Abstract
Background
Hashimoto’s thyroiditis (HT) is the most common autoimmune cause of hypothyroidism, often accompanied by persistent non-specific symptoms despite normalized thyroid hormone levels. Lifestyle factors, including mood, sleep, diet, and exercise, are increasingly considered in the supportive management of HT, but comprehensive characterization of lifestyle patterns in HT patients remains limited.
Objective
To systematically assess the lifestyle patterns of HT patients, including psychological well-being, sleep quality, quality of life, dietary habits, and physical activity.
Methods
A single-center, cross-sectional study was conducted with 226 participants (105 HT patients and 121 healthy controls). Emotional status was assessed using the GAD-7 and PHQ-9; sleep quality with the Pittsburgh Sleep Quality Index (PSQI); and health-related quality of life with the SF-36. Dietary habits and physical activity were evaluated using validated questionnaires. Serum TPOAb and TgAb levels were measured, and correlations with exercise parameters were analyzed using Spearman correlation and multivariable linear regression. All HT participants were biochemically euthyroid at enrollment; prior clinical history of hypothyroidism and LT4 treatment were extracted from medical records.
Results
HT patients exhibited higher anxiety and depression scores, poorer sleep quality, and lower quality of life compared with controls. They also reported distinct dietary patterns, including higher daily intake of meat, dairy, vegetables, and fruits and less frequent use of iodized salt. In terms of physical activity, HT patients showed more conservative exercise patterns, with greater time spent in low-intensity activity and less in moderate-intensity activity. Among HT patients, high-intensity exercise time was inversely associated with TPOAb levels after multivariable adjustment.
Conclusion
HT patients displayed poorer psychological status, impaired sleep, and reduced quality of life, together with distinct dietary adjustments and conservative exercise patterns. In this biochemically euthyroid HT cohort, high-intensity exercise time was inversely associated with TPOAb levels.
Trial registration
Not applicable.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12902-026-02296-w.
Keywords: Hashimoto’s thyroiditis, Lifestyle factors, Psychological distress, Sleep quality, Quality of life, Dietary habits, Physical activity, Exercise intensity, Thyroid autoantibodies
Introduction
Hashimoto’s thyroiditis (HT) is the most common autoimmune disease leading to hypothyroidism. HT shows a marked female predominance in epidemiological studies [1]. HT is pathologically characterized by lymphocytic infiltration of the thyroid tissue, leading to the gradual destruction of thyroid follicular cells. The presence of high titers of thyroid peroxidase antibodies (TPOAb) and/or thyroglobulin antibodies (TgAb) is considered a hallmark of the disease, with up to about 90% of patients exhibiting elevated TPOAb levels [2, 3]. The global prevalence of HT is on the rise, with epidemiological data varying by region and diagnostic criteria. The pathogenesis of the disease is complex, involving the interaction of genetic, environmental, and lifestyle factors.
Currently, there are no specific drugs that can effectively halt the progression of HT. A meta-analysis suggested that selenium supplementation might help reduce anti-thyroid peroxidase (TPOAb) levels in some patients [4]. But long-term, large-scale clinical trials are still needed for definitive confirmation. Consequently, most patients who eventually develop hypothyroidism must rely on lifelong levothyroxine (LT4) replacement therapy [5]. However, many patients continue to experience persistent non-specific symptoms such as debilitating fatigue, mood fluctuations, cognitive decline, and a generally low quality of life, even after their thyroid hormone levels have been normalized by treatment [6, 7]. This has prompted us to explore complementary interventions beyond conventional drug therapy.
In recent years, there has been a growing focus on the lifestyle interventions in the management of HT. These non-pharmacological approaches, such as mood management, dietary modifications, and improved sleep, are considered effective complements to medication [8]. For instance, existing literature have confirmed that HT patients often suffer from depression and anxiety, with a significantly higher prevalence than in healthy individuals [9]. A high symptom burden and poor quality of life are common in HT patients, even in euthyroid individuals [10]. Furthermore, poor sleep quality is frequently reported in HT patients and is associated with increased fatigue [11]. In terms of nutrition, research has found that the dietary patterns of HT patients are linked to oxidative stress and inflammation, suggesting that a predominantly plant-based Mediterranean-style diet may be beneficial. In addition, supplementation with certain micronutrients and vitamins (e.g., selenium, zinc, vitamin D) may also have a positive impact on HT patients [12, 13].
