Yoga and mindfulness-based lifestyle interventions for mental and physical health in South Asian immigrant women aged 40 years and older: a pilot study Open Access

Cardiometabolic and mental health risks intersect in South Asian immigrants, especially women. South Asian immigrant women face a disproportionate burden of cardiometabolic risk and greater central adiposity at comparatively lower body mass index (BMI) as well as higher levels of stress and a greater burden of mood and anxiety disorders compared to other racial/ethnic groups (Deshpande et al., 2023; Mahadevan et al., 2023; SAPHA). This susceptibility is driven by a combination of visceral fat distribution, life course adversity and sociocultural factors – conditions that may be amplified by migration and acculturation pressures (Deshpande et al., 2023; Gadgil et al., 2020; Mahadevan et al., 2023).

Standard BMI thresholds under-recognize visceral obesity in South Asians, while other anthropometric measures (e.g. waist-to-hip ratio [WHR]) better index cardiometabolic risk. Additionally, cardiometabolic risk rises at lower BMI cut-offs in South Asian individuals compared to those of White European ancestry. Thus, anthropometrics and fasting biomarkers (lipids, HbA1c and insulin) are essential in research with South Asian women to detect subclinical cardiometabolic risk (Darbandi et al., 2020; Deshpande et al., 2023).

Beyond biology, acculturative stress, shifts in diet and activity patterns with time in the USA, and persistent stigma around mental health care may contribute to distress, sleep problems and physical inactivity, yet these concerns are often under-recognized in clinical settings. Thus, targeted, culturally responsive interventions are needed for this high-risk population (Mahadevan et al., 2023; SAPHA).

Mind–body and lifestyle approaches such as yoga and mindfulness-based interventions represent promising, integrative strategies with physiological and psychological effects. Meta-analyses show yoga and mindfulness may lower blood pressure, reduce depressive symptoms and improve sleep and quality of life through autonomic regulation, stress reduction and anti-inflammatory pathways (Chen et al., 2024; Geiger et al., 2025). Effects on lipid profiles have also been reported, though findings vary by duration, intensity and participant risk (Ghazvineh et al., 2022). However, culturally tailored interventions and evidence remain limited in South Asian immigrant women.

In midlife and older adults, maintaining lower-extremity function is another critical determinant of healthy aging. The Short Physical Performance Battery (SPPB) is a validated measure of balance, gait speed and chair stands and is predictive of disability, hospitalization and mortality across diverse populations. Thus, its conclusion is supported as an objective medical/physiological outcome to capture functional health that is highly relevant to cardiometabolic risk and independence (de Fatima Ribeiro Silva et al., 2021).

Study rationale and expectations: Given the elevated cardiometabolic risk at lower BMI among South Asians, the role of central adiposity in vascular risk, and the known effects of mind–body interventions on autonomic tone and health behaviors, we included vital signs, anthropometrics (BMI, WHR), fasting biomarkers (lipids, HbA1c, insulin), and SPPB to comprehensively profile physiological status alongside mental health and lifestyle outcomes. We expected improvements in self-reported mindfulness, mood, sleep and physical activity and objective cognition, physical performance and blood pressure (especially systolic given its positive correlation with arterial stiffness (Laurent and Boutouyrie, 2020; Lu et al., 2023)), with possible trends in lipid and glucose parameters over 12 weeks.

This study used a 12-week pre- and post-intervention design to investigate the impacts of yoga enhanced with mindfulness-based behavioral lifestyle interventions on the mental and physical health outcomes of South Asian immigrant women. Using a single-arm design, we guided participants through a sequence of 14 visits, which included baseline data collection, 12-week intervention and post-intervention assessments. The Institutional Review Board at the University of Texas Health Science Center at San Antonio (UT Health San Antonio) approved this study.

To ensure a diverse participant pool, this study staff used various strategies to recruit South Asian women from different communities. These included outreach at local South Asian community events and health fairs, collaboration with community leaders and healthcare practitioners and word-of-mouth. Individuals expressing interest underwent a prescreening process, either via phone or in-person, to determine their eligibility.

We incorporated the following inclusion criteria: immigration to the USA from South Asian countries; aged 40 years or above; proficiency in English, Urdu or Hindi; and absence of any disabilities impeding the performance of yoga movements. We excluded participants if they reported a history of acute psychosis, ongoing substance misuse, unmanaged depression and cognitive impairments.

