Integrating Weight Management into Sleep (Respiratory) Practice: From Passive Advice to Active Intervention

"Obstructive sleep apnoea (OSA) affects an estimated one billion adults worldwide, most of whom are overweight or obese. Yet care remains largely mechanical: diagnose, prescribe positive airway pressure (PAP), advise weight loss, and judge success by device-reported AHI. Weight-loss advice is rarely structured or followed up, and PAP, while controlling AHI and symptoms, has not been shown to alter cardiometabolic trajectory. This presentation argues for a shift in the sleep physician's role. Weight loss is disease-modifying: a 20% BMI reduction is associated with an approximately 57% fall in AHI, acting chiefly on pharyngeal collapsibility, the dominant OSA endotype. In SURMOUNT-OSA, tirzepatide reduced AHI by 20–24 events/h versus placebo over 52 weeks, with or without PAP, alongside improvements in hypoxic burden, sleepiness, blood pressure, hsCRP and patient-reported outcomes. Mediation analyses show these cardiometabolic benefits are driven predominantly by weight loss, with AHI and hypoxic-burden reduction independently mediating selected outcomes. Meta-analytic and real-world data support a class effect. A practical model of care is then outlined: patient selection, clinical and financial consent, monitoring for gastrointestinal effects, lean-mass loss and weight regain, and multidisciplinary co-management with primary care, dietetics, exercise physiology and psychology. Incretin therapy is positioned as complementary to PAP, not a replacement. Finally, Asia-Pacific realities are addressed, including variable approval and reimbursement, out-of-pocket costs, and growing cosmetic and grey-market GLP-1 use, underscoring why sleep physicians must own the medical narrative."