Exercise is a potentially modifiable lifestyle factor for patients with HT, but its clinical relevance depends on thyroid status and treatment context. In untreated overt hypothyroidism, restoration of thyroid hormone status remains the priority before substantial exercise loading is considered. In treated patients, structured exercise programmes may be associated with changes in symptoms and, in some settings, thyroid function tests, although the certainty of evidence varies and exercise intensity is not consistently reported across studies [14, 15]. However, sustained high training loads may act as a physiological stressor and influence endocrine and immune responses, including cytokine profiles [16]. These considerations underscore the need to examine how exercise intensity relates to clinical markers in HT.
Numerous studies have examined individual lifestyle factors in Hashimoto’s thyroiditis (HT), yet current lifestyle recommendations remain fragmented and sometimes controversial. A comprehensive understanding of the overall lifestyle patterns in HT patients is important for clinical management. Therefore, this study aims to systematically assess lifestyle characteristics—including anxiety, depression, sleep quality, quality of life, dietary habits, and physical activity—in individuals with and without HT. In addition, we will explore the relationship between exercise intensity and thyroid antibody levels among HT patients. The findings may contribute to a better understanding of lifestyle factors associated with HT.
Methods
Study population
This study utilized a single-center, cross-sectional design. A total of 226 participants aged 18–65 years were enrolled from both the outpatient and inpatient departments of the Shanghai Geriatric Medical Center. Among them, 105 were classified into the Hashimoto’s thyroiditis (HT) group, and 121 served as the non-HT (healthy control) group. Inclusion Criteria: (1) HT Group: The diagnostic criteria included positivity for serum thyroid peroxidase antibodies (TPOAb) and/or thyroglobulin antibodies (TgAb), or sonographic evidence of diffuse thyroiditis [17]. (2) Non-HT Group: No history of thyroid disease, negative serum TPOAb and TgAb, and normal thyroid function. Exclusion Criteria: History of thyroid surgery or radioactive iodine treatment. Current use of medications known to affect thyroid function (e.g., amiodarone, lithium salts). Severe impairment of cardiac, hepatic, or renal function, or other chronic wasting diseases. Pregnant or breastfeeding women. This study was conducted in accordance with the principles of the Declaration of Helsinki and approved by the Research Ethics Committee of Shanghai Geriatric Medical Center. Written informed consent was obtained from all participants prior to enrollment.
Anthropometric and biochemical measurements
Information on medical history (e.g., hypertension, diabetes, dyslipidemia, rheumatoid arthritis, cerebrovascular disease, coronary heart disease) and lifestyle factors (cigarette smoking and alcohol consumption) was collected using a questionnaire. Body weight and height were measured while wearing light clothing without shoes, and body mass index (BMI) was calculated as weight divided by the square of height (kg/m2). Serum free triiodothyronine (FT3), free thyroxine (FT4), and thyroid-stimulating hormone (TSH), thyroid peroxidase antibody (TPOAb), and thyroglobulin antibody (TgAb) were measured by electrochemiluminescence immunoassay (ECLIA) using the Roche Cobas e601 analyzer (Roche Diagnostics, Mannheim, Germany). In the HT group, HT duration, prior clinical history of hypothyroidism, and levothyroxine (LT4) treatment (use and daily dose) were extracted from medical records. Thyroid status at the time of assessment was classified based on serum TSH and FT4 as euthyroid, subclinical hypothyroidism (elevated TSH with normal FT4), or overt hypothyroidism (elevated TSH with low FT4) according to established definitions [2, 5]. All HT participants were biochemically euthyroid at enrollment. For clinical description, HT participants were additionally categorized according to prior clinical history as no prior hypothyroidism, history of overt hypothyroidism, or history of subclinical hypothyroidism. Biochemical control among LT4-treated participants was defined using the local laboratory reference range for TSH (0.27–4.20 mIU/L).
Assessment of anxiety and depression
To assess the emotional status of participants, we employed two widely used self-rating instruments: the Generalized Anxiety Disorder-7 (GAD-7) for anxiety and the Patient Health Questionnaire-9 (PHQ-9) for depression [18, 19]. Both scales evaluate the frequency of symptoms experienced over the past two weeks. The GAD-7 comprises 7 items, each scored from 0 (“not at all”) to 3 (“nearly every day”), yielding a total score of 0 to 21. The PHQ-9 consists of 9 items with the same 0–3 scoring system, producing a total score of 0 to 27. For both scales, higher scores reflect more severe symptoms. All questionnaires were self-administered under the guidance of trained research staff to ensure data quality.
