Obesity and Sleep Apnoea: Beyond Airway Obstruction

"Obesity and obstructive sleep apnoea (OSA) are often approached as separate clinical problems: obesity as excess weight and OSA as upper-airway obstruction. This conventional framework, however, fails to capture the complex bidirectional relationship between adiposity, sleep-disordered breathing and cardiometabolic disease. Obesity is a chronic, relapsing disease characterised by dysfunctional adipose tissue, visceral and ectopic fat accumulation, inflammation, insulin resistance and altered neuroendocrine signalling. These processes can substantially influence respiratory mechanics, upper-airway collapsibility and ventilatory control, contributing to the development and progression of OSA. Conversely, untreated OSA produces recurrent intermittent hypoxia, sleep fragmentation and sympathetic activation, promoting oxidative stress, endothelial dysfunction, hypertension, insulin resistance and broader cardiometabolic consequences. The interaction between obesity and OSA therefore creates a self-reinforcing cycle that extends far beyond the airway. This presentation explores the pathophysiological continuum linking obesity, OSA and cardiometabolic disease, and considers its implications for public health. Traditional treatment strategies, including lifestyle intervention, positive airway pressure and metabolic/bariatric surgery, remain fundamental. However, emerging pharmacological therapies offer an opportunity to address upstream biological drivers of disease. In particular, GLP-1 receptor agonists and dual GIP/GLP-1 receptor agonists represent an important evolution in obesity management, with emerging evidence demonstrating improvements in OSA severity and cardiometabolic risk alongside substantial weight reduction. The future of sleep medicine may therefore lie beyond treating airway obstruction alone. A personalised, integrated approach—combining airway therapy, obesity treatment, lifestyle intervention and cardiometabolic risk reduction—offers an opportunity to treat the patient rather than simply the apnoea. Obesity is more than a weight issue, and OSA is more than an airway problem. "