Abstract
Evidence from clinical trials has shown positive effects of yoga on hypothyroidism. To date, there is no review of these studies. This systematic review evaluates the efficacy of yoga as a therapeutic intervention for hypothyroidism.
PubMed, Medline, PsycINFO, and Science Direct databases were searched to identify relevant literature. The review included clinical studies that evaluated the effects of yoga on hypothyroidism. Studies that were not conducted inenglish, unavailable, non-experimental, or those that were reviews, case studies, case reports, not based on yoga, involved yoga as a intervention, or included a mixed population were excluded.
Eleven studies (n = 516) met the eligibility criteria. Of these, four studies were RCTs, two non-RCTs and five were pretest-posttest studies. The duration of the yoga intervention varied from 1 to 6 months. Most of these studies adopted a combination of suryanamaskar, asana, pranayama and meditation. On quality assessment, one study had a low risk of bias (1 RCT), six studies had a moderate risk of bias (3 RCTs, one non-RCT and two pretest-posttest studies), and four studies had a high risk of bias (1 non-RCT and three pretest-posttest studies). The outcome measures assessed were TSH, T3, T4, and thyroid medication usage, lipid indices, BMI, heart rate variability, pulmonary measures, blood glucose, anxiety, depression, self-esteem, quality of life and sleep. The majority of the studies reported significant improvements in these outcomes following yoga intervention.
This systematic review reports evidence for effects of yoga on various outcome measures in hypothyroidism, suggesting its possible role in the management of hypothyroidism. However, there is a need for adequately powered, high-quality RCT studies in the future to draw a definitive conclusion.
Keywords: Endocrine disorder, Pranayama, Systematic review, Meditation, Yoga therapy
1. Introduction
Hypothyroidism is the most common endocrine disorder that affects a significant portion of the global population [1]. It is common among women compared to men [2]. Around 10 % of the Indian population is affected by hypothyroidism [3]. Hypothyroidism is an independent risk factor for cardiovascular disease, metabolic syndrome, infertility and depression [4]. Conventional management of hypothyroidism includes thyroxin hormone replacement therapy, which is found to be effective [5]. However, early diagnosis, adequate treatment and achieving euthyroid state have remained challenging in the hypothyroidism treatment. In addition to thyroxin replacement therapy, lifestyle modification, including a healthy diet, adequate physical activity and good quality sleep, may help to achieve euthyroid state and disease remission [6].
Yoga is a discipline that includes body, breath, mind and behaviour practices. It promotes a healthy lifestyle. Over the past two decades, a growing body of evidence has demonstrated the health-benefiting effects of yoga in healthy and clinical populations [7]. Yoga is found to be effective in improving clinical conditions such as heart disease, hypertension, diabetes, endocrine disorders, depression, musculoskeletal disorders etc. [8]. Over the last two decades, a considerable number of studies have assessed the effects of yoga on hypothyroidism [[9], [10], [11]]. These studies have shown promising results of yoga practice on clinical parameters of hypothyroidism. However, to date, no systematic review study is available. This study reviewed the existing clinical evidence for the effects of yoga on hypothyroidism.
2. Methodology
2.1. Search and study selection
A comprehensive search was performed by the two independent authors using PubMed, Medline, PsycINFO, and Science Direct databases from their inception to July 2022. The authors constructed the literature search around the keywords for “yoga" and “hypothyroidism". The complete search strategy for PubMed/Medline was (Yoga [mesh] OR Yoga[tiab] OR Asanas[tiab] OR Pranayama[tiab] OR “Yogic breathing"[tiab] OR “Cleansing technique” [tiab]) AND (Hypothyroidism[mesh] OR Hypothyroidism[tiab] OR “Underactive thyroid” [tiab] OR “Low thyroid” [tiab]). In total, 49 records were retrieved.
2.2. Selection criteria
Clinical trials published in English that evaluated the effectiveness of yoga or yoga-based interventions in patients with hypothyroidism were included in this review. Studies published in another language, review articles, case studies, and studies that used yoga as a co-intervention and had a mixed population were excluded.