Pittsburgh sleep quality index (PSQI)
Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI), a validated and standardized 19-item self-reported questionnaire evaluating sleep quality over the past month [20]. The questionnaire generates seven component scores, including subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbances, use of sleep medications, and daytime dysfunction. Each component is scored from 0 to 3, and the global score is calculated as the sum of these seven components, ranging from 0 to 21. Lower global scores indicate better sleep quality, while a score greater than 5 suggests significant sleep difficulties.
Health-related quality of life
Health-related quality of life was evaluated using the 36-Item Short Form Survey (SF-36) [21]. The SF-36 comprises 36 items covering eight core domains: physical functioning, role limitations due to physical health, bodily pain, general health, vitality, social functioning, role limitations due to emotional problems, and mental health. For these eight domains, participants were asked to report their health status over the past four weeks. Each domain is scored on a scale from 0 to 100, with higher scores indicating better health status and quality of life. The health change item, a separate question, is considered independently to reflect perceived changes in overall health over the past year.
Dietary assessment
A food frequency questionnaire was used to assess participants’ dietary habits. The questionnaire documented the weekly intake of 13 food items, with frequency classified as everyday, ≥ 3 times per week, < 3 times per week, and never. The assessed 13 food groups included protein sources (meat, fish, eggs, seafood, beans, and nuts), dairy products, vegetables, fruits, and carbohydrate sources (staple foods such as refined rice and flour, whole grains such as oats, millet, quinoa, rye, and brown rice), as well as olive oil and iodized salt.
Exercise assessment
Physical activity was assessed using an exercise patterns questionnaire. Participants were asked to report the types of exercises performed during the past month, including frequency and duration, from which total exercise time (expressed as minutes per week) was calculated. Exercises were further categorized into low, moderate, or high intensity according to the standards of the Yale Physical Activity Survey (YPAS) [22]. Specifically, low-intensity exercises required minimal effort without noticeable changes in breathing or heart rate; moderate-intensity exercises involved a moderate effort, causing slightly faster breathing and a modest rise in heart rate while still allowing conversation; high-intensity exercises demanded substantial effort, leading to rapid breathing, a marked increase in heart rate, and difficulty maintaining conversation.
Statistical analysis
All statistical analyses were performed using Stata software (version 18.0; StataCorp, College Station, TX). Continuous variables are presented as mean ± SD, except for skewed variables, which are presented as median with interquartile range (25th–75th percentiles). Categorical variables are presented as counts and percentages. Between-group comparisons were conducted using the Student’s t test or the Wilcoxon rank-sum test, as appropriate, and chi-squared tests for categorical variables. For mood, sleep, and health-related quality-of-life measures, adjusted between-group comparisons were conducted using multivariable linear regression with group (HT vs. control) as the main predictor and age, sex, BMI, diabetes, and dyslipidemia as covariates. To examine associations between exercise parameters and thyroid antibody levels (TPOAb and TgAb) among HT participants, Spearman correlation analysis was first performed. Multivariable linear regression models were then used to evaluate associations between exercise parameters and antibody levels using sequential adjustment (Model 1: unadjusted; Model 2: adjusted for age, sex, and BMI; Model 3: additionally adjusted for diabetes and dyslipidemia). A two-sided P value < 0.05 was considered statistically significant.
Results
Baseline characteristics
A total of 226 participants were included in this study, with 105 in the Hashimoto’s thyroiditis (HT) group and 121 in the non-HT (healthy control) group (Table 1). No significant differences were observed between the two groups in age and BMI. However, the proportion of females was higher in the HT group than in the non-HT group (81% vs. 62%, P = 0.002). Regarding comorbidities, the prevalence of diabetes (13.3% vs. 5.0%, P = 0.014) and dyslipidemia (32% vs. 17%, P = 0.010) was higher in the HT group. Smoking and alcohol consumption did not differ significantly between groups.
Table 1.
