Tinnitus, the perception of sound when no external noise is present, affects a significant portion of the population. While often linked to hearing loss, tinnitus can also occur in individuals with normal hearing, suggesting a connection to other underlying health conditions. Research increasingly points to a relationship between tinnitus and obesity, highlighting the potential impact of body composition on auditory health.
Understanding Tinnitus
Tinnitus is an auditory perception that can be bothersome to patients. It is categorized into two types: subjective tinnitus, which only the affected individuals can perceive, and objective tinnitus, which can be detected by physicians or others. While objective tinnitus often stems from mechanical issues of vascular or muscular origins, many subjective tinnitus cases are attributed to hearing loss. Nevertheless, subjective tinnitus also occurs in individuals with normal hearing. In such cases, research has found correlations between tinnitus and various physical conditions, including pain, infection, and sleep quality, as well as mental health issues like anxiety and depression. Furthermore, subjective tinnitus has a significant relationship with brain metabolism and structure. Therefore, some diseases that cause changes in the brain network through chronic inflammatory responses or are associated with structural and functional changes in the brain might be connected to subjective tinnitus.
Obesity and Tinnitus: An Emerging Association
Some authors have also identified an association between tinnitus and obesity. Özbey-Yücel and Uçar reviewed several articles and suggested that this relationship may be due to an elevated inflammatory response in obese patients. Michaelides et al. found that pulsatile tinnitus is also linked to obesity and that weight reduction can be an effective treatment for this condition. Furthermore, McCormack et al. determined that both body mass index (BMI) and body fat percentage were significantly associated with tinnitus. However, they did not evaluate the type of obesity or the distribution of fat in obese patients.
Obesity is categorized into subtypes based on the distribution of body fat, with each subtype associated with distinct health conditions and disease characteristics. The gold standard for evaluating body fat distribution is an imaging workup such as computed tomography or magnetic resonance imaging. However, due to considerations of time and cost, dual-energy X-ray absorptiometry is commonly recommended for evaluating body composition, and bioelectrical impedance analysis (BIA) has also demonstrated high precision in this regard.
Investigating Body Composition and Tinnitus
One study aimed to investigate the relationship between body composition, as assessed by BIA, and tinnitus, as well as the chronicity of tinnitus in individuals with age-normative hearing levels. They specifically excluded individuals with hearing loss, which is known to be associated with tinnitus, from this study. They also considered other factors that are linked to both tinnitus and obesity in order to identify the specific body composition patterns that are associated with tinnitus.
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Methods Used in the Study
Data source: Data from the ninth Korea National Health and Nutritional Examination Survey (KNHANES) was used. Data were extracted on age; sex; household income (quintile); weight; height; BMI; waist circumference; the body fat, muscle, and fluid percentage of each region; hypertension; diabetes; Patient Health Questionnaire-9 (PHQ-9); Generalized Anxiety Disorder-7 (GAD-7); history of dizziness; tinnitus; air-conduction hearing thresholds at 0.5 kHz, 1 kHz, 2 kHz, 4 kHz, and 8 kHz; and tympanic membrane status evaluated by tympanometry. The three individuals who selected “I don't remember” regarding their history of dizziness were classified as having no such history.
Body composition measurements, including body fat, muscle, and fluid percentages, were conducted using bioelectrical impedance analysis (BIA) with the Inbody 970 device (Inbody, Seoul, Korea). The regional percentages of body fat, muscle, and fluid relative to total body mass were calculated by dividing the mass of each component in a given region by the total body weight. For the arms and legs, the percentages of each composition were determined by averaging the values from both the right and left sides.
The PHQ-9 is a valid tool for evaluating depressive mood, while the GAD-7 is a developed survey used for evaluating anxiety. Air-conduction pure tone audiometry was carried out in a double-walled soundproof booth using an AD629 audiometer (Interacoustics, Assens, Denmark). Tympanometry was performed with a Titan IMP440 screener (Interacoustics, Assens, Denmark). Audiological assessments were conducted only on individuals aged 40 and above in the 9th KNHANES, a decision likely influenced by the increased prevalence of hearing loss in this age group. All participants in the ninth KNHANES gave informed consent for this survey, which was approved by the Institutional Review Board (IRB) before the survey was conducted (IRB No. 2018-01-03-4C-A). The 9th KNHANES was conducted according to the examination guidelines provided by the Korea Disease Control and Prevention Agency.
