4. Discussion
eating behavior, fat-free mass
SECONDARY, EVENT
Mindful eating and the combination of mindful eating and YogaDance showed more improvements than YogaDance alone. The estimated effect sizes were small, at most 0.11 and 0.35 in complete-case and intention-to-treat analyses, respectively, in any case far smaller than the anticipated effect size used for the sample size calculation. However, notably for the combined mindful eating and YogaDance group, but also for the mindful eating group alone, there were a few results for several secondary outcomes, showing a small reduction in fat percent and waist circumference as well as improved eating behavior and mental quality of life. These results were only found in complete-case analyses, implying that they could cautiously be interpreted as efficacy estimates in the event that participants adhered fully to the intervention.As this study investigated the effect of combining mindful eating and YogaDance on fat mass, there is not much comparable evidence in the literature. However, some relevant results for other body composition measures exist for the individual effects of yoga, dance, and mindful eating interventions [A randomized controlled trial on mindful eating in overweight women also found improved eating behavior but no effects on body weight, waist circumference, fat mass, or fat-free mass [This study has some strengths. Firstly, to our knowledge, this is the first randomized controlled trial to investigate a novel exercise approach that combines yoga, dance, and mindful eating. Secondly, the study provided a comprehensive investigation through the use of a wide range of outcomes including anthropometric and body composition outcomes as well as physical activity, quality of life, and eating behavior.The study has several limitations. The large drop-out, which is unevenly distributed across intervention groups, is a key limitation that may have led to selection bias. It seemed that participants preferred YogaDance over mindful eating. One explanation could be that the trial coincided partly with the last lockdown period in Denmark due to the SARS-CoV-19 pandemic. The trial was initiated during the lockdown, but most restrictions had been lifted when the trial terminated. People may have preferred activities that involved more physical activity. The sample size would have needed to accommodate a higher drop-out rate (at least 40%) to ensure that sufficient participants would eventually complete the trial. However, it should be noted that the drop-out rate in this study is no different from what has been seen in the past for weight management trials [Low compliance, which was different between intervention groups, is another key limitation as it may have introduced a selection bias. Moreover, it may dilute the effects of the interventions. It would have been useful to supervise daily training activities remotely, for instance, through online video meetings, to ensure high compliance. A too-low training load may also have diluted the benefits of the interventions. Specifically, a total of four mindful eating workshops with a duration of only 90 min and unsupervised daily training based on handout workbooks might have resulted in a low training intensity. It was a compromise, as participants were encouraged to do exercises at home as well. Monitoring participants’ training loads by means of %HR max, MET, or %VOThere are also some additional limitations. The wide range used for some inclusion criteria such as age, BMI and waist circumference introduced a large between-participant heterogeneity, making it much more difficult to observe large effects. Moreover, the effect of YogaDance depended highly on each participant’s ability and technical skills, which for many participants were low due to excess body weight and a history of inactivity. The significant results obtained in the complete-case analyses should also be interpreted cautiously, as they are based on a reduced, random subgroup of participants and therefore selection bias cannot be ruled out (as randomization was broken), although the reasons for missing data seem to render complete-case analyses meaningful [