After excluding the duplicates and applying the inclusion and exclusion criteria, a total of 11 studies, encompassing 15 articles (4 studies were publications from the same trial, i.e., salami slicing), met the predefined selection criteria. The PRISMA study search flowchart is presented in Fig. 1.
Fig. 1.
PRISMA flow diagram of study search and included studies.
2.3. Risk of bias assessment
The studies included in this review were heterogeneous in nature; hence, we used different methods to assess the risk of bias.
The RoB 2 tool assesses the risk of bias across five domains and gives an overall rating categorizing the study as having a low risk of bias, some concerns or a high risk of bias.
The JBI Critical Appraisal Checklists do not employ a rating system, but to facilitate the comparison of methodological quality among studies, they provide an overall rating based on the mean scores of the questions in the checklist [12]. The cut-off values for the overall rating are defined as follows: M>0.60 = high methodological quality; 0.30≤ M ≤ 0.60 = moderate methodological quality, and M < 0.30 = low methodological quality [13].
The risk of bias in randomised controlled trials was evaluated using the Cochrane Risk-of-Bias (RoB 2) tool for randomised controlled trials [14], and two non-randomised control studies and five pretest-posttest studies were assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Quasi-Experimental Studies [15].
3. Results
3.1. Study characteristics
This comprehensive review includes a total of 11 studies, consisting of four RCTs, two non-RCTs, four single-group pretest-posttest studies, and one three-group pretest-posttest study. The distribution of studies across different years is graphically depicted in Fig. 2. A total of 516 subjects participated in these studies, with study durations ranging from 1 month to 6 months. Each study employed different yoga interventions, with the majority of studies incorporating a combination of suryanamaskar, asanas, pranayama, relaxation and chanting components of yoga. Some studies adopted a specific component of yoga, such as pranayama practices or hand mudras. One study used a yoga-based bioenergy healing technique known as Yoga Prana Vidya as an intervention to treat hypothyroid patients. Detailed information regarding the included studies is presented in Table 1.
Fig. 2.
Year-wise distribution of studies.
Table 1.
Characteristics of the included studies.
Author(s) and Year | Study design | Sample size | Sample characteristics [Gender, Age range/mean (yeas)] | Intervention (Details, frequency and duration) | Control group | Assessments | Findings |
---|---|---|---|---|---|---|---|
Chawla et al., 2020 [16] | RCT | 83 (YG = 42, CG = 41) | Female (n = 73) & Male (n = 10); 21-65 years | OM chanting, loosening exercises, Surya namaskar, asana practices, bandha, pranayama and kriyas; 45 min per session for 6 months (thrice weekly for first 2 months and twice weekly for next 4 months) + Thyroxine medication | IC: Thyroxine medication only | Thyroid function test (fT3, fT4, TSH), Anti-TPO, blood glucose, HbA1c, Liver function tests, Muscle related enzymes, Kidney function tests, Lipid profile Quality of life, depression, quality of sleep Anthropometric parameters (weight, BMI, waist circumference, waist-hip ratio and fat%), signs and symptoms like fatigue, bradycardia assessed on a scale of 0-3 |