We provided preliminarily eligible candidates with comprehensive study details and the study consent form electronically, via email or in-person, to review with their health-care providers and family before enrollment. After recruiting 30 eligible participants, we used the REDCap platform and emailed the link to participants to obtain electronic consent by UT Health San Antonio Institutional Review Board (IRB) guidelines. The study team made themselves available to answer any questions or concerns related to signing the informed consent and assisting with technical issues with the platform. Official enrollment occurred after the participant provided their informed consent. Guided by the Consolidated Standards of Reporting Trials (CONSORT) framework, a study flow diagram visually illustrated the trajectory of participant flow (Figure 1).

After signing e-consent, participants completed self-reported questionnaires using the same REDCap platform. The study team made themselves available to answer any questions or concerns related to completing the questionnaires and assisted with technical issues with the platform. Participants also self-reported demographic information (i.e. age, country of birth, medical, surgical and medication history). Participants then visited UT Health San Antonio School of Nursing Biobehavioral lab to complete objective assessments. We divided participants into two groups (lower-risk vs higher-risk) based on their pre-intervention scores: the higher-risk group was defined by GAD-7 ≥ 5, PHQ-8 ≥ 5 and PSQI ≥ 5. The higher-risk group comprised 10 participants, while the lower-risk group comprised 18 participants.

Self-reported questionnaires and objective assessments are detailed below.

• Five Facets of Mindfulness Questionnaire (FFMQ): 39-item questionnaire, with 5 sub-scores (observing, describing, acting with awareness, nonjudging of inner experience, and nonreactivity to inner experience) assess mindfulness in everyday life. The total score ranges from 39 to 195, with higher scores indicating higher levels of mindfulness (Baer et al., 2006).

• Generalized Anxiety Disorder-7 (GAD-7): assesses the presence and severity of anxiety symptoms. Scores range from 0 to 21, with 0–4 representing normal/minimal anxiety, 5–9 mild anxiety, 10–14 moderate anxiety and 15–21 severe anxiety (Spitzer et al., 2006).

• Patient Health Questionnaire Depression Scale (PHQ-8): total score ranges from 0 to 24, with scores below 4 indicating normal/minimal depression, 5–9 mild depression, 10–14 moderate depression, 15–19 moderately severe depression and scores greater than 20 indicating severe depression (Kroenke et al., 2009).

• Pittsburgh Sleep Quality Index (PSQI): evaluates sleep quality and disturbances over one month. Scores range from 0 to 21 and a score of 5 or greater indicates poor sleep quality (Buysse et al., 1989).

• Rosenberg Self-Esteem Scale (RSE): assesses self-esteem. Scores range from 10 to 40, and higher scores indicate higher self-esteem (Rosenberg, 1989).

• Godin Leisure-Time Physical Activity Questionnaire (GLTPA): measures the frequency and duration of mild, moderate and strenuous physical activities and calculates the energy expenditure of physical activity in metabolic equivalent of task minutes per week (Godin, 2011).

• The study team standardized protocols to measure resting heart rate, blood pressure, height [inches], weight [kg] and waist and hip circumferences [inches]. BMI (kg/m²) and WHR were calculated, given evidence that abdominal indices outperform BMI in CVD risk prediction and that South Asians exhibit elevated risk at comparatively lower BMI (Darbandi et al., 2020; Deshpande et al., 2023).

• Short Physical Performance Battery (SPPB): consists of balance, gait speed and chair stands. The total SPPB score ranges from 0 to 12, and higher scores indicate higher physical performance (Guralnik et al., 1995). SPPB predicts disability, hospitalization and mortality (de Fatima Ribeiro Silva et al., 2021).

• The 6-Minute Walk Distance (6MWT): measures functional exercise capacity by evaluating participants’ ability to walk for 6 minutes at their maximum speed (Matos Casano et al., 2025).

• Hand grip strength: evaluates strength and endurance. Measured using a handheld dynamometer to assess an individual’s upper extremity strength, with participants squeezing it with maximum effort for a few seconds. Three repetitions were performed on both hands, and the average value was recorded in kilograms (Vaishya et al., 2024).

• Montreal Cognitive Assessment (MoCA): assesses participants’ cognitive domains, including attention and concentration, memory, language, calculations and orientation. The maximum score is 30, and a score of 26 or higher is generally considered normal. A score of 22 or lower suggests the presence of mild cognitive impairment, and a score of 18 or lower suggests the presence of dementia (Nasreddine et al., 2005).

• Fasting lipid panel, HbA1c, and insulin to profile cardiometabolic risk in an at-risk population (Deshpande et al., 2023). The samples were analyzed by Quest Diagnostics.

