Obesity, a complex and multifactorial condition, has reached epidemic proportions worldwide, with significant implications for both individual and public health.1 Defined by the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) as a body mass index (BMI) of ≥30 kg/m², obesity is recognized as a significant risk factor for numerous chronic diseases, including cardiovascular disease (CVD), type 2 diabetes, hypertension, and certain cancers.2,3 The prevalence of obesity is rising at an alarming rate, not only in developed nations but also in developing countries, contributing to a global health crisis that demands urgent attention.3

The measurement of obesity typically relies on body mass index (BMI), a ratio of weight (in kilograms) to height (in meters squared), commonly used in clinical and research settings.4 Many large-scale, population-based studies, comprising millions of individuals from 189 studies followed for over a decade, have shown that a BMI above approximately 25 kg/m2 is associated with a progressive increase in mortality rate and chronic disease risk. A BMI of 25 kg/m2 or higher defines overweight, 30 kg/m2 or higher defines obesity, and 40 kg/m2 or higher (or 35 kg/m2 or more with comorbidities), defines severe obesity.5 Thus, although an elevated BMI increases the risk of CVD and other health complications, not every overweight/obese patient develops risk factors or health issues. For any given level of total body fat, individuals characterized by a low accumulation of abdominal visceral adipose tissue generally have a lower CVD risk profile than individuals closely matched for BMI or for total body fat but with high levels of visceral adipose tissue. Those with excessive visceral fat display a constellation of metabolic abnormalities, including insulin resistance, glucose intolerance leading to type 2 diabetes, atherogenic dyslipidemia (including increased triglyceride levels, increased concentrations of non-high-density lipoprotein [HDL] cholesterol and apolipoprotein B, low HDL cholesterol levels, small dense low-density lipoprotein [LDL] and HDL particles), elevated blood pressure (BP), subtle chronic inflammation, and a prothrombotic profil. This risk cluster characterizes the so-called metabolic syndrome.6 Visceral obesity is commonly assessed using waist circumference (WC) and waist-to-hip ratio (WHR), with established thresholds for increased metabolic risk set at WC ≥102 cm (WHR >1.0) for males and ≥88 cm (WHR >0.85) for females. It is thus recommended that a combination of both BMI and WC be used to assess the association of cardiovascular risk. However, for Asians, the cut-offs for overweight (≥23.0 kg/m²) and obesity (≥25.0 kg/m²) are lower than those for age- and gender-matched Caucasians due to higher risks related to body fat, metabolic disturbances, and cardiovascular comorbidities.7,8,9 (Refer to Table 1 for BMI and WC levels according to various international guidelines, along with their associated comorbidity risks).

The etiology of obesity is multifaceted, involving a complex interplay of genetic, ethinicity, hormonal, behavioral, environmental, and societal factors.10 High-calorie, nutrient-poor diets and physical inactivity are primary drivers.11 However Genes can regulate susceptibility to visceral obesity.5 Offspring of viscerally obese parents often develop the same pattern when they reach their 30s and 40s, a finding that may reflect both heritability and shared environmental factors. Similarly, Ethnicity also associates with variations in visceral adiposity and ectopic fat.1,5,6,18 Large imaging cardiometabolic studies have shown susceptibility to visceral adiposity/ectopic fat greatest in Asians, then Caucasians, and then African Americans. Hormonal aberrations also play a dominant role. The hypothalamic-pituitary-adrenal (HPA) axis and the endocannabinoid (EC) system can also modulate visceral adiposity/ectopic fat. Maladaptive responses to stress associate with chronic exposure of various tissues, including adipose tissue, to glucocorticoids, which can contribute to visceral and liver fat accumulation.5 Adipose tissue contains EC receptors, and overactivation of the EC system may occur in visceral obesity, leading to altered metabolism of visceral adipocytes.19 Lifestyle changes inducing weight loss as induced by regular practice of yoga can mitigate such overactivity of the EC system.19 It is important to comprehend that aberrant lifestyle is a key contributor to visceral obesity. It is now apparent that because excess body weight and obesity result largely from lifestyle, even for those with a genetic susceptibility, the clinician should also evaluate factors such as nutritional quality and level of physical activity.