Baseline Characteristics of the Study Population
| Overall N = 2261 |
Non-HT N = 1211 |
HT N = 1051 |
p-value2 | |
|---|---|---|---|---|
| Women | 160 (71%) | 75 (62%) | 85 (81%) | 0.002 |
| Age (years) | 48.31 (13.56) | 47.31 (12.59) | 49.48(14.57) | 0.231 |
| BMI (kg/m2) | 23.70 (3.93) | 23.56 (4.40) | 23.86 (3.33) | 0.575 |
| Smoke n(%) | 28 (14%) | 21 (17%) | 7 (6.7%) | 0.13 |
| Drink n(%) | 40 (18%) | 22 (18%) | 18 (17.1%) | 0.426 |
| Hypertension n(%) | 50 (22%) | 24 (20%) | 26 (25%) | 0.373 |
| Diabetes n(%) | 20 (8.85%) | 6 (5.0%) | 14 (13.3%) | 0.014 |
| Dyslipidemia n(%) | 44 (23%) | 20 (17%) | 24 (23%) | 0.010 |
| Osteoarthritis n(%) | 7 (3.1%) | 5 (4.1%) | 2 (1.9%) | 0.335 |
| Rheumatoid arthritis n(%) | 3 (1.3%) | 1 (0.8%) | 2 (1.9%) | 0.480 |
| Cerebrovascular disease n(%) | 5 (2.2%) | 1 (0.8%) | 4 (3.8%) | 0.128 |
| Coronary heart disease n(%) | 6 (2.7%) | 1 (0.8%) | 5 (4.8%) | 0.066 |
| Asthma n(%) | 2 (0.9%) | 1 (0.8%) | 1 (1.0%) | 0.920 |
| Anemia n(%) | 5 (2.2%) | 4 (3.3%) | 1 (1.0%) | 0.230 |
| Myalgia n(%) | 1 (0.4%) | 0 (0.0%) | 1 (1.0%) | 0.282 |
| Depression n(%) | 4 (1.8%) | 1 (0.8%) | 3 (2.9%) | 0.248 |
1n (%);Mean (SD)
2Pearson’s Chi-squared test; Wilcoxon rank sum test
Within the HT group, the median disease duration was 2.00 years (IQR 0.04–4.98). At enrollment, all 105 HT participants were biochemically euthyroid. According to prior clinical history, 79/105 (75.2%) had no documented hypothyroidism, 21/105 (20.0%) had a history of overt hypothyroidism, and 5/105 (4.8%) had a history of subclinical hypothyroidism. All participants with a history of overt hypothyroidism, along with two of the five with subclinical hypothyroidism, were receiving levothyroxine (LT4) replacement at enrollment. None of the LT4-treated participants were biochemically undertreated or overtreated (Table 2).
Table 2.
Thyroid-related clinical characteristics and prior thyroid history of patients with Hashimoto’s thyroiditis
| Variable | Value |
|---|---|
| HT duration, years | 2.00 (0.04–4.98) |
| Current biochemical thyroid status at enrollment | |
| Euthyroid | 105 (100.0%) |
| Prior thyroid history1 | |
| No prior hypothyroidism | 79 (75.2%) |
| History of overt hypothyroidism | 21 (20.0%) |
| History of subclinical hypothyroidism | 5 (4.8%) |
| Current LT4 use, n (%) |
23 (21.9%) 21 participants with overt hypothyroidism and 2/5 with subclinical hypothyroidism |
| LT4 treatment adequacy at enrollment2 | All LT4-treated participants were biochemically controlled; undertreated = 0; overtreated = 0 |
| Levothyroxine daily dose among LT4-treated participants, µg | 50.00 (25.00–59.38) |
| TSH, mIU/L | 2.00 (1.39–3.23) |
| FT4, pmol/L | 15.80 (14.20–17.30) |
| FT3, pmol/L | 4.70 (4.40–5.10) |
| TPOAb, IU/mL | 145.00 (16.65–496.10) |
| TgAb, IU/mL | 172.00 (57.50–433.25) |
1Historical thyroid categories were based on prior clinical diagnosis rather than current biochemical status
2Biochemical control among LT4-treated participants was defined using the local laboratory reference range for TSH at enrollment (0.27–4.20 mIU/L)
Emotional status, sleep habits, and quality of life
In unadjusted comparisons, HT participants had higher anxiety and depression scores than controls (P = 0.035 and P = 0.005, respectively). These between-group differences remained significant after adjustment for age, sex, BMI, diabetes, and dyslipidemia (adjusted P = 0.042 and 0.046, respectively) (Table 3).