After baseline data collection, participants started the intervention phase. The intervention consisted of 12 sessions (one session per week), each lasting 120 min. Each session consisted of behavioral lifestyle education fused with mindfulness (30 min) and Ashtanga yoga (90 min, including 20 min of meditation/breathing and journaling). Details of the intervention can be found in Table 1. The research team managed the group and ensured weekly attendance by sending reminders and mindfulness messages to the participants. In every group session, the team encouraged participants to engage in physical activity outside the weekly sessions, incorporate the mindfulness-based behavioral lifestyle training and follow the assigned journal activity for that week.

Our intervention used interactive educational sessions to raise mindfulness-based behavioral lifestyle awareness among participants. We used publicly available resources from the Diabetes Prevention Program Group Lifestyle Balance (Diabetes Prevention Program Research Group, 2002). Our team guided participants through the Mindfulness for Insomnia book to enhance the mindfulness component (i.e. mindful eating, walking in nature and stress management via reframing negative thoughts) (Orzech and Moorcroft, 2019). We emphasized cultivating a non-judgmental attitude and awareness toward one’s thoughts, feelings and sensations. Each participant received a journal and was instructed to set at least three goals using the SMART (specific, measurable, attainable, realistic and timely) criteria on the first day (Bodenheimer and Handley, 2009). We encouraged participants to update their progress on their goals every week and write about their experiences either before or after each yoga session, with prompts provided during each session.

A certified yoga instructor led each session. We encouraged participants to practice the intervention at home at least two to three times per week to adopt the skill/behavior as part of their daily lives. The yoga instructor created and tailored four yoga videos for the group, so participants could practice yoga at home at their convenience (videos ranged between 15 and 45 min).

Guided by prior research, we determined a sample size of n = 25 generated sufficient power for this feasibility study. Accounting for an estimated 20% attrition rate, we recruited n = 30 participants (Moore et al., 2011).

We assessed feasibility by recruiting participants within the designated timeframe (12-weeks), monitoring adherence to weekly sessions and evaluating retention rates. We measured the program’s acceptability/satisfaction using a ten-point Likert scale (0 = very dissatisfied; 10 = very satisfied). We examined the effect of the study intervention on mental and physical health outcomes through self-reported questionnaires and objectively measured assessments described in baseline procedures.

Statistical analyses were conducted using descriptive statistics as mean and standard deviations. All statistical tests were two-sided. Data were expressed as mean ± SD with the significance threshold set at p < 0.05 for all p-values. A paired-sample t-test was conducted to compare pre- and post-intervention scores in response to the intervention within the same group of participants. Independent sample t-tests were used to assess the intervention’s effects on individuals at risk for anxiety, depression and sleep problems. We used Statistical Package for the Social Sciences (IBM SPSS Statistics Version 28) for the analysis.

In all, 30 participants completed baseline data collection (Figure 1); 28 (93%) completed post intervention assessments and were included in pre–post analyses. Measure specific denominators are reported if missingness occurs.

Feasibility outcome: We recruited and enrolled all 30 participants within the designated time frame (12-week). For n = 30, mean age of participants was 53 ± 6 years, with a BMI of 28.9 ± 4.2 kg/m² (overweight category) and a WHR of 0.81 ± 0.06 cm. Participants resided in the USA for an average of 28.9 ± 8.9 years. Most (n = 25, 83%) were married and employed (n = 26, 86%). The participants migrated from Pakistan (n = 18, 60%), India (n = 6, 20%), Tanzania (n = 4, 13%) and Bangladesh (n = 2, 7%). The prevalent chronic conditions reported among participants were as follows: high blood pressure in nine individuals (32%), high cholesterol in four individuals (14%), cancer in four individuals (14%) and diabetes in three individuals (11%). Of these, 28 participants (93%) completed the study and participated in end-of-study assessments. Two participants did not complete final assessments because of work-related time constraints and travel. We used data from the 28 (93%) participants who completed end-of-study assessments in the final analyses. On average, participants attended 8.1 ± 2.5 of the 12 intervention sessions, and the weekly program received high satisfaction ratings with an average score of 8.8 ± 1.2 out of 10.

Participants showed significant improvements in the following self-reported physical and mental health assessments (Table 2). The Five Facet Mindfulness Questionnaire (FFMQ) total score improved significantly by 25% (p < 0.01). Specifically, there were improvements in individual sub-scores with observing improving by 22%, nonreactivity to inner experience by 13% and describing by 9%. Participants reported improvement in their Godin Leisure-Time Physical Activity (GLTPA) total score by 53% (p = 0.007), with specific improvements in sub-scores for strenuous activity by 190% and moderate physical activity by 54%. The Rosenberg Self-Esteem Scale (RSE) score improved by 8% (p = 0.005). Participants reported a significant reduction in Patient Health Questionnaire (PHQ-8) Depression score by −50% (p < 0.01) and in Pittsburgh Sleep Quality Index (PSQI) global scores by −25% (p = 0.02). The General Anxiety Disorder (GAD-7) score also showed a reduction of −27%, but it did not reach statistical significance.