Obesity also profoundly affects mental and social well-being, often leading to stigma, discrimination, and psychological distress, which can exacerbate mental health disorders such as depression and anxiety.12 Moreover, the systemic inflammation associated with excess adipose tissue, particularly visceral fat, contributes to the development and progression of atherosclerosis, a key factor in the pathogenesis of cardiovascular disease.13 Adipose tissue is now recognised as an endocrine organ, secreting bioactive substances, like pro-inflammatory cytokines, that crucially influence the development of insulin resistance, dyslipidemia, and hypertension.14 Obesity directly increases the risk of various cardiovascular issues, including coronary artery disease (CAD), heart failure (HF), and arrhythmias, particularly sudden cardiac death (SCD) and atrial fibrillation (AF).15 A 10-kg increase in body weight elevates the risk of coronary artery disease by 12%.16 In young adults, excess weight is a crucial risk factor for non-ST segment elevation myocardial infarction (NSTEMI). Obesity is also an independent risk factor for ST-elevation myocardial infarction (STEMI) in this demographic.17 The Framingham Heart Study observed that a 1 kg/m² rise in BMI increased the risk of heart failure by 5% in males and 7% in females, and obesity typically advances the onset of heart failure by at least a decade compared to individuals with a normal BMI.18 Nearly 50% of patients diagnosed with heart failure are obese, and approximately 40% are overweight.19 Obese patients have more than a 1.50-fold greater risk of developing atrial fibrillation, which also increases the risks of sudden cardiac death and heart failure. Each unit increase in BMI heightens the risk of atrial fibrillation by 4%.20 A recently published study reported that high BMI contributed to 2.3–2.4 million deaths and 70.7–77.0 million disability-adjusted life years (DALYs).21 The global number of high-BMI-related DALYs has more than doubled for both genders. Cardiovascular diseases are found to be the leading cause of high-BMI-related DALYs, followed by diabetes, renal ailments, and malignancies.21

Managing obesity to reduce cardiovascular disease risk requires a comprehensive approach that addresses both genetic and environmental factors, as well as related conditions like hypertension and diabetes.22 Traditional methods, such as dietary changes and physical activity, are often difficult to maintain, while pharmacotherapy and bariatric surgery offer varying levels of success with both potential risks and exponential increases in associated costs.

Pharmacologic interventions have been widely employed in obesity management, with FDA-approved agents such as phentermine/topiramate (Topamax tablets), naltrexone/bupropion, glucagon-like peptide-1 (GLP-1) receptor agonists (semaglutide, liraglutide, tirzepatide), and orlistat demonstrating moderate weight loss efficacy (5-22%).23,24,25 However, their widespread adoption remains limited due to multiple drawbacks, including adverse effects, high costs, and the need for continuous administration to prevent weight regain.

The side effect profile of these medications is significant, often including gastrointestinal disturbances (nausea, vomiting, diarrhea), cardiovascular concerns (hypertension, tachycardia), and neuropsychiatric effects (insomnia, anxiety, cognitive impairment).26,27 Additionally, GLP-1 receptor agonists have been linked to thyroid cancer risk, raising concerns about their long-term safety. These adverse effects frequently lead to poor adherence, treatment discontinuation, and limited real-world effectiveness.28

Beyond tolerability concerns, the financial burden of pharmacologic obesity treatments is substantial, particularly for GLP-1 receptor agonists such as semaglutide and tirzepatide, which exceed $1,000 per month without insurance coverage.29 The high cost limits accessibility and poses a significant barrier to long-term adherence, especially in resource-limited settings. Furthermore, a major challenge with pharmacologic therapy is its reliance on continuous administration to maintain weight loss. Clinical trials indicate that up to 80% of lost weight is regained within a year of stopping GLP-1 receptor agonists, emphasizing the high dependency and lack of sustainability associated with these treatments.30

While bariatric surgery remains the most effective intervention for severe obesity, it is an invasive procedure with potential postoperative complications, including nutrient deficiencies, surgical risks, and gastrointestinal disorders. Additionally, a subset of patients experiences postoperative weight regain, necessitating adjunctive strategies to sustain long-term benefits.31 Given these limitations, there is an urgent need for integrative, cost-effective, and sustainable interventions that address the multifaceted nature of obesity without imposing additional health or economic burdens.

