The relationship between obesity and obstructive sleep apnea in four community-based cohorts: an individual participant data meta-analysis of 12,860 adults

Neda Esmaeili; Laura Gell; Théo Imler; Mohammadreza Hajipour; Luigi Taranto-Montemurro; Ludovico Messineo; Katie L Stone; Scott A Sands; Najib Ayas; John Yee; John Cronin; Raphael Heinzer; Andrew Wellman; Susan Redline; Ali Azarbarzin

doi:10.1016/j.eclinm.2025.103221

The relationship between obesity and obstructive sleep apnea in four community-based cohorts: an individual participant data meta-analysis of 12,860 adults

EClinicalMedicine. 2025 Apr 23:83:103221. doi: 10.1016/j.eclinm.2025.103221. eCollection 2025 May.

Authors

Neda Esmaeili¹, Laura Gell^{1

2}, Théo Imler³, Mohammadreza Hajipour⁴, Luigi Taranto-Montemurro^{1

2}, Ludovico Messineo¹, Katie L Stone⁵, Scott A Sands¹, Najib Ayas⁴, John Yee², John Cronin², Raphael Heinzer³, Andrew Wellman¹, Susan Redline¹, Ali Azarbarzin¹

Affiliations

¹ Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
² Apnimed, USA.
³ Center for Investigation and Research in Sleep and Pulmonary Department, University Hospital of Lausanne, Lausanne University, Lausanne, Switzerland.
⁴ Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
⁵ Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA.

Abstract

Background: Obesity is a well-established risk factor for obstructive sleep apnea (OSA). We assessed the reciprocal prevalence of obesity and OSA and how it varies by age and sex.

Methods: Following a systematic review through March 27, 2025, the final sample included four community-based cohort studies in the US and Switzerland. OSA severity was quantified using the apnea-hypopnea index (AHI, all apneas plus hypopneas with ≥4% oxygen desaturation/hour). Random effects individual participant data (IPD) meta-analyses estimated prevalences. Logistic regression compared odds of OSA across weight groups.

Findings: Among 12,860 adults (mean ± SD age: 66.6 ± 7.3 years), 7222 (56.2%) had OSA (AHI ≥5 events/h) and 3309 (25.7%) had obesity (BMI ≥30 kg/m²). IPD meta-analysis showed 31.5% [95% CI: 16.8-48.5] of individuals with OSA had obesity and 44.4% [36.5-52.5] had overweight status (25 ≤ BMI < 30). Among subgroups of individuals with obesity and overweight, 74.3% [63.8-83.5] and 59.8% [46.5-75.7] had any OSA, respectively. Obesity was higher in females than males with OSA, and in younger (<65 years) vs. older individuals. Odds ratios for OSA in subgroups of individuals with overweight and obesity compared to BMI <25 kg/m² were 2.18 [1.73-2.76] and 4.84 [3.09-6.00], respectively.

Interpretation: Our analyses show that most adults with OSA do not have obesity, with 44.4% having overweight and 23.5% having normal weight or underweight. Obesity was more prevalent among females compared to males and in younger individuals (<65 years) compared to older individuals with OSA. Recognizing OSA is not exclusive to obesity highlights the need for personalized treatment plans.

Funding: American Academy of Sleep Medicine, National Heart, Lung, and Blood Institute, and Apnimed.

Keywords: Apnea-hypopnea index; Community-based study; Non-obese; Obesity; Overweight; Sleep apnea.