TYPE Systematic Review

PUBLISHED 13 October 2022

DOI 10.3389/fpubh.2022.1020709

Global prevalence and

OPEN ACCESS epidemiological trends of
Hashimoto’s thyroiditis in adults:
EDITED BY
Masoud Dadashi,
Alborz University of Medical
Sciences, Iran

REVIEWED BY
A systematic review and
Mengli Guo,
Guangzhou First People’s
Hospital, China
meta-analysis
Ke Ding,
Central South University, China
Xiaojie Hu1,2 , Yuquan Chen3 , Yiting Shen1 , Rui Tian1 ,
*CORRESPONDENCE
Huafa Que Yuqin Sheng1 and Huafa Que1,2*
[email protected]
1
Department of Traditional Chinese Surgery, Longhua Hospital Affiliated to Shanghai University of
SPECIALTY SECTION
Traditional Chinese Medicine, Shanghai, China, 2 Longhua Medical College, Shanghai University of
This article was submitted to Traditional Chinese Medicine, Shanghai, China, 3 Institute of Medical Information/Medical Library,
Life-Course Epidemiology and Social Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
Inequalities in Health,
a section of the journal
Frontiers in Public Health
Objective: Although Hashimoto’s thyroiditis is associated with cardiovascular
RECEIVED 16 August 2022
ACCEPTED 29 September 2022 disease and malignancy, the global status of Hashimoto’s thyroiditis is not well
PUBLISHED 13 October 2022 characterized across regions. Our objective was to evaluate the prevalence and
CITATION trends of Hashimoto’s thyroiditis in adults in regions with different economic
Hu X, Chen Y, Shen Y, Tian R, Sheng Y
and Que H (2022) Global prevalence
income levels around the world.
and epidemiological trends of Methods: For this systematic review and meta-analysis, we searched
Hashimoto’s thyroiditis in adults: A
systematic review and meta-analysis. PubMed, Embase, MEDLINE, Scopus, and Web of Science databases, and 48
Front. Public Health 10:1020709. random-effects representative studies from the inception to June 2022 were
doi: 10.3389/fpubh.2022.1020709
included without language restrictions to obtain the overall prevalence of
COPYRIGHT Hashimoto’s thyroiditis in adults worldwide. In addition, we stratified by time
© 2022 Hu, Chen, Shen, Tian, Sheng
and Que. This is an open-access of publication, geographic region, economic level of the region of residence,
article distributed under the terms of gender, diagnostic method, etc.
the Creative Commons Attribution
License (CC BY). The use, distribution Results: A total of 11,399 studies were retrieved, of which 48 met the
or reproduction in other forums is research criteria: 20 from Europe, 16 from Asia, five from South America,
permitted, provided the original
author(s) and the copyright owner(s)
three from North America, and three from Africa. Furthermore, there
are credited and that the original are two projects involving 19 countries and 22,680,155 participants.
publication in this journal is cited, in The prevalence of Hashimoto’s thyroiditis was 7.5 (95%CI 5.7–9.6%),
accordance with accepted academic
practice. No use, distribution or while in the low-middle-income group the prevalence was 11.4 (95%CI
reproduction is permitted which does 2.5–25.2%). Similarly, the prevalence was 5.6 (95%Cl 3.9–7.4%) in
not comply with these terms.
the upper-middle-income group, and in the high-income group, the
prevalence was 8.4 (95%Cl 5.6–11.8). The prevalence of Hashimoto’s
varied by geographic region: Africa (14.2 [95% CI 2.5–32.9%]), Oceania
(11.0% [95% CI 7.8–14.7%]), South America and Europe 8.0, 7.8% (95% Cl
0.0–29.5%) in North America, and 5.8 (95% Cl 2.8–9.9%) in Asia. Although
our investigator heterogeneity was high (I2 ), our results using a sensitivity
analysis showed robustness and reliability of the findings. People living
in low-middle-income areas are more likely to develop Hashimoto’s
thyroiditis, while the group in high-income areas are more likely to
develop Hashimoto’s thyroiditis than people in upper-middle-income
areas, and women’s risk is about four times higher than men’s.