fT4 levels ↑*, TSH and Anti-TPO levels ↓* in both YG and CG, but only YG achieved clinical euthyroid range of TSH. FBS and cholesterol levels ↓* in YG compared to CG. Amount of thyroxine medication ↑* in CG but not in YG. Significant improvement in depression, sleep quality and quality of life (in physical and psychological domain) in YG compared to CG. YG showed ↓* in weight, BMI, waist circumference and fat%. Severity of all symptoms except bradycardia and hyporeflexia decreased in YG. |
Chintala et al., 2019 [17] | RCT | 50 (YG = 25, CG = 25) | Female only; 18-30 years | Loosening practices, Pranayama (chandranadi, bhramari, nadishuddi and pranava) and shavasana; thrice weekly for 1 month + standard medical treatment | IC: Standard medical treatment only | Deep breathing test, Valsalva maneuver, Handgrip test, Cold pressor test HRV |
YG showed ↑* in delta heart rate in deep breathing test and Valsalva ratio and ↓* in diastolic blood pressure in both hand grip test and cold pressor test compared to CG. Lfnu ↓* and Hfnu ↑* in both YG and CG, but magnitude of change is more in YG. |
Javed Akhtar, 2019 [18] | RCT | 56 (YG = 29, CG = 27) | Female (n = 35) & Male (n = 21); 18+ years (details not mentioned) | Yoga practices for 6 months; details of practices, length and frequency of session not mentioned | IC: No intervention | Quality of life (using WHOQOL-BREF) | YG reported significant improvement in physical and psychological aspect of quality of life compared to CG. No significant change reported in social and environmental domain. |
Kamatchi et al., 2022 [19] | RCT | 30 (YG = 15, CG = 15) | Female only; 45-55 years | Yoga practices that included surya namaskar, asanas, pranayama, bandhas, mudras and yoga Nidra; 60 min per session, 6 days a week for 8 weeks | IC: No intervention | LDL Triglycerides Self confidence Self Esteem |
LDL ↓*, Triglycerides ↓*, self-confidence ↑* and self-esteem ↑* in YG compared to CG. |
Sharma et al., 2016 [20] | NRCT | 20 (YG = 10, CG = 10) | Female and Male; 18-60 years | Yoga therapy for 3 months that included asanas, pranayama, bandha, savasana and yoga nidra; length and frequency of session not mentioned | IC: No intervention-routine work | T3, T4 and TSH | YG reported significant improvement in T3, T4 and TSH after yoga intervention. |
Swami et al., 2010 [21] | NRCT | 40 (YG = 20, CG = 20) | Female and Male; 39.70 ± 8.27 years (YG), 35.65 ± 6.53 years (CG) | Pranayama and meditation; 45 min every day for 6 months | Details not mentioned | TSH and Pulmonary function tests (FEV1, FVC, FEV1/FVC, PEFR, PEF, MVV and IC) | Non-significant decrease in TSH levels, and significant improvement in FEV1, MVV and IC was reported after yoga intervention. TSH was negatively correlated with FVC and PEFR. |
Rani et al., 2021 [10] | One group pretest-posttest study | 38 | Female only; 34.2 ± 4.7 years | Integrated yoga practices that included Suryanamaskar, breathing practices, asanas, pranayama and meditation; 60 min per session, 5 days a week for 3 months | None | Depression, sTSH levels, lipid profile, BMI, anxiety, fatigue, and stress | There was a ↓* in depression, sTSH, BMI, fatigue, anxiety, lipid profile indices (HLD ↑*) and stress levels after yoga intervention. A 23.5 % decrease in the mean thyroxin dosage in patients was reported. |
Nilkantham et al., 2016 [9] | One group pretest-posttest study | 22 | Female only; 36.7 ± 7.2 years |
Loosening practices, asanas, Suryanamaskar, pranayama, and relaxation techniques; 1 h session, 4 days in a week for 6 months | None | Lipid profile (total cholesterol, triglycerides, HDL and LDL), TSH level | ↓* in total cholesterol, LDL, triglycerides and thyroxine medication requirement, and ↑* in HDL was reported after yoga intervention. There was a non-significant reduction in TSH level. |