Definition of tinnitus and subject classification: In the ninth KNHANES, tinnitus was assessed through a survey and defined as present when a participant reported the symptom lasting for five minutes or more within the past year. Acute tinnitus was further defined as lasting for five minutes or more but less than 6 months, while chronic tinnitus was defined as having a duration of 6 months or more.
The study subjects were classified into two groups-the tinnitus group and the non-tinnitus group-based on the presence or absence of tinnitus. Those with tinnitus were also categorized into chronic and acute subgroups according to the chronicity of the condition.
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Definition of obesity and central obesity: Obesity was defined according to the guidelines provided by the World Health Organization, using total body fat percentage with a cutoff of 25% for males and 35% for females. Central obesity was diagnosed based on the Korean Society for the Study of Obesity guidelines, using waist circumference with a threshold of 90 cm or over for males and 85 cm or over for females.
Statistical analysis: Analysis of variance and the chi-square test were conducted to compare the variables among the groups. Multinomial logistic regression analysis was performed to compare the categorical variables among the groups after adjusting other factors. Multivariate analysis of covariance was performed for significant variables identified in the univariable study to control for other covariates and adjusted mean value of body composition in each part of the body. A P-value < 0.05 was considered to indicate statistical significance. All statistical analyses were performed with SPSS version 25.0 (IBM Corp., Armonk, NY, USA).
Key Findings
Demographic factors, economic status, underlying diseases, and audiological characteristics of each group: Among the 6265 KNHANES participants who were initially considered, 3377 were screened out due to lack of data. Subsequently, 256 individuals with abnormal tympanic membranes were excluded. To control for the effect of hearing loss, they excluded 375 individuals who had a hearing threshold higher than 40 dB in the better ear. Ultimately, 2257 individuals were included in this study. Of these, 204 were classified into the tinnitus group, and 2125 were classified into the non-tinnitus group.
The mean age of the tinnitus group (60.22 ± 11.30 years) was older than that of the non-tinnitus group (57.09 ± 10.68 years, P < 0.001). Tinnitus prevalence was higher among men (11.76%) than among women (6.90%, P < 0.001). The mean household income was significantly lower in the tinnitus group (quintile mean = 2.91 ± 1.31) than in the non-tinnitus group (quintile mean = 3.34 ± 1.36, P < 0.001). Hypertension was more prevalent in the tinnitus group (36.68%) than in the non-tinnitus group (29.30%, P = 0.030). However, there was no significant difference in the prevalence of diabetes between the groups (P = 0.215). The tinnitus group showed higher PHQ-9 (3.00 ± 4.42) and GAD-7 scores (2.57 ± 4.02) than the non-tinnitus group (PHQ-9: 2.10 ± 3.28, P < 0.001; GAD-7: 1.92 ± 3.22, P < 0.001). The history of dizziness was higher in the tinnitus group (50.25%) than in the non-tinnitus group (33.33%, P < 0.001). The mean hearing level was worse in the tinnitus group (21.66 ± 9.44 dB) than in the non-tinnitus group (16.81 ± 8.52 dB, P < 0.031).
After controlling for age, there was a significant difference only in mean hearing level (P < 0.001) between the groups in the male population. Household income (P = 0.108), hypertension (P = 0.080), and diabetes (P = 0.497), PHQ-9 score (P = 0.053), and GAD-7 score (P = 0.083) were not significantly different between the groups in the male population. And, household income (P = 0.002), PHQ-9 score (P = 0.002), GAD-7 score (P < 0.001), history of dizziness (P < 0.001), and mean hearing level (P = 0.004) were significantly different among the groups in the female population, while other variables such as hypertension and diabetes did not show significant differences.