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Hu et al. 10.3389/fpubh.2022.1020709

Conclusions: Global Hashimoto’s thyroiditis patients are about four times

as many as males, and there are discrepancies in the regions with different
economic levels. In low-middle-income areas with a higher prevalence of
Hashimoto’s thyroiditis, especially countries in Africa, therefore local health
departments should take strategic measures to prevent, detect, and treat
Hashimoto’s thyroiditis. At the same time, the hidden medical burden other
diseases caused by Hashimoto’s thyroiditis should also be done well.
Systematic review registration: https://www.crd.york.ac.uk/prospero/,
identifier: CRD 42022339839.

KEYWORDS

Hashimoto’s thyroiditis, global prevalence, epidemiological trends, systematic review,

meta-analysis

Introduction Search strategy and selection criteria

Hashimoto’s thyroiditis (HT), also known as autoimmune Five database including PubMed, Embase, MEDLINE,
thyroiditis (AIT) or chronic lymphocytic thyroiditis, is an Scopus, and Web of Science databases were searched from
autoimmune disease of the thyroid gland, often characterized by inception until June 2022, with no language restrictions.
an enlarged thyroid gland, lymphocytic infiltration, and elevated The retrieval strategies included three core panels, associated
serum autoimmune antibody levels. HT is a common cause of with using AND connectors: (1) Hashimoto’s thyroiditis, (2)
hypothyroidism in iodine-replete settings and increases the risk Prevalence, and (3) Observational studies. The three core
of malignancy (1–3).
The prevalence of HT varies by region and socioeconomic
level, ranging from 4.8–25.8% in women and 0.9–7.9% in men
(4). As we all known, the prevalence of HT varies significantly
depending on geographic location. Although several previous
studies have systematically described the prevalence of HT,
none of them reviewed global HT prevalence and trends.
Current researches have shown that the global prevalence of
various autoimmune diseases was increasing (5), it is worth
being exploring whether the global prevalence of HT has also
increased. This study aimed to quantify the possible healthcare
burden and plan for the future by assessing the global prevalence
and trends of HT by analyzing the prevalence of HT in
different regions.

Methods
Registration

Meta-based analysis was applied in this study. Compared

with traditional literature review or the emerging bibliometric
analysis, systematic review and meta-analysis had a relatively
broad horizon of the current hotspots and can quantitatively
reflect the research status in the field (1–3). This systematic
review was conducted in accordance with the Preferred
Reporting Items for Systematic Reviews and Meta-Analysis FIGURE 1
Protocols guidelines (4) and is registered with the International Study selection.
Prospective Register of Systematic Reviews (CRD42022339839).

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Hu et al.
TABLE 1 Characteristics of included studies.

Source Year Nation Income Continent Case Total Type of study design Sample type Test method Time Sample source
group period

Okayasu I 1991 Japan High income Asia 328 1,826 Cross-sectional study Thyroid tissue Pathological section 1990 Clinic-based study
Okayasu I 1994 USA High income North 457 2,040 Cross-sectional study Thyroid tissue Pathological section 1975-1992 Clinic-based study
America
Morinaka S 1995 Japan High income Asia 61 6,348 Cross-sectional study Serum Antibodies, ultrasound, 1990-1994 Clinic-based study
fine needle aspiration
Tomimori E 1995 Brazil Upper middle South America 72 547 Cross-sectional study - Ultrasound 1990-1995 Population-based study
income
Nagata K 1998 Japan High income Asia 142 1,039 Cross-sectional study Serum Antibody 1998 Population-based study
Aghini-Lombardi F 1999 Italy High income Europe 50 1,411 Cross-sectional study Serum Antibody 1998 Population-based study
Pedersen IB 2003 Denmark High income Europe 787 4,184 Array research Serum Antibody 1997-1998 Population-based study
Völzke H 2003 Germany High income Europe 47 3,941 Cross-sectional study Serum Antibody 1997-2001 Population-based study
Teng W 2006 China Upper middle Asia 32 3,761 Cross-sectional study Serum Antibody 1999 Population-based study
income
Camargo RY 2006 Brazil Upper middle South America 82 420 Cross-sectional study Serum Antibodies, ultrasound 1998-2005 Population-based study
income
03