Table 3.
Mood, sleep and quality of Life in patients with Hashimoto’s thyroiditis and healthy individuals
| Overall N = 2261 |
Non-HT N = 1211 |
HT N = 1051 |
p-value2 | adjusted p-value3 | |
|---|---|---|---|---|---|
| Anxiety | 4.25 (2.08) | 3.36 (1.87) | 5.28 (2.30) | 0.035 | 0.042 |
| Depression | 4.64 (2.39) | 3.74 (1.80) | 5.68 (2.92) | 0.005 | 0.046 |
| PSQI (Pittsburgh Sleep Quality Index) | |||||
| Sleep quality | 1.00 (0.78) | 0.81 (0.76) | 1.23 (0.75) | < 0.001 | 0.002 |
| Sleep latency | 1.04 (0.92) | 0.97 (0.86) | 1.11 (0.99) | 0.232 | 0.714 |
| Sleep duration | 0.63 (0.87) | 0.51 (0.84) | 0.76 (0.89) | 0.031 | 0.431 |
| Sleep efficiency | 1.01 (1.19) | 1.10 (1.25) | 0.88 (1.10) | 0.159 | 0.249 |
| Sleep disturbances | 1.05 (0.66) | 0.91 (0.52) | 1.22 (0.76) | < 0.001 | 0.002 |
| Use of sleeping medication | 0.28 (0.78) | 0.10 (0.49) | 0.40 (0.91) | 0.013 | 0.041 |
| Daytime dysfunction | 1.18 (1.04) | 0.99 (0.98) | 1.31 (1.07) | 0.048 | 0.031 |
| Global score | 5.85 (3.81) | 4.92 (3.28) | 6.92 (4.11) | < 0.001 | 0.003 |
| SF-36 | |||||
| Physical functioning | 88.03 (15.24) | 88.68 (16.63) | 86.96 (12.68) | 0.446 | 0.699 |
| Physical limitation | 86.15 (27.82) | 91.32 (23.43) | 77.70 (32.20) | < 0.001 | 0.012 |
| Bodily pain | 83.52 (17.08) | 85.04 (16.79) | 81.03 (17.37) | 0.111 | 0.225 |
| General health | 64.94 (22.13) | 71.62 (18.52) | 54.01 (23.30) | < 0.001 | < 0.001 |
| Vitality | 71.36 (17.14) | 72.07 (16.29) | 70.20 (18.50) | 0.463 | 0.111 |
| Social functioning | 93.78 (19.43) | 97.42 (19.63) | 87.84 (17.67) | < 0.001 | < 0.001 |
| Emotional limitation | 86.33 (28.03) | 90.63 (24.05) | 79.28 (32.51) | 0.006 | 0.025 |
| Mental health | 73.70 (16.93) | 78.05 (17.62) | 71.04 (15.98) | 0.005 | 0.048 |
| Health change | 50.26 (21.69) | 55.79 (20.86) | 41.22 (20.03) | < 0.001 | < 0.001 |
1Mean (SD)
2Student’s t test or Wilcoxon rank-sum test, as appropriate
3Multivariable linear regression adjusted for age, sex, BMI, and the prevalence of diabetes and dyslipidemia
In unadjusted comparisons, HT participants reported poorer subjective sleep quality, shorter sleep duration, more sleep disturbances, greater use of sleep medication, and more daytime dysfunction (all P < 0.05). In multivariable analyses, differences in the majority of PSQI components remained significant after adjustment, except sleep duration (Table 3).
Based on the SF-36, the HT group reported lower scores in multiple domains, including role limitations due to physical health, general health, social functioning, role limitations due to emotional problems, mental health, and health change (all P ≤ 0.006). After adjustment for age, sex, BMI, diabetes, and dyslipidemia, these between-group differences remained significant. In contrast, physical functioning, bodily pain, and vitality did not differ between groups before and after adjustment (Table 3).