Singh et al., 2011 [11] | One group pretest-posttest study | 20 | Female only; 35 – 55 years | Yoga therapy practices that included loosening exercises, asanas, pranayama, bandha and shavasana; 1 h per session daily for 1 month | None | Quality of life (using WHOQOL-BREF) | Yoga practice significantly improved all domains of quality-of-life scale including overall perception of quality of life and overall perception of health. |
Tripathi et al., 2018 [22] | Pretest-posttest study | 7 | Female (n = 6) and Male (n = 1); 30 – 65 years | Yoga hand mudra named T-Mudra; Regular practice for 3 months | None | Pathological parameters (TSH, T3 and T4) and 4G-Quantum magnetic resonance analyzer parameters (FT4, T3, Thyroid secretion Index and Pituitary secretion index) | Both pathological parameters and 4G-Quantum analyser parameters significantly improved after T-mudra intervention. |
Swapan Banerjee, 2019 [23] | Three group pretest-posttest study | 150 (YG = 45, YG + Diet = 78, Diet = 27) | Female only; 30-50 years | Surya namaskar and yoga asanas; 45 min session per day for 4 months | Diet | TSH, BMI | Diet + yoga practice or only yoga practice brought significant improvement in TSH and BMI compared to only diet change in all subjects of hypothyroidism associated with obesity. |
Abbreviations: YG: Yoga group, CG: Control group, IC: Inactive control; fT3: free triiodothyronine; T3: Tri-iodothyronine; fT4: free thyroxine; T4: Thyroxin; TSH: thyroid stimulating hormone; Anti-TPO: Anti-thyroid peroxidase; ↑*: Significant increase; ↓*: Significant decrease; FBS: Fasting blood sugar; HRV: Heart rate variability; LFnu = Normalized low frequency power; HFnu = Normalized high frequency power; HDL: High-density lipoprotein; LDL: Low-density lipoprotein; FEV1: Forced Expiratory Volume in 1 s; FVC: Forced Vital Capacity; PEFR: Peak Expiratory Flow Rate; MVV: Maximal Voluntary Ventilation; IC: Inspiratory Capacity; sTSH: serum thyroid-stimulating hormone; BMI: Body mass index; WHOQOL-BREF: World Health Organization Quality of Life Brief Version; RCT: Randomised controlled trial; NRCT: Non-randomised controlled trial.
3.2. Methodological quality (risk of bias)
Among the 4 RCTs, three RCTs [[17], [18], [19]] were found to have some concerns of bias, indicating a moderate level of methodological quality, and only one RCT demonstrated an overall low risk of bias, suggesting high methodological quality [16]. Of the two non-RCTs, one [20] had moderate, while the other [21] was assessed as having low methodological quality. Assessment of the five pretest-posttest studies showed moderate methodological quality in two studies [10,23] and low quality in the other three studies [9,11,22]. The detailed results of the quality appraisal are presented in Fig. 3 and Table 2.
Fig. 3.
Methodological quality assessment for RCTs.
Table 2.
Methodological quality assessment for NRCTs and pretest-posttest studies.
Study | Q1 | Q2 | Q3 | Q4 | Q5 | Q6 | Q7 | Q8 | Q9 | Mean | Quality |
---|---|---|---|---|---|---|---|---|---|---|---|
Sharma et al. | 1 | 0 | 0 | 1 | -1 | 0 | 1 | 1 | 1 | 0.44 | Moderate |
Swami et al. | 1 | -1 | -1 | 1 | -1 | 0 | 1 | 1 | 1 | 0.22 | Low |
Rani et al. | 1 | 1 | n/a | -1 | -1 | 1 | n/a | 1 | 1 | 0.43 | Moderate |
Nilkantham et al. | 1 | 1 | n/a | -1 | -1 | 0 | n/a | 1 | 1 | 0.28 | Low |
Singh et al. | 1 | 1 | n/a | -1 | -1 | 0 | n/a | 1 | 0 | 0.14 | Low |
Tripathi et al. | 1 | 1 | n/a | -1 | -1 | 1 | n/a | 1 | -1 | 0.14 | Low |
Swapan Banerjee | 1 | 0 | -1 | 1 | -1 | 0 | 1 | 1 | 1 | 0.33 | Moderate |
Note: 1 = Yes, -1 = No, 0 = Unclear, n/a = Not applicable.