In recent years, there has been growing interest in complementary and alternative therapies for obesity management, particularly those that offer a holistic approach to health. This line of thinking has emerged due to the substantial accumulation of evidence that lifestyle changes are perpetuated by yoga and its physical component, including yoga Exercises (asanas) and its mental component; meditation plays a crucial role in mitigating stress and increasing cardiovascular resilience akin to leading exercise modalities. However, other exercise systems, including resistance and aerobic exercises, lack profound changes in the brain, leading to stress mitigation associated with yoga, particularly with its mindfulness (dharana) and meditation (dhyana) components. We also recently showed that Yoga is the best exercise to increase heart rate variability (HRV), a marker of cardiovascular health in people with cardiovascular disease, compared to other modalities, including resistance and aerobic training. Yoga, a mind-body practice that combines physical postures, breath control, and meditation, has thus emerged as an evidence-based, promising intervention for obesity and related conditions.32,33,34 Yoga promotes physical activity and energy expenditure, enhances mindfulness, reduces stress, and improves psychological well-being, making it a suitable choice for long-term weight management.35

Clinical research has demonstrated that yoga is effective in reducing BMI, waist circumference, and other cardiometabolic risk factors.34 Even modest weight loss achieved through yoga practice can significantly reduce the risk of cardiovascular disease, emphasizing the importance of this integrative approach in preventing and managing obesity. Furthermore, yoga's ability to reduce systemic inflammation and improve stress-related biomarkers highlights its potential as a therapeutic intervention for reducing cardiovascular risk in individuals with obesity.

This review consolidates existing research on yoga's role in managing obesity and its efficacy in ameliorating cardiovascular risks. It seeks to explore how both short-term and long-term yoga practices influence body composition, cardiovascular health metrics, and psychological well-being in obese populations.

Objective: The aim of this review was to examine the role of yoga practice in managing obesity, thereby reducing cardiovascular risk and enhancing well-being.

Data Sources: We searched several databases from their inception to September 2024, including Medline/PubMed, Scopus, Embase and Cochrane Central Library, to identify relevant studies.

Search Strategy: The search strategy was designed to capture studies focusing on the role of yoga in obesity management and its effects on cardiovascular risk factors. Keywords used included "Yoga," "Obesity," "Cardiovascular Risk," and their respective synonyms "Mind-body practices," "Weight Management," and "Heart Disease."

Study Selection: The search was not limited to specific study designs or methodologies, allowing for the inclusion of a diverse array of publications such as randomized controlled trials (RCTs), cohort studies, case reports, and expert opinions. We restricted our search to studies involving human subjects and published in English to focus on the most applicable and high-quality data.

Screening Process: Initial screening involved reviewing titles and abstracts to determine relevance based on predefined inclusion criteria. This task was performed independently by two reviewers, with any disagreements resolved through discussion or consultation with a third reviewer.

Data Extraction and Quality Assessment: Following the initial screening, data pertaining to study design, population demographics, intervention specifics, and primary outcomes were systematically extracted. The quality of the included studies was rigorously assessed using validated checklists from the Cochrane Collaboration, tailored to each study design.

Data Synthesis: Given the narrative nature of this review, selection criteria were broad to include studies that provide significant insights into the mechanisms by which yoga affects obesity and cardiovascular risk factors. Priority was given to studies that offered detailed descriptions of yoga interventions, participant characteristics, and measured outcomes related to physical and psychological health. The collected articles were organized based on study design and common themes such as the impact of yoga on physical health metrics (e.g., weight, BMI, blood pressure), psychological and behavioral changes, and specific effects on cardiovascular health. This thematic organization helps in discussing the multifaceted benefits of yoga and its potential mechanisms of action within the contexts of obesity and cardiovascular health.

