Weight Management in Obesity-Associated Sleep-Disordered Breathing: Mechanisms, Clinical Management, and Emerging Therapies

OBJECTIVE: To review the mechanistic links between obesity and sleep-disordered breathing (SDB) and summarize practical approaches to weight-directed, sleep-directed, and phenotype-informed management. METHODS: We conducted a focused narrative review of clinical trials, systematic reviews, meta-analyses, guidelines, and mechanistic studies identified through PubMed/MEDLINE, Embase, and Google Scholar. Search terms included obesity, obstructive sleep apnea, obesity hypoventilation syndrome, weight loss, positive airway pressure, bariatric surgery, incretin-based pharmacotherapy, endotypes, and circadian disruption. RESULTS: Obesity promotes sleep-disordered breathing through upper airway mechanical loading, reduced lung volumes, inflammation, altered ventilatory control, and sleep behavior pathways. Positive airway pressure remains a core therapy for many patients with obstructive sleep apnea and obesity hypoventilation syndrome. Sustained weight loss provides complementary disease modification. Lifestyle intervention, metabolic and bariatric surgery, and incretin based pharmacotherapy can improve obstructive sleep apnea, although residual disease is common. Tirzepatide has shown clinically meaningful reductions in apnea-hypopnea index in adults with obesity and moderate to severe obstructive sleep apnea, largely in association with weight reduction. In obesity hypoventilation syndrome, stable ambulatory patients generally require positive airway pressure. Durable weight loss of approximately 25% to 30% may be needed to resolve hypoventilation. Therapies targeting endotypes and device based options may help selected patients, but they remain adjunctive, investigational, or directed by specialists. CONCLUSION: Obesity associated sleep-disordered breathing is best managed as a heterogeneous cardiometabolic and sleep breathing condition. Treatment should integrate positive airway pressure or other sleep specific therapy with individualized weight management. Ongoing reassessment is needed for residual disease, obesity hypoventilation syndrome, and atypical phenotypes.