3.3. Impact of yoga on thyroid hormonal status
Out of 11 studies, seven assessed TSH, three assessed T3, and three assessed T4. Five studies – 1 RCT [16], one non-RCT [20] and three pretest-posttest studies [10,22,23] - reported a significant decrease in TSH levels after yoga and two studies – 1 non-RCT [21] and one pretest-posttest study [9] - reported a non-significant decrease. Out of the three studies that assessed fT3 or T3, one non-RCT [20] and one pretest-posttest study [22] reported significant improvement, whereas 1 RCT [16] showed a non-significant increase. The three experimental studies that evaluated T4 reported significant improvement [16,20,22]. One RCT found a significant decrease in anti-TPO antibody levels [16].
3.4. Impact of yoga on lipid profile
Among the four studies that assessed lipid profile, significant improvement was reported in total cholesterol [9,10,16], low-density lipoprotein cholesterol [9,10,19], very low-density lipoprotein cholesterol [10], high-density lipoprotein cholesterol [9,10] and triglycerides [9,10,19] following yoga intervention. These results indicate that yoga-based interventions can improve lipid indices in hypothyroid patients.
3.5. Impact of yoga on Managing anthropometric measures and sign and symptoms
One RCT assessed various anthropometric measures and found a significant reduction in weight, BMI, waist circumference and fat% [16]. Two more studies - one single-group, pretest-posttest study [10] and one three-group, pretest-posttest study [23] also reported a significant reduction in BMI following yoga practice.
3.6. Impact of yoga on mental and physical health
Among the psychological variables, one RCT study [19] reported a significant change in self-confidence and self-esteem. Two studies [10,16] reported significant improvement in depression, anxiety and stress in hypothyroidism. Three studies assessed the quality of life using the WHO-QOL-BREF questionnaire before and after yoga intervention. Of them, two RCT studies [16,18] found significant improvement in the physical and psychological domains compared to the control group but no improvement in social relationships and environmental domains. However, one pretest-posttest study [11] reported significant improvement in all the domains of the quality-of-life scale, including overall perception of quality of life and overall perception of health.
One RCT study [16] reported significant improvement in sleep quality and a decrease in clinical symptoms, namely fatigue, sleepiness, cold intolerance, dry skin, loss of appetite, constipation, menstrual disturbance and myxedema. No improvement in bradycardia and hyporeflexia was reported. Another single-group pretest-posttest study [10] also reported a significant reduction in fatigue after a yoga intervention.
3.7. Impact of yoga on cardiac autonomic functions and pulmonary functions
One RCT study [17] on HRV found that short-term Pranayama intervention significantly reduces Lf.
LF(nu) and brings more improvement in HF(nu) compared to the control group. The same study also reported a significant increase in delta heart rate and Valsalva ratio and a significant reduction in diastolic blood pressure compared to the control group. This suggests that pranayama combined with standard medical therapy is more beneficial in improving cardiovascular autonomic function in hypothyroid patients. Another non-RCT study [21] reported that pranayama and meditation significantly improve several pulmonary indices, namely, forced expiratory volume in the first second (FEV1), Maximum voluntary ventilation (MVV) and inspiratory Capacity (IC).
3.8. Impact of yoga on blood glucose, other hormones and organs
One RCT study [16] assessed fasting blood sugar (FBS), HbA1c, liver function tests, muscle-related enzymes and kidney function tests and reported a significant decrease only in FBS. No significant change was reported in HbA1c, muscle-related enzymes or any of the indices of liver function tests and kidney function tests. Another pretest-posttest study [22] found significant improvement in the pituitary secretion index after yoga hand mudra practice.
3.9. Impact of yoga on thyroid medication
A pretest-posttest study [9] reported a significant reduction in thyroxine medication after six months of yoga practice. One RCT study [16] reported an insignificant reduction in thyroxine medication compared to the control group, where it significantly increased.
4. Discussion
This systematic review included eleven studies (n = 516). Based on the findings of these studies, yoga was found to be a promising intervention in improving thyroid function, mental health, quality of life and pulmonary function among patients with hypothyroidism. Many of the included studies incorporated integrated yoga practices, including asanas, pranayama, relaxation, meditation and mudra components, to get maximum benefits. Six studies exclusively enrolled female participants, while the remaining five studies had both male and female subjects. To the best of our knowledge, it is the first systematic review study assessing the effects of yoga on hypothyroidism.