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Comparison of body fat, muscle, and fluid percentage of each region between the groups: Since the distribution and amount of fat, muscle, and fluid significantly differ according to sex, their sex-specific associations with tinnitus were analyzed.
Men: Men with tinnitus exhibited a higher percentage of body fat in each region (P = 0.005 for the total body; P = 0.007 for the arms; P = 0.006 for the trunk; P = 0.011 for the legs), a higher waist circumference (P = 0.011), and less muscle mass in each region (P = 0.024 for the arms, P = 0.010 for the legs). Additionally, they had lower total body and intracellular fluid levels (P = 0.007 for total body fluid; P = 0.002 for total intracellular fluid).
Women: Female participants exhibited a marginal difference in leg muscle percentage between the groups (P = 0.050), but no other differences were observed in terms of fat, muscle, and fluid percentages in various body regions.
Multivariable analysis of fat and muscle distribution: A multivariable analysis using body composition variables that were significantly different in each region according to univariable analysis was conducted. Other variables that differed significantly between the groups were included as covariates. After adjusting for age and mean hearing level, the tinnitus group exhibited higher total body fat percentage (P = 0.010), arm fat percentage (P = 0.014), leg fat percentage (P = 0.029), and trunk fat percentage (P = 0.008). In addition, the tinnitus group had lower leg muscle percentage (P = 0.038), body fluid percentage (P = 0.010), and intracellular fluid percentage (P = 0.009) compared to the non-tinnitus group in the male population. Furthermore, waist circumference was significantly greater in the tinnitus group (mean waist circumference = 91.42 ± 0.88 cm; 95% CI 89.69-93.15 cm) than in the non-tinnitus group (mean waist circumference = 88.90 ± 0.32 cm; 95% CI 88.28-89.52 cm, P = 0.007).
The female population did not exhibit any differences in leg muscle percentage after adjusting for other factors (P = 0.552).
Subgroup analysis for chronic tinnitus and acute tinnitus: The tinnitus cohort was categorized into two groups: those with chronic tinnitus and those with acute tinnitus, based on the duration of their symptoms.
Demographic factors: Among the tinnitus group, 152 were classified into the chronic tinnitus group and 47 were classified into the acute tinnitus group. The mean age of the chronic acute group (60.78 ± 11.01 years) was older than that of the other groups, followed by the acute tinnitus group (58.43 ± 12.12 years), and then the non-tinnitus group (57.09 ± 10.68 years, P < 0.001). The gender distribution of each group was different (chronic tinnitus M:F = 86:66; acute tinnitus M:F = 19:28; non-tinnitus M:F = 788:1270, P < 0.001).
Men: The chronic tinnitus, acute tinnitus, and non-tinnitus groups showed statistically significant differences only in hearing thresholds (P < 0.001) and exhibited no differences in household income, diabetes, hypertension, PHQ-9 score, GAD-7 score, and history of dizziness after controlling for age in the male population.
The body fat percentage in various regions was compared among the chronic tinnitus group, the acute tinnitus group, and the non-tinnitus group within the male population. Significant differences were observed in the total body fat percentage (P = 0.019), arm fat percentage (P = 0.026), leg fat percentage (P = 0.039) and trunk fat percentage (P = 0.024) among the groups. Furthermore, there were significant differences in leg muscle percentage (P = 0.036), total body fluid (P = 0.025), and intracellular fluid percentage (P = 0.007) across the groups. Additionally, significant differences were found in the mean waist circumference (P = 0.040) among these groups.
After controlling for age and mean hearing level, significant differences were observed among the groups in the male population for total body fat percentage (P = 0.035), arm fat percentage (P = 0.049), trunk fat percentage (P = 0.030), waist circumference (P = 0.028), body fluid percentage (P = 0.036), and intracellular fluid percentage (P = 0.032).
The Role of Diet and Lifestyle
While the precise mechanisms linking obesity and tinnitus require further investigation, the evidence suggests that body composition, particularly fat distribution and muscle mass, may play a role, especially in men. This highlights the importance of considering diet and lifestyle factors in managing tinnitus symptoms.
