Aligning obstructive sleep apnoea care with underlying drivers: A lifestyle-metabolic perspective

Continuous positive airway pressure (CPAP) remains the cornerstone of obstructive sleep apnoea (OSA) treatment and can provide rapid symptomatic relief. However, long-term adherence is often suboptimal, and a device-focused model may overlook upstream lifestyle and metabolic drivers. Increasing evidence shows that OSA commonly coexists with, and is partly driven by, modifiable factors such as poor diet quality, physical inactivity, alcohol use, circadian disruption, and adiposity. Emerging anti-obesity pharmacotherapies further support the concept that modifying mechanical and metabolic control can markedly reduce OSA severity. Framing OSA within a lifestyle-metabolic paradigm may therefore improve both symptom control and long-term cardiometabolic outcomes. In this perspective with targeted evidence synthesis, we argue for integration of structured lifestyle and behavioural interventions into routine OSA care and outline a pragmatic multidisciplinary model for implementation. Randomised controlled trials consistently show that healthy dietary patterns, structured physical activity, alcohol reduction, and interdisciplinary lifestyle programmes can reduce OSA