Hypothyroidism is a highly prevalent chronic disease that increases the risk of other metabolic disorders such as obesity, heart disease and depression. The present review indicates that yoga may help to improve cardiovascular risk factors such as dyslipidaemia, BMI and pulmonary function in hypothyroidism.
Five studies have reported significant decreases in TSH levels, and three studies have reported significant improvement in T4, suggestive of improved thyroid gland function. These findings can be correlated with the findings from previous studies, which reported improvement in endocrine functioning of the pituitary gland (increase in LH and FSH levels), ovary, testis and pineal gland [[24], [25], [26]]. Four studies have reported improvement in the lipid profile. These findings are consistent with the systematic review by Ghazvineh et al., 2022 who concluded that yoga has a substantial effect on lipid profiles [27]. Two studies have reported improvement in psychological measures - anxiety and depression. These findings are consistent with the results of a previous systematic review report by Cramer et al., 2013 on 12 RCTs with 619 participants. This study by Cramer reports yoga to be effective in improving depression [28]. Similarly, another systematic review and meta-analysis by Cramer et al., 2018 on 8 RCTs with 319 participants reported yoga as an effective and safe intervention for individuals with elevated levels of anxiety [29].
Based on the reviewed studies, suryanamaskara and asana (physical postures) are the two components that are found to be more beneficial in improving BMI, dyslipidaemia, and thyroid function. Following this, breathing practices are beneficial in improving lung function. The studies included in the review are heterogeneous in nature. This prevents us from making a definite conclusion.
A schematic representation of the impact of yoga on hypothyroidism is provided in Fig. 4.
Fig. 4.
Schematic representation of the impact of yoga in patients with hypothyroidism
The possible mechanism underlying the positive effects of yoga in improving outcome measures in hypothyroidism may be attributed to its immune-modulation properties [30,31] as Hashimoto's thyroiditis is considered the most common cause of hypothyroidism. Yoga helps modulate immune function by decreasing inflammatory cytokines. Yoga promotes hypothalamus-pituitary-adrenal axis down-regulation, which might have contributed to improvement in lipid profile [32]. In addition, yoga improves mindfulness; this helped the participants to become aware of their lifestyle and diet and promote healthy behaviour.
Yoga also promotes weight reduction and BMI by modifying metabolic activity [33]. Yoga breathing techniques have been shown to improve lung capacity [34,35]. Moreover, yoga helps regulate the hyperactivity of the hypothalamus-pituitary-adrenal axis and improves sympathovagal balance [36].
The strengths of this review are a) this is the first study, of its kind to report a systematic review of studies evaluating the efficacy of yoga in hypothyroidism, b) given the diversity of the included studies, multiple methods were employed to assess the risk of bias.
There are a few limitations of this review. Due to a lack of an adequate number of RCT studies and the moderate to low quality of the included studies, this review fails to report strong evidence supporting the efficacy of yoga in hypothyroidism.
5. Conclusion
The number of randomised clinical trials evaluating the efficacy of yoga in hypothyroidism is very low. However, the available evidence suggests the positive influence of yoga on hypothyroidism. Further, this review strongly recommends more adequately powered RCTs with robust study methodologies to reach a definitive conclusion regarding the efficacy of yoga in hypothyroidism.
Sources of funding
None.
Author's contribution
AB: Literature review, data extraction, manuscript preparation.
KM: Conceptualization, Manuscript preparation, Manuscript approval.
Declaration of generative AI in scientific writing statement
No generative AI is used in scientific writing statements.
Declaration of competing interest
Authors declare no conflict of interest.
Acknowledgement
The authors would like to thank to Mr Shivam and Ms Darshana for their help in making figures included in this study.
Footnotes
Peer review under responsibility of Transdisciplinary University, Bangalore.
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