Participants showed significant improvements in the following objectively measured assessments which examined the impact of the intervention on their physical and cognitive health outcomes (Table 2). Mobility improved significantly, including the Short Physical Performance Battery (SPPB) total score by 5% (p = 0.01), with specific improvements in sub-scores for repeated chair stands by 5% (p = 0.02). Further, gait speed and balance tests (subscores for the SPPB) showed a 100% improvement. The Hand Grip Strength score improved by 1% (p < 0.001). The Montreal Cognitive Assessment (MoCA) score improved by 4% (p = 0.017). Systolic blood pressure improved by 4% (p = 0.015). Other objectively measured assessments did not reach statistical significance.

The independent sample t-test analysis revealed significant differences in percentage improvements from baseline to end-of-study between the lower-risk (n = 18) and higher-risk (n = 10) groups across various measures (Table 3). For instance, the lower-risk group demonstrated a substantial increase in mindfulness as assessed by the Five Facets of Mindfulness Questionnaire (FFMQ) from baseline to week 12 compared to the higher-risk group, with a percentage improvement of 36% in the lower-risk group versus 8% in the higher-risk group. Similarly, the General Anxiety Disorder-7 (GAD-7) scores exhibited notable reductions in both the lower-risk and higher-risk groups, with improvements of −28% and −27%, respectively, after intervention. Likewise, the Patient Health Questionnaire-8 (PHQ-8) scores showed significant reductions in both groups, with improvements of −45% and −52% for the lower-risk and higher-risk groups, respectively. Additionally, the Pittsburgh Sleep Quality Index (PSQI) global scores showed substantial reductions in both groups, with improvements of −14% and −34% for the lower-risk and higher-risk groups, respectively. Finally, the Rosenberg Self-Esteem (RSE) scores improved by 5% and 15% for the lower-risk and higher-risk groups, respectively, after intervention.

This study achieved 93% retention (28/30 completed the study) with high satisfaction and good attendance, confirming feasibility of a 12-week yoga and mindfulness enhanced behavioral lifestyle intervention in community-dwelling South Asian immigrant women aged ≥ 40 years. We observed significant improvements in mindfulness (FFMQ), depression (PHQ-8), sleep (PSQI), self-esteem (RSE), physical activity (GLTPA), cognition (MoCA), physical performance (SPPB), handgrip strength, and systolic blood pressure (SBP). Together, these results support the acceptability and multi-domain potential of a combined yoga and mindfulness-based lifestyle approach in an at-risk, underserved population.

Comparable research involving physical activity/yoga and mindfulness interventions reported similar outcomes across diverse populations, age groups, intervention durations, and various yoga styles such as Yoga Nidra and Yin Yoga. Findings related to improvements in FFMQ total and subscores have been reported (Lemay et al., 2021; Livingston and Collette-Merrill, 2018; Roberts and Montgomery, 2016; Zimmaro et al., 2020). Similar to previous findings, our participants demonstrated reductions in the “Nonjudging of Inner Experience” sub-score. This may be potentially influenced by linguistic nuances and heightened participant awareness of negative thoughts (Roberts and Montgomery, 2016). Despite this observation, the overall upward trend in mindfulness scores reinforces the efficacy of the intervention.

The observed improvements in self-esteem, sleep quality and depression scores following the intervention are consistent with existing literature on the beneficial effects of yoga and mindfulness practices (Currie et al., 2022; Guthrie et al., 2018; Verma et al., 2021). Despite improvements in other domains, the persistence of poor sleep quality score ≥ 5 at the end of study suggests the need for additional targeted interventions. While the study did not find statistically significant changes in anxiety (GAD-7) scores, the absence of self-reported diagnoses or management of anxiety, depression and insomnia at baseline indicates the intervention’s potential to positively impact mental well-being in participants without diagnosed mental health conditions, particularly in light of the cultural stigma surrounding mental health in this population (Karasz et al., 2019).