Dietary habits
Significant differences in dietary habits were observed between the two groups. As shown in Table 4, daily consumption of meat (64% vs. 42%, P = 0.011), dairy products (50% vs. 31%, P = 0.016), vegetables (89% vs. 72%, P = 0.007), and fruits (64% vs. 46%, P = 0.015) was higher in the HT group. In contrast, a higher proportion of the non-HT group reported eating fish ≥ 3 times per week (34% vs. 20%, P = 0.032). Group differences were also observed in olive oil and iodized salt consumption: olive oil use was more frequent in the HT group (P = 0.031), while reduced use of iodized salt (< 3 times per week) was more common among HT participants than controls (49% vs. 22%, P < 0.001).
Table 4.
Intake frequencies of main food groups per week in patients with Hashimoto’s thyroiditis and healthy individuals
| Everyday1 | ≥ 3/week1 | < 3/week1 | Never1 | p-value2 | |
|---|---|---|---|---|---|
| Meat | 0.011 | ||||
| Non-HT (%) | 42 | 36 | 20 | 2 | |
| HT (%) | 64 | 20 | 15 | 1 | |
| Fish | 0.032 | ||||
| Non-HT (%) | 5 | 34 | 59 | 2 | |
| HT (%) | 8 | 20 | 72 | 0 | |
| Egg | 0.219 | ||||
| Non-HT (%) | 49 | 35 | 16 | 1 | |
| HT (%) | 55 | 24 | 21 | 0 | |
| Bean | 0.238 | ||||
| Non-HT (%) | 13 | 40 | 45 | 2 | |
| HT (%) | 10 | 30 | 59 | 1 | |
| Seafood | 0.117 | ||||
| Non-HT (%) | 2 | 18 | 66 | 13 | |
| HT (%) | 4 | 9 | 78 | 10 | |
| Nuts | 0.599 | ||||
| Non-HT (%) | 14 | 17 | 60 | 10 | |
| HT (%) | 20 | 12 | 58 | 10 | |
| Dairy | 0.016 | ||||
| Non-HT (%) | 31 | 25 | 39 | 6 | |
| HT (%) | 50 | 22 | 25 | 3 | |
| Vegetable | 0.007 | ||||
| Non-HT (%) | 72 | 21 | 7 | 0 | |
| HT (%) | 89 | 10 | 2 | 0 | |
| Fruit | 0.015 | ||||
| Non-HT (%) | 46 | 31 | 22 | 0 | |
| HT (%) | 64 | 18 | 16 | 2 | |
| Staples | 0.826 | ||||
| Non-HT (%) | 86 | 12 | 2 | 0 | |
| HT (%) | 86 | 10 | 4 | 0 | |
| Whole Grains | 0.225 | ||||
| Non-HT (%) | 17 | 29 | 50 | 4 | |
| HT (%) | 19 | 17 | 60 | 4 | |
| Olive oil | 0.031 | ||||
| Non-HT (%) | 8 | 12 | 33 | 46 | |
| HT (%) | 9 | 3 | 46 | 43 | |
| Iodized salt | < 0.001 | ||||
| Non-HT (%) | 33 | 17 | 22 | 27 | |
| HT (%) | 28 | 7 | 49 | 17 |
1Values are percentages
2Pearson’s Chi-squared test
Exercise patterns and their association with thyroid autoantibodies
In terms of activity intensity (Fig. 1a), the HT group spent more time on low-intensity activities (median 385.19 vs. 240.01 min/week, P < 0.05) but less time on moderate-intensity activities (median 69.82 vs. 155.02 min/week, P < 0.05) and high-intensity activities (showed a non‑significant trend). As shown in Fig. 1b, the five most common types of physical activity in the HT group were housework (63.8%), strolling (33.3%), striding (10.5%), jogging (8.6%), and swimming (5.7%). While in the non-HT group, the top five were housework (52.1%), brisk walking (14%), jogging (14%), walking (12.4%), and cycling (8.3%). Furthermore, compared with the non-HT group, the HT group demonstrated more conservative exercise patterns and lower activity diversity (Fig. 1c).
Fig. 1.
Physical exercise per week in patients with Hashimoto’s thyroiditis and healthy individuals. a The distribution of exercise time (min/week) at different intensity. b The top 5 most popular exercises. c The cumulative counts of exercise types and their distribution
Because all HT participants were biochemically euthyroid at enrollment, analyses were conducted in the overall HT group without further stratification by current thyroid functional status. Spearman correlation analysis revealed an inverse correlation between high-intensity exercise time and TPOAb levels (r = − 0.32, P < 0.05). A nonsignificant trend toward a negative association was also observed between moderate-intensity exercise and TgAb levels, whereas no significant correlations were found for low-intensity exercise (Fig. 2). In multivariable regression, high-intensity exercise time remained inversely associated with TPOAb levels after adjustment for age, sex, and BMI (P = 0.039), and this association persisted after further adjustment for diabetes and dyslipidemia (P = 0.045). No significant associations were observed between exercise parameters and TgAb levels in adjusted models (Table 5).