Okosieme OE 2007 Nigeria Lower middle Africa 7 104 Cross-sectional study Serum Antibody 2006 Clinic-based study
income
Kurata S 2007 Japan High income Asia 25 1,626 Cross-sectional study Serum,thyroid tissue Antibodies, ultrasound, 2002-2007 Clinic-based study
fine needle aspiration
Teng X 2008 China Upper middle Asia 67 778 Array research Serum Antibodies, ultrasound 2005 Population-based study
income
Camargo RY 2008 Brazil Upper middle South America 183 1,085 Cross-sectional study Serum Antibody 2004 Population-based study
income
Döbert N 2008 Germany High income Europe 98 700 Cross-sectional study Serum Antibodies, ultrasound 2006 Population-based study
Benvenga S 2008 Italy High income Europe 4064 23,000 Array research Serum,thyroid tissue Antibodies, ultrasound, 1975-2005 Clinic-based study
fine needle aspiration
Teng XC 2011 China Upper middle Asia 363 3,813 Cross-sectional study Serum Antibodies, ultrasound 2007 Population-based study

10.3389/fpubh.2022.1020709
income
Deshpande P 2016 Australia High income Oceania 17 198 Cross-sectional study Serum Antibody 1994 Population-based study
Fernando RF 2012 Sri Lanka Lower middle Asia 353 5,200 Cross-sectional study Serum Antibody 2007-2008 Population-based study
income
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Sardu C 2012 Italy High income Europe 678 25,885 Cross-sectional study NR NR 2009 Population-based study

(Continued)
 TABLE 1 (Continued)
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Hu et al.
Source Year Nation Income Continent Case Total Type of study design Sample type Test method Time Sample source
group period

Aghini Lombardi F 2013 Italy High income Europe 224 1,065 Cross-sectional study Thyroid tissue Antibodies, ultrasound 2010 Population-based study
Vecchiatti SM 2015 Brazil Upper middle South America 106 4,613 Cross-sectional study Thyroid tissue Pathological section 2003-2007 Clinic-based study
income
Wu Q 2015 China Upper middle Asia 172 6,152 Cross-sectional study Serum Antibody 2013 Population-based study
income
Flores-Rebollar A 2015 Mexico Upper middle North 36 427 Cross-sectional study Serum Antibodies, ultrasound 2010-2015 Population-based study
income America
Li Y 2016 China Upper middle Asia 187 2,856 Array research Serum Antibody 2013 Population-based study
income
Caturegli G 2016 USA High income North 4 1,075 Cross-sectional study NR NR 2015 Population-based study
America
Tammaro A 2016 Italy High income Europe 2828 7,976 Array research Serum Antibody 2003-2010 Population-based study
Tolentino Júnior 2019 Brazil Upper middle South America 85 60,413 Cross-sectional study NR NR 2016 Population-based study
DS income
Pilli T 2019 Italy High income Europe 9 142 Cross-sectional study Serum Antibody 2014-2019 Clinic-based study
04

Troshina EA 2021 Russia Upper middle Europe 428 100,000 Cross-sectional study Serum Antibody 2018 Population-based study
income
Chen Y 2021 China Upper middle Asia 298 2,946 Cross-sectional study Serum Antibodies,ultrasound 2016-2021 Population-based study
income
Kim HJ 2021 South Korea High income Asia 29429 217,05883 Array research NR NR 2002-2017 Population-based study
Yu ZW 2021 China Upper middle Asia 148 1,159 Cross-sectional study Thyroid tissue Pathological section 2016-2020 Population-based study
income
Józków P 2017 Poland High income Europe 29375 586,703 Cross-sectional study Serum Antibody 2006-2013 Clinic-based study
Izic B 2021 Bosnia and Upper middle Europe 358 82,000 Array research Serum Antibody 2015-2020 Population-based study
Herzegovina income
Gu F 2016 China Upper middle Asia 17 5,293 Cross-sectional study Serum Antibodies, ultrasound 2011 Population-based study
income

