognitive performance, and quality of life in baby boomers. Adults born between 1946 and 1964, residing in the City of Busselton, Western Australia, and listed on the electoral roll in the region, were invited to participate in this population-based study (6,690 individuals). Invitations to participate were issued in a randomized order, with recruitment efforts focused on sequential 10% sample draws. Of the 6690 adults invited, 5107 agreed to participate (response rate 76.3%). Recruitment for the cohort began in 2010. The baseline or first wave of data (“T0”) was collected between May 2010 and December 2015, resulting in a cohort aged 45–70 years. The first wave of follow-up (“T1”) data of these participants was collected between 2016 and 2021. For the current study only participants who completed audiometric tests at T0 and T1 were included. This article focuses on the methods for this study. The full protocol of the study, including all measurements, is described elsewhere [ 19 ]. The study was conducted according to the Declaration of Helsinki and was approved by The University of Western Australia Human Research Ethics Committee (Number RA/4/1/2203). All participants gave their informed written consent before inclusion in the study. Outcome assessment Data on demographics, general health and environmental factors were collected using a self-administered clinical history questionnaire that was completed by all participants who attended the testing centre. Audiometric hearing thresholds, objective measures of general health, including anthropometry and blood pressure, were gathered from physical assessments at the study centre. During this visit, a fasting venous blood sample was collected for biochemistry testing and analysed for biochemical measures [ 20 ]. For the current study, data on demographics, general health and environmental factors were based on the data from the baseline (T0) visit. The only data used from the follow-up visit (T1) were those related to hearing thresholds. Demographics Demographic data included sex and age at the time of first assessment. Based on this variable age groups were created based on 5-year intervals (45–50, > 50–55, > 55–60, > 60–65, > 65–70 years of age). Highest education level obtained was scored (no school, primary, secondary school, other (e.g., technical school, college) or university) as well as the average annual total household income in Australian dollars (AUD). Ear-related health variables Hearing outcome assessment. Hearing levels were determined at T0 and T1 by pure tone air and bone conduction threshold measurements using automated audiometry with AMTAS software (AMTAS, Audiometry Incorporated, USA) controlling a Conera audiometer (GNOtometrics, Copenhagen, Denmark), with Sennheiser HDA 200 (Wennesbostel, Germany) headphones, on a NOAH platform (Hearing Instrument Manufacturers’ Software Association, Copenhagen, Denmark) and conducted in a sound-proof booth (Acoustic Designs, Australia). Quality control of the testing procedures was guaranteed by (i) training of the technical staff, and (ii) the use of Qualind quality assessment methods built into the automated audiometer software [ 21 ]. The testing protocol was in accordance with Hughson-Westlake methods (James et al). Audiometry was supervised by a trained nurse, who instructed the participant, fitted the headset, started the test, and ensured that the data were saved. She/he did not have any training in assessing the quality of the test. The automated audiometer system incorporates a system of grading the quality of the test: as “good”, “fair”, “poor” or “fail’. For the study, only participants with a complete hearing assessment at both T0 and T1 and with automated test-quality ratings of “good” or “fair” at both time points were included.Air conduction thresholds were recorded at 250, 500, 1,000, 2,000, 4,000, and 8,000 Hz. The four-frequency Pure Tone Averages (PTA) for both ears were calculated as the mean of the air conduction hearing levels for 500, 1,000, 2,000, and 4,000 Hz; the lowest average was considered as the better ear (4FPTA). Similarly, the best ear high frequency pure tone average (HFPTA) was calculated by taking the mean of the air conduction hearing levels for 4,000 and 8,000 Hz. These 4FPTA and HFPTA of the best ear were used to categorize hearing loss in scales of impairment based on the WHO classification (no impairment 89 mm Hg) [ 23 ]. Cardiovascular disease. Participants were categorized as having a heart disease if they reported any of the following conditions/situations: angina, having a cardiac pacemaker/implant, myocardial infarction, coronary bypass or stent. A stroke was scored if participants indicated that they were told by their doctor that the patient had a transient ischemic attack (TIA), stroke or underwent carotid surgery. Peripheral artery disease (PAD) was indicated by an ankle brachial index (ABI) at the left or right of 30 kg/m2 obese [ 18 ]. Diabetes. A fasting venous blood sample was collected for biochemistry testing. The outcomes included general chemistry of plasma (Fasting Plasma Glucose; FPG) and whole blood (glycated haemoglobin; HbA1c). The criteria of the American Diabetes Association (ADA) 2019 were used to classify participants as having diabetes or pre-diabetes based on FPG and HbA1c outcomes (diabetes; glycated haemoglobin > 6.5% or fasting plasma glucose > 7.0 mmol/L®; pre-diabetes; glycated haemoglobin 5.7–6.4% or fasting plasma glucose 5.6–6.9 mmol/L) [ 24 ]. Smoking. Pack years of smoking was calculated based on the outcomes of two questions:” Have you ever smoked cigarettes?” (No, Yes). In case of ‘Yes’, participants were asked how many cigarettes per day they smoked and the number of years that they reported smoking. The duration of smoking in years was calculated based on the age reported by participants that they started and stopped smoking. Based on these, numbers of pack years of smoking per participant were calculated in which one pack years was defined as 20 cigarettes per day for a year. Pack years were described as a continuous variable as well as in categories of smoking pack years; 0 pack years = never smokers / 0.01–20 pack years = ligh
## Related Clinical Research

- [WHO Guidelines for Preventing Up to 45% of Dementia Cases](https://medichelpline.com/clinical-feed/medical-news-today-0-dementia-new-who-guidelines-show-how-to-prevent-up-to-45-of-cases.md)
- [Lifestyle Changes May Help Prevent Multimorbidity In Prediabetes](https://medichelpline.com/clinical-feed/medical-news-today-23-diet-weight-loss-and-150-minutes-of-exercise-may-protect-against-chronic.md)
- [InControl web platform pilot assessing usability and feasibility in older adults with chronic musc](https://medichelpline.com/clinical-feed/plos-one-13-feasibility-acceptability-and-usability-of-incontrol-web-platform-intervention.md)
- [Multiple Long-Term Conditions in India: Prevalence, Quality of Life Impact, and Healthcare Use](https://medichelpline.com/clinical-feed/bmj-open-7-multiple-long-term-conditions-and-their-association-with-quality-of-life-and.md)
- [Obesity-related multimorbidity patterns and reduced quality of life in Iranian adults](https://medichelpline.com/clinical-feed/bmj-open-19-obesity-related-patterns-of-multimorbidity-and-their-association-with-health.md)

## Navigation
- [← Back to General Feed](https://medichelpline.com/clinical-feed/general.md)
- [← All Clinical Specialties](https://medichelpline.com/clinical-feed.md)
## Medical & Regulatory Disclaimer

> [!CAUTION]
> MedicHelpline content is structured for research, educational, and professional discovery purposes. It does not constitute individual medical advice, clinical diagnosis, or treatment recommendations.
> Always verify dosing, contraindications, and regulatory alerts against official product labeling and primary regulatory sources before clinical decision-making.