Fig. 2.
The correlation between exercise parameters and thyroid antibodies levels in patients with Hashimoto’s thyroiditis
Table 5.
Linear regression analysis of exercise parameters and thyroid antibodies levels in patients with Hashimoto’s thyroiditis
| Model 1 | Model 2 | Model 3 | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Beta | R 2 | P-value | Beta | Adjusted R2 | P-value | Beta | Adjusted R2 | P-value | |||||
| TPOAb | |||||||||||||
| Exercise types | -1.95 | 0.01 | 0.280 | -2.10 | 0.02 | 0.293 | -2.03 | 0.02 | 0.308 | ||||
| Low-intensity exercise time | 0.01 | 0.00 | 0.864 | -1.90 | 0.01 | 0.932 | -1.82 | 0.01 | 0.941 | ||||
| Moderate-intensity exercise time | -0.08 | 0.00 | 0.655 | -7.65 | 0.01 | 0.684 | -7.21 | 0.01 | 0.702 | ||||
| High-intensity exercise time | -0.74 | 0.05 | 0.031 | -4.79 | 0.05 | 0.039 | -3.25 | 0.06 | 0.045 | ||||
| TgAb | |||||||||||||
| Exercise types | -4.04 | 0.00 | 0.966 | 4.79 | 0.06 | 0.605 | 4.21 | 0.07 | 0.632 | ||||
| Low-intensity exercise time | 0.15 | 0.01 | 0.405 | -1.52 | 0.07 | 0.882 | -1.38 | 0.07 | 0.895 | ||||
| Moderate-intensity exercise time | -0.88 | 0.01 | 0.342 | -7.17 | 0.08 | 0.441 | -6.82 | 0.08 | 0.468 | ||||
| High-intensity exercise time | -1.25 | 0.01 | 0.481 | -8.45 | 0.07 | 0.931 | -7.93 | 0.08 | 0.942 | ||||
Model 1: crude model; Model 2: adjusted for age, sex, and BMI; Model 3: adjusted for age, sex, BMI and prevalence of diabetes and dyslipidemia
Discussion
Hashimoto’s thyroiditis (HT) is the most common autoimmune cause of hypothyroidism and is frequently accompanied by persistent symptoms despite treatment [23]. Lifestyle factors have been increasingly considered in the comprehensive management of autoimmune endocrine disorders [24]. In this cross-sectional study of biochemically euthyroid adults with HT, participants reported poorer psychological status, impaired sleep, and reduced health-related quality of life compared with controls, together with distinct dietary habits and more conservative exercise patterns. Within the HT group, high-intensity exercise time was inversely associated with TPOAb levels after multivariable adjustment. These findings extend previous work by providing an integrated description of lifestyle characteristics in adults with HT.
Consistent with previous reports, HT participants had higher anxiety and depression scores and worse sleep quality than controls, and the differences remained after adjustment for age, sex, BMI, diabetes, and dyslipidemia [25]. Psychological distress and impaired quality of life in HT are likely multifactorial; thyroid hormone status, autoimmunity, comorbidities, and treatment factors may all contribute. In our cohort, all HT participants were biochemically euthyroid at enrollment, although a subset had a prior history of overt or subclinical hypothyroidism and/or LT4 treatment (Table 2). Previous studies have reported that symptomatic distress and impaired quality of life can occur even in euthyroid HT and may be associated with thyroid autoantibody positivity [26, 27]. Potential mechanisms include low-grade systemic inflammation and cytokine signalling affecting central neurotransmission, together with the chronic burden of symptoms such as fatigue and sleep disturbance [28]. Further studies integrating longitudinal thyroid function, treatment changes, and symptom trajectories are needed to clarify these relationships.