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Bjøro T 1984 Norway High income Europe 56 1,640 Cross-sectional study Serum Antibody 1979 Population-based study
Chabchoub G 2006 Tunisia Lower middle Africa 246 1,079 Array research Serum Antibody 1990-2003 Clinic-based study
income
Dingle PR 1966 England High income Europe 52 469 Cross-sectional study Serum Antibody 1962 Population-based study
frontiersin.org

Jacobs A 1969 England High income Europe 99 989 Cross-sectional study Serum Antibody 1969 Population-based study
Tunbridge WM 1977 England High income Europe 56 2779 Cross-sectional study Serum Antibody 1972-1974 Population-based study

(Continued)
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components are all composed of subject words and free

Population-based study

Population-based study
Population-based study
Population-based study
Population-based study
Population-based study
words, which are retrieved from Pubmed’s MeSH interface
Sample source

Clinic-based study
(Appendix 1).
The articles we included were all observational studies
which reported the prevalence of HT with no interventions.
We excluded articles for which full-text or original data were
not available, and studies with a sample size fewer than 100
participants. Two authors (XH and YiS) independently screened
1985-1990

1967-1972
1979-1980
1990-1991
period
Time

eligible research records in accordance with title and abstract,

1970

1981
2004
respectively. And two additional authors (RT and YuS) retrieved
Antibodies, ultrasound
the full text of potentially eligible articles to determine final
inclusion. Inconsistent choices are resolved through discussion
Total Type of study design Sample type Test method

or third-party author participation.

Antibody
Antibody
Antibody
Antibody
Antibody
Antibody

Data extraction and quality assessment

Data were extracted by one author using a standardized

template, cross-checked by another author, and ambiguities
Serum
Serum
Serum
Serum
Serum
Serum
Serum

resolved by discussion. Extracted data included the year of

publication, first author, country of publication, geographic
location, study type, sample size, diagnostic method, duration,
Cross-sectional study
Cross-sectional study
Cross-sectional study
Cross-sectional study
Cross-sectional study
Cross-sectional study
Cross-sectional study

sample source, and prevalence. We used an existing checklist

modified by Hoy D to assess the quality of included studies (6).
The list contained a total of nine questions, each question could
be answered “yes” or “no,” and answering “yes” earns one point.
The final score for each study was between zero and nine. Zero to
three was low quality, four to six was medium quality, and seven
1,137
2,961
2,551
4,110
2,115
3,018
698

to nine was high quality.

Statistical analyses
Case

124

282
176
457
262
353
89
Continent

We performed a meta-analysis of the extracted data and

carried out statistical analysis using R software (version 4.0.3).
Oceania
Europe
Europe
Europe
Europe

The meta package in R software (version 4.0.3, Auckland

Asia

Asia

University, USA) was mainly used for data analysis and the main
Upper middle
High income
High income
High income
High income
High income
High income

outcome was assessed via single-arm analysis. For the prevalence

Income

or proportion, firstly, the normality test was conducted. If the

group

income

data did not conform to the normality, it would be transformed

by logarithm, logit, or double anti-sinusoidal transformation,
and then, the inverse variance weighting method was used
Nation

Australia
England

Norway
Finland
Finland

to combine.
China
Japan

The Cochrane Q-test and I2 value were used to test

whether there was significant heterogeneity among all studies
(7). According to the Meta-analysis of Observational Studies in
Epidemiology guideline (8), if P > 0.10 and I2 ≤ 50%, it indicated
Year