Dietary Considerations
There is limited evidence that directly shows specific foods (or the exclusion of specific foods) improves tinnitus symptoms. However, it is beyond question that a healthy diet has many beneficial effects on the body, which may lessen the impact of tinnitus.
One diet-related tinnitus issue that receives a lot of discussion is the consumption of caffeine. There is very little scientific evidence that shows caffeine exacerbates tinnitus symptoms. That being said, tinnitus patients should track their own experience with caffeine and adjust accordingly. If caffeine seems to impact your tinnitus, then consider reducing your consumption; if caffeine has no impact and/or is an enjoyable part of your daily routine, then you may want to continue consumption as normal.
A study published in Ear and Hearing, the official journal of the American Auditory Society, observed all kinds of people and looked closely at their diets. The data shows that your diet may increase or diminish your vulnerability to certain inner ear disorders, tinnitus among them. Vitamin B12 wasn’t the only nutrient that was associated with tinnitus symptoms. And there’s more. This research also revealed that tinnitus symptoms can also be impacted by dietary patterns. For example, your likelihood of developing tinnitus will be reduced by a diet high in protein. Diet by itself isn’t likely to dramatically change your hearing, and actually, you’d most likely have to have a pretty severe deficiency for this to be the cause. Other problems, like exposure to loud sound, are far more likely to impact your hearing.
Nutrients are essential: Your diet is going to have an effect on the health of your hearing. Obviously, your hearing will be helped by a balanced diet. So it isn’t hard to see how issues such as tinnitus can be an outcome of poor nutrition.
Quantities vary: Certainly, if you want to keep your hearing healthy you need a certain amount of B12 in your diet. You will be more susceptible to tinnitus if you get less than this. But your ears won’t necessarily be healthy just because you get enough B12.
The Benefits of Exercise and Social Engagement
Exercise isn’t only good for your physical body - it’s also good for your emotional well-being and can help minimize the burden of tinnitus. Many tinnitus patients report feelings of social isolation, due to difficulties with interpersonal communication, sound sensitivity, and/or irritability. Unfortunately, removing yourself from social situations creates a cycle of negative reinforcements that may make tinnitus an even larger problem. Social experiences with friends, family, and peers can positively distract patients from their tinnitus symptoms. They can also improve emotional wellness, general feelings of contentment and optimism. Some patients believe that having tinnitus means they must give up activities that they enjoy. That is absolutely not the case. Some activities may even provide the benefit of directly masking the sound of tinnitus. Tinnitus patients may need to make adjustments or take certain precautions prior to engaging in specific recreational activities - particularly activities that involve loud noise.
Additional Therapies and Coping Strategies
Several therapeutic approaches can further aid in managing tinnitus:
Mindfulness-Based Stress Reduction (MBSR): A therapy that emphasizes “mindfulness” - a deliberate and non-judgemental awareness of one’s physical sensations, sensory perceptions, emotional reactions, and cognitive processes. Rather than struggling (often in vain) to ignore tinnitus, MBSR teaches patients to wholly accept, embrace, and control their experience. In doing so, patients put themselves in a better position to manage their condition.
Acceptance and Commitment Therapy (ACT): Like other mindful-based approaches, ACT emphasizes the need to reduce experiential avoidance of tinnitus. Patients are taught to fully experience thoughts, perceptions, and emotions in a direct, non-judgemental way.
Stress Reduction Techniques: Several of the options listed above have the benefit of reducing stress. In general, any activity that lowers stress may also lessen the intensity of tinnitus symptoms.
Biofeedback: Biofeedback is relaxation technique that teaches patients to control certain autonomic body functions, such as pulse, muscle tension, and skin temperature. The goal of biofeedback is to help people manage stress and anxiety by changing the body’s reaction to these negative influences.
Hypnotherapy: Hypnotherapy has been shown to promote relaxation and reduce anxiety. It may also alter neural connections between areas of the brain.
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