We also observed differences in self-reported dietary patterns. HT participants more frequently reported daily intake of meat and dairy products, while frequent fish consumption was less common. However, the concurrent higher intake of vegetables and fruits suggests a mixed pattern rather than a clearly Western-style diet [29]. Lower iodized salt use may reflect efforts to limit iodine exposure, but could also indicate broader health-conscious behaviour or other clinical advice [30, 31]. Given the cross-sectional design and the categorical nature of the food-frequency assessment, these observations should be interpreted as descriptive and hypothesis-generating.
Regular physical activity may contribute to supportive care in Hashimoto’s thyroiditis through beneficial effects on metabolic function, body weight, cardiovascular health, mood, and perceived energy levels [32, 33]. However, clinical context remains important. In untreated overt hypothyroidism, restoration of thyroid hormone status takes priority before substantial exercise loading is considered, whereas some treated patients may continue to report fatigue or exercise limitation despite biochemical control [6, 7]. In our cohort, all HT participants were biochemically euthyroid at enrollment, and no undertreated or overtreated LT4 users were identified. HT participants reported greater time spent in low-intensity activities and less time in moderate-intensity activity, together with lower diversity of exercise types. These conservative patterns may reflect fatigue, mood symptoms, prior thyroid dysfunction, or comorbidities, and could also be influenced by the higher proportion of females and metabolic comorbidities in the HT group. Notably, within HT participants, high-intensity exercise time was inversely associated with TPOAb levels in correlation and regression analyses, which likely reflects that patients with lower autoimmune activity or lower symptom burden are better able to maintain higher activity levels.
However, this association should not be interpreted as evidence that high-intensity exercise reduces thyroid autoantibody levels. Reverse causation is plausible (e.g., individuals with lower symptom burden or fewer functional limitations may be more able to engage in vigorous activity), and residual confounding by prior thyroid dysfunction, LT4 use, disease duration, weight change, symptom burden, and clinical management may remain. Importantly, high-intensity training can also act as a physiological stressor, with potential activation of the HPA axis and effects on thyroid regulation [34, 35], emphasizing that any intervention should be individualized and progressive. Evidence from randomized exercise interventions in hypothyroidism suggests that structured programmes may be associated with changes in thyroid function tests in some settings, but the certainty of evidence has been reported as moderate for TSH and very low for T4, with substantial heterogeneity and limited reporting of exercise intensity [14]. Animal studies provide mechanistic hypotheses (e.g., reduced inflammatory markers after high-intensity interval training in hypothyroid models) [36], but their relevance to thyroid autoimmunity in humans remains uncertain.
This study has several limitations. First, lifestyle behaviours were self-reported and may be subject to recall and reporting bias. Second, participants were recruited from a single centre, which may limit generalisability. Third, the cross-sectional design precludes inference on temporal order and causality for the associations between lifestyle factors and antibody levels. Finally, all HT participants were biochemically euthyroid at enrollment, which improves internal consistency but limits generalisability to untreated or biochemically uncontrolled hypothyroidism. In addition, residual confounding by prior thyroid dysfunction, LT4 use, disease duration, and symptom burden may remain. Prospective cohorts and interventional studies with detailed clinical data are needed to determine whether these associations persist across clinically relevant subgroups.
Conclusion
HT patients displayed poorer psychological status, impaired sleep, and reduced quality of life, together with distinct dietary habits and more conservative exercise patterns compared with controls. In this biochemically euthyroid HT cohort, high-intensity exercise time was inversely associated with TPOAb levels among HT participants. These findings should be regarded as descriptive and exploratory and warrant confirmation in prospective and interventional studies.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
We thank all participants for their contribution to this study. We also express our gratitude to the clinical staff for their assistance in questionnaire administration and data collection.
Author contributions
SM collected the data, conducted the statistical analyses, and drafted the manuscript. YL conceived the study and supervised the work. PY contributed to the statistical analyses. QC, MA, and DM assisted with data collection and processing. LZ, JZ, and XS revised the manuscript. All authors reviewed and approved the final manuscript.
Funding
This work was supported by the Specialized Training Foundation of Zhongshan Hospital (Grant No. 2023-007) and the Shanghai Oriental Talent Youth Program.
Data availability
The data that support the findings of this study are available from the corresponding authors upon reasonable request.
Declarations
Ethics approval and consent to participate
Written informed consent was obtained from all participants. The study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Shanghai Geriatric Medical Center.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Supplementary Materials
Data Availability Statement
The data that support the findings of this study are available from the corresponding authors upon reasonable request.