1990
1971
1972
1996
1993
2005
2008
TABLE 1 (Continued)

that there was no statistical heterogeneity among the research

results, and the fixed effect model was applied to analyze the
results; If P ≤ 0.1 and I2 > 50%, the random effect model
Prentice LM

O’Leary PC

was used for meta-analysis. Publication bias was evaluated using

Gordin A

Konno N
Source

Bryhni B

Egger’s test combined with a funnel plot. If there was obvious

Aho K

Li YS

publication bias, we would use the trim-and-fill method to adjust

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FIGURE 2
Literature quality assessment.

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FIGURE 3
Global prevalence of Hashimoto’s thyroiditis.

for prospective plot asymmetry. And provided that necessary, Result

sensitivity analysis was performed by grouping or omitting
each study. Given that it was infeasible to make a quantitative Study characteristics
synthesis and conduct a meta-analysis, a narrative approach
and descriptive statistics were used. In addition, we performed A total of 11,399 records were retrieved and identified across
subgroup analyses by income, geographic region, study type, five databases. After removing duplicate literature, 7,989 articles
diagnostic method, time of the study, and source of participants. were screened out. Hundred and fifty four studies were reviewed

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FIGURE 4
Global prevalence of Hashimoto’s thyroiditis, by time of study implementation.

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FIGURE 5
Global prevalence of Hashimoto’s thyroiditis, by sex.

for full text, and a total of 48 studies were finally included years, from 9% before 2000 to 6.5% after 2000 (Figure 4). HT
(9–56) (Figure 1). All studies were observational (40 cross- prevalence of female adults was 3.86 adult males times (17.5
sectional, eight cohort studies) involving 22,680,155 participants vs. 6.0%) (Figure 5). The prevalence of HT in clinical studies
(Table 1). Thirty-seven of the 48 studies were population-based was 8.6% higher than in population-based studies (8.6 vs.
and 11 were clinical-based. Thirty-seven of the 48 studies were 7.5%) (Figure 6). The prevalence of HT in adults from different
population-based and 11 were clinical-based. Twenty-seven continents was diverse, with the highest prevalence of HT in
studies confirmed HT was due to serum autoantibody levels, African adults (14.2%), followed by Oceania (11.0%), 8.0% in
nine studies that used serum autoantibodies combined with both South American and European adults, and 7.8% in North
ultrasonography to confirm the diagnosis, three studies that America. The lowest prevalence of HT in Asian adults was
used serum autoantibodies to combine ultrasonography and fine 5.8% (Figure 7). According to the latest income classification
needle aspiration, four studies on biopsy, only one study on of the World Bank (https://datatopics.worldbank.org/world-
ultrasonography alone, and four items not reported. Participants developmentindicators/the-world-by-incomeand-region.htm),
spanned from 1962 to 2021 and included studies published we conducted a subgroup analysis according to low-income,
from 1966 to 2021 (Table 1). Twenty-one studies were published lower-middle-income, upper-middle-income, and high-income
before 2000 and 27 studies were published after 2000. Of the groups. The results showed that the prevalence of HT adults in
48 studies, 20 were from Europe, 16 from Asia, five from South the low-middle-income group was 11.4%, in the upper-middle-
America, three from North America, two from Africa, and two income group, the prevalence was 5.6%, and in the high-income
from Oceania, involving 19 countries. The quality scores of group, the prevalence was 8.4% (Figure 8).
48 articles are all six points or above, and the detailed quality
assessment results are shown in Figure 2.