The NICE guidelines (2020) and AHA/ACC/TOS guidelines (2013) suggest that even a weight loss of 5%–10% is adequate to have an impact on clinical outcomes.36,37 The Look AHEAD trial robustly demonstrated that even modest weight losses at one year lead to substantial reductions in cardiovascular risk factors among overweight and obese patients, with the degree of benefit directly correlating with the extent of weight loss.38 A retrospective study using data from >500,000 patients from the primary care record database found that a 13% weight loss led to a 19%–41% reduction in cardiovascular risk factors.36

There is a plethora of evidence that has demonstrated the benefits of yoga practice in reducing and managing obesity.39,34 It is safe and effective as a primary or supplemental self-care method for weight loss, weight maintenance, and the prevention of obesity and metabolic syndrome (MetS). Studies of yoga for weight loss/MetS have found significant reductions in abdominal obesity, positive changes in the ghrelin axis, and a reduction in several cardiometabolic risk factors.40,41 In particular, the mind-body aspect of yoga therapy has also been found to prompt psychosocial alterations associated with sustainable weight loss since practitioners have found it to be a simple means to achieve and maintain weight loss and therefore remain motivated.42

This review highlights the existing published evidence regarding the effect of yogic intervention along with pranayama and meditation in overweight and obese individuals on reduction in adiposity, which is a direct and indirect risk factor for CVD.

A total of 18 randomized controlled trials (RCTs) were included in this systematic review, including one pilot RCT. Sample sizes varied between 16 and 106 participants, with a total of 978 individuals enrolled across all studies. The age of participants ranged from 18 to 75 years. Geographically, the highest number of RCTs were conducted in India (n = 7), followed by the United States (n = 4), Australia (n = 2), and one trial each in the United Kingdom, Korea, Thailand, Sweden, and Puerto Rico. Most studies implemented a structured yoga intervention incorporating Asana, Pranayama, Meditation, and Relaxation, with some studies specifically incorporating Bikram Yoga (n = 2), Viniyoga (n = 1), and cleansing practices (n = 1). The intervention duration ranged from 2 to 12 months, with session lengths varying between 45 and 90 minutes. Session frequency ranged from twice daily to 3 to 6 times per week. In contrast, control groups received either no intervention or standard care, including usual medical treatment, health education, or lifestyle advice. Some studies employed minimal contact strategies such as brief health education sessions or general hypertension education.

The included studies assessed various anthropometric measurements and indices, including body mass index (BMI) (n = 11), waist circumference (n = 6), weight (n = 8), fat mass percentage (n = 3), waist-to-hip ratio (WHR) (n = 2), body fat percentage (n = 1), head circumference (n = 1), and muscle mass percentage (n = 1). Significant improvements in anthropometric outcomes were observed in the intervention group compared to the control. Weight reduction ranged from 1 kg to 12 kg, with an average BMI reduction of 1 to 3 points across studies. Waist circumference decreased by up to 2-3 cm, with one study reporting a significant reduction from 96.98 ± 9.54 cm to 90.73 ± 7.31 cm following the intervention. Additionally, fat mass percentage and body fat percentage decreased by an average of 2 to 3 points in the intervention group compared to controls. However, no significant changes were reported in waist-to-hip ratio (WHR).

Of the eighteen RCTs, five RCTs lasting 14 weeks to 1 years investigated the effect of yoga intervention in obese patients with coronary artery disease (CAD) or coronary heart disease (CHD). Three of these studies assessed the impact on cardiovascular events, while the remaining two focused solely on BMI. Six trials, spanning 10 weeks to 1 year, evaluated the effects of yoga on waist circumference and mediators of obesity-related pathological changes in patients with metabolic syndrome (MetS). The remaining seven studies, with durations ranging from 15 days to 1 year, reported anthropometric changes in overweight or obese individuals, along with inflammatory markers such as C-reactive protein (CRP) and the effects of adherence to yoga interventions on outcomes (Table 2).