Furthermore, the demonstrated upturn in cognitive function (measured by MoCA), including attention, executive function, language, and memory following the intervention align with previous research, indicating the cognitive benefits of yoga and mindfulness practices (Lai et al., 2023; Shin, 2021). Encouragingly, the data also reflects increased engagement in physical activities beyond the yoga sessions, leading to improvements in overall physical activity levels and mobility, particularly in terms of balance, grip strength and blood pressure. These improvements serve as vital predictors of holistic health, emphasizing the potential of yoga and mindfulness interventions to contribute to comprehensive well-being.

Our finding of significant improvement in systolic blood pressure alone is supported by current literature. In midlife and older adults, arterial stiffening from vascular aging disproportionately elevates systolic and pulse pressures, whereas diastolic pressure tends to plateau or fall with age; thus, SBP is a more responsive and prognostic component of cardiovascular risk (Laurent and Boutouyrie, 2020; Lu et al., 2023). Mind–body practices have been shown to reduce sympathetic drive and improve baroreflex function, aligning with an SBP-predominant response (Chen et al., 2024; Geiger et al., 2025). Our findings therefore accord with vascular aging physiology and current syntheses showing yoga and mindfulness can lower BP, with stronger effects often seen for systolic pressure.

While lipids and glucose markers did not reach significance over 12 weeks in this pilot study, our findings are consistent with previous research: short-duration trials sometimes show limited biochemical change, whereas longer duration or higher-dose programs can improve lipid profiles and metabolic markers. For example, a 12-week yoga program did not affect inflammatory biomarkers or metabolic risk factors associated with CVD in patients with hypertension (Wolff et al., 2015). Additionally, meta-analyses of similar durations in type 2 diabetes patients showed some improvements in glucose markers and triglycerides, but non-significant changes in total cholesterol, suggesting short trials frequently lack power or duration to detect robust metabolic effects (Chen et al., 2022). Conversely, systemic reviews and meta-analyses incorporating longer duration or higher dose yoga interventions generally demonstrate significant reductions in total cholesterol, LDL, triglycerides and fasting glucose, supporting the hypothesis that extended practice is needed to influence cardiometabolic endpoints (Djalilova et al., 2019; Ghazvineh et al., 2022; Ramamoorthi et al., 2019). Future trials should therefore extend duration and include powered cardiometabolic endpoints.

Strengths of this study include focus on an understudied group, community-embedded delivery, high retention, and the combination of self-reported and objective outcomes (including SPPB and fasting biomarkers). Limitations include the single-arm design, modest sample size, and 12-week duration, which may be insufficient to detect changes in lipids and glucose markers. Seasonal and cultural calendar effects (e.g. Spring Break, Ramadan) may have also influenced attendance and activity.

Community-delivered, culturally tailored yoga and mindfulness programs are feasible and acceptable for South Asian immigrant women and may serve as adjunctive strategies for mental health, sleep, and vascular risk management (especially SBP).

A randomized controlled trial with ≥ 6–12 months follow-up should test clinically important endpoints (24-h ambulatory BP, lipid fractions including LDL-C/HDL-C/TG, HbA1c, and insulin resistance) and mechanisms (heart rate variability). Stratification by baseline risk (e.g. SBP ≥ 130 mmHg, WHR, or waist circumference thresholds relevant to South Asians) is recommended.

A 12-week yoga and mindfulness lifestyle program was feasible, acceptable, and associated with improvements in mental health, sleep, physical function, cognition and SBP in South Asian immigrant women aged ≥ 40 years. Medical and physiological components, such as vital signs, anthropometrics, SPPB, and fasting biomarkers, were included to characterize cardiometabolic risk in a population known to have greater visceral adiposity and thus elevated cardiometabolic risk at lower BMI. The observed change in SBP aligns with vascular aging mechanisms whereby systolic, more than diastolic, pressure reflects arterial stiffness in mid- to late-life. These promising signals warrant a randomized controlled trial with longer follow-up and formal cardiometabolic endpoints.

The authors are grateful to all the participating women. The authors also thank all the community leaders and healthcare practitioners who promoted the research and supported raising awareness regarding participation.

This work was supported by UT Health San Antonio School of Nursing Office for Faculty Excellence, the Office of Nursing Research and Scholarship and the Migliorino-Piccione Research Award.

The University of Texas Health Science Center’s Institutional Review Board for the Protection of Human Participants approved all procedures (approval number: 22-503H). Informed consent was obtained from all participants in this research. Written informed consent to participate in the research was provided electronically by indicating consent on the online survey before proceeding to the survey items.

Informed consent for publication included an explicit agreement for the use of de-identified data for publication and deposit into an online data repository. Participants were only directed to the survey items once they indicated their consent to participate by checking a box.

For this study, all participants provided written informed consent before their involvement in the research.