Quality assessment

Meta-analysis results We conducted a subgroup analysis according to different

diagnostic methods. The results of analysis indicated that
We extracted data points from 48 studies that met the the prevalence of HT diagnosed by serum autoantibodies
inclusion criteria to form the initial data. The initial data was 7.8 (95% Cl 5.4–10.5%), and the prevalence of HT
was tested by Shapiro-Wilk (SW), P = 0.002047 < 0.05, diagnosed by ultrasonography was 13.2 (95% Cl 5.7–9.6%).
which did not conform to the normal distribution, so we Similarly, the prevalence of HT was diagnosed by pathological
adopted Freeman-Tukey double arcsine transformation. After examination was 12.5 (95% Cl 3.3–26.5%) (Figure 9). The
the transformation, the data showed a normal distribution. prevalence rate of HT diagnosed by serum autoantibody level
We executed a data pooled meta-analysis and estimated the combined with color Doppler ultrasound was 10.4 (95% Cl 5.1–
global prevalence of HT in adults to be 7.5% (Figure 3). The 17.1%), while the prevalence rate of HT diagnosed by serum
prevalence of HT in adults has declined over the past 60 autoantibody level, color Doppler ultrasonography, and fine

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FIGURE 6
Global prevalence of Hashimoto’s thyroiditis, by study source.

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FIGURE 7
Global prevalence of Hashimoto’s thyroiditis, by geographic location.

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FIGURE 8
Global prevalence of Hashimoto’s thyroiditis, by income.

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FIGURE 9
Subgroup analysis of diagnostic methods.

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needle aspiration (FNA) was 4.7 (95% 0.0–21.0%) (Figure 9).

We performed a subgroup analysis of samples diagnosed with
HT. The prevalence of HT confirmed by serum was 7.8 (95%
Cl 5.8–10.1%), the prevalence of HT confirmed by serum
or pathological tissue was 7.6 (95% Cl 0.0–30.2%), and the
prevalence of HT confirmed by thyroid tissue alone was 14.1
(95% Cl 5.2–26.5%).
The prevalence of HT in adults varies significantly across
countries, ranging as high as 22.8 (95% Cl 20.3–25.4%) in
Tunisia and 18.8 (95% Cl 17.6-−20.0%) in Denmark, while the
prevalence in South Korea is as low as 0.1%, and in adults in
Russia and Bosnia and Herzegovina, The prevalence of HT was
0.4% (Figure 10).
Among the 48 observational studies, 42 studies were low risk
(good quality), and 6 studies were rated as medium risk, making
a risk of bears evaluation chart (Figure 11). Funnel plots and
Egger’s test linear regression were used to test for publication
bias. There was a publication bias in each study (P < 0.05). The
results are shown in the Appendix 1 (Figure 12). We used the
trim-and-fill method to correct for publication bias. Sensitivity
analysis showed that the literature included in this study had
little impact on the results of the study analysis, and removing
any one of the studies would have a small impact (Figure 13).

Discussion
This systematic review and meta-analysis provides a
comprehensive assessment of the prevalence of HT in adults
worldwide, which is associated with the occurrence of various
malignant tumors (2, 57, 58). In total, this study pooled 48
studies involving more than 20 million adult patients with HT
and performed subgroup analyses by type of study, diagnostic
method, the timing of study conduct, patient source, gender,
geographic location, and economic level. We found that the
prevalence of HT in adults varies widely across continents.
African adults have the highest prevalence of HT, more than
double the prevalence in Asia. We also found that the prevalence
of HT in adults decreased as time went by. Unlike previous
studies (59–61), the prevalence of Hashimoto’s thyroiditis in
adults decreased over time.
In our study, the overall prevalence of HT in adults was
7.5%, with a prevalence of 17.5% in women and 6.0% in men.
The risk of developing HT in adult women is approximately 4
times than that of adult men. Tunbridge et al. reported that in
the United States, 10% of the population had thyroid antibodies,
a prevalence of 14% in whites and about 5% in blacks (49). In
the report, the prevalence of female HT was higher, and the ratio
of female HT patients to male HT patients was 8–9:1 (60). In
contrast, the prevalence of HT in the study by Gu et al. was much
FIGURE 10 lower (3.2%) (24).
Prevalence of Hashimoto’s thyroiditis by country. Our study involved 19 countries and 6 continents (Europe,
Asia, South America, North America, Africa, and Oceania), and

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FIGURE 11
Literature quality risk assessment chart.

the prevalence data of HT adults in various regions of the world

were aggregated to estimate the prevalence of HT in adults and
development trend as far as possible. From 1960 to the present,
we pooled data on adults with HT every 20 years to assess
trends in the prevalence of HT in adults. We were surprised to
find that the prevalence of HT in adults decreased regardless
of whether we divided the study by time before and after 2000
or every 20 years. This is inconsistent with most studies. This
may be related to different regions and periods, socioeconomic
development, availability, and availability of medical resources.
The progress of the social economy will promote people to
pay more attention to physical health, increase the records
of hospital visits, and also increase the chances of HT being
detected and recorded. Therefore, studies in different periods
in the same region have shown an increase in the prevalence
of HT. Whether this is due to an increase in the prevalence of
HT due to an increase in the number of people with HT or
FIGURE 12 an increase in the probability of being detected is unclear. In
Trim-and-fill method to adjust for funnel plot asymmetry. our study, which pooled population-based and clinical-based
studies separately, the prevalence of HT in adults was lower in

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FIGURE 13
Sensitivity analysis chart of included studies.

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population-based studies than in clinical studies (7.2 vs. 8.6%). be related to the regional economy, dietary habits, lifestyle, and
This provides persuasive evidence for our hypothesis. Another diagnostic criteria of HT in different periods of the included
reason may be that in the studies we included, the proportion of studies. Sensitivity analysis showed that each study included in
studies in different regions and different periods was different. the study had little effect on the results and had good stability.
The lowest prevalence of HT in adults (6.7%) was observed The studies we included may have some selection bias, but the
in 2000–2021, with a higher proportion of studies in Asia and information in the studies was insufficient to assess these errors.
Europe during this period, and a relatively high proportion of We hope that the diagnostic criteria for HT will be unified as
HT studies in North and South America between 1960–1981. much as possible in future research so that the research results
When we performed a subgroup analysis according to the will be more convincing.
latest income classification of the World Bank, we found an
interesting phenomenon. A higher prevalence of HT among
adults in low- and middle-income countries is conceivable.
Conclusions
However, the higher prevalence of HT in adults in high-income
In conclusion, we found that the prevalence of Hashimoto’s
countries than in upper-middle-income countries is indeed an
thyroiditis in adult females is approximately four times that of
interesting finding. This may be related to the pathogenesis of
male patients, and the prevalence of HT is relatively high in
HT. People living in economically developed countries have
adults worldwide, especially in Africa. There are differences in
increased pressure from various aspects (62), and mental health
the prevalence of HT among adults at different economic levels.
status is also an important cause of HT (61).
The prevalence of HT in low- and middle-income countries
In our systematic review, Africa had the highest prevalence
is the highest, and the prevalence in high-income countries is
(14.2%) while Asia had the lowest prevalence (5.8%). The
higher than that in upper-middle-income countries. Therefore,
prevalence varies widely, which may be related to lifestyle
we suggest that public health departments in low- and middle-
and dietary habits. The pathogenesis of Hashimoto’s thyroiditis
income countries should take strategic measures to prevent,
is still unclear, and some studies have pointed out that the
detect, and treat HT as early as possible, while high-income
lack of micronutrients may be related to the pathogenesis of
countries should also pay attention to the prevalence of HT and
thyroiditis, such as vitamin D deficiency (4, 63). In Africa,
the burden of medical services.
some people still live a traditional way of life (gathering,
hunting, nomadic animals) (64). The lack of diversification
of nutrient intake due to geographic location, environmental Data availability statement
factors, and economic level may explain the high prevalence
of HT in African adults. It may also be related to the number The original contributions presented in the study are
of studies included, with 16 studies included in Asia and only included in the article/supplementary material, further inquiries
two studies from Africa. We cannot rule out differences due to can be directed to the corresponding author/s.
differences in the number of included cases. HT is a chronic
inflammatory disease, and chronic inflammation increases the
risk of a variety of malignancies (65–67). The studies we Author contributions
included were all observational studies, most of which were
cross-sectional studies, only to assess the prevalence of HT, with XH and YShen conceptualized, involved, and conducted this
no follow-up for later cancer risk and treatment in HT patients. study. XH wrote the first draft under the guidance of HQ. YC,
Therefore, our pooled estimates of the adult prevalence of HT YShen, YSheng, and RT reviewed drafts and provided input
may underestimate the actual burden on health care. for all versions. XH and YC accessed, verified, analyzed, and
Our study systematically evaluated the global adult interpreted the data. All authors contributed to the article and
prevalence of HT for the first time and includes the largest approved the submitted version.
number of studies on the prevalence of HT in adults. However,
our study also involves certain limitations. The period of the
Funding
studies we included was large. From 1962 to 2021, there may
exist differences in the diagnostic criteria and detection methods
This project was supported by the Shanghai Key Clinical
of HT in different periods. In many cases, we were unable to
Specialty Construction Project of China (shslczdzk03801).
obtain specific information on the diagnostic criteria for HT in
the studies. Although we were unable to unify the diagnostic
criteria for HT, we analyzed the prevalence of HT in adults by Acknowledgments
detection method. There was considerable heterogeneity among
studies, and we performed subgroup analyses where possible, The authors thank YC from Institute of Medical
but this did not reduce heterogeneity between studies. This may Information/Medical Library, Chinese Academy of Medical

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Hu et al. 10.3389/fpubh.2022.1020709

Sciences and Peking Union Medical College for his contribution Publisher’s note
to data analysis.
All claims expressed in this article are solely those of the
Conflict of interest authors and do not necessarily represent those of their affiliated
organizations, or those of the publisher, the editors and the
The authors declare that the research was conducted in the reviewers. Any product that may be evaluated in this article, or
absence of any commercial or financial relationships that could claim that may be made by its manufacturer, is not guaranteed
be construed as a potential conflict of interest. or endorsed by the publisher.

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Appendix
Literature search strategies.
Pubmed: ((((epidemiology[Title/Abstract])) OR
(incidence[Title/Abstract])) OR (prevalence[Title/Abstract]))
AND ((”Hashimoto Disease"[Mesh]) OR
((((((((((((((((((((((((Disease, Hashimoto[Title/Abstract]))
OR (Hashimoto Struma[Title/Abstract])) OR
(Hashimoto Thyroiditis[Title/Abstract])) OR
(Hashimoto Thyroiditides[Title/Abstract])) OR
(Thyroiditides, Hashimoto[Title/Abstract])) OR
(Thyroiditis, Hashimoto[Title/Abstract])) OR
(Hashimoto’s Syndrome[Title/Abstract])) OR
(Hashimoto Syndrome[Title/Abstract])) OR
(Hashimoto’s Syndromes[Title/Abstract])) OR
(Hashimotos Syndrome[Title/Abstract])) OR (Syndrome,
Hashimoto’s[Title/Abstract])) OR (Syndromes,
Hashimoto’s[Title/Abstract])) OR (Hashimoto’s
Struma[Title/Abstract])) OR (Chronic Lymphocytic
Thyroiditis[Title/Abstract])) OR (Chronic Lymphocytic
Thyroiditides[Title/Abstract])) OR (Lymphocytic
Thyroiditides, Chronic[Title/Abstract])) OR
(Lymphocytic Thyroiditis, Chronic[Title/Abstract])) OR
(Thyroiditides, Chronic Lymphocytic[Title/Abstract]))
OR (Thyroiditis, Chronic Lymphocytic[Title/Abstract]))
OR (Hashimoto’s Disease[Title/Abstract])) OR
(Disease, Hashimoto’s[Title/Abstract])) OR (Hashimotos
Disease[Title/Abstract])) OR (Autoimmune
thyroiditis[Title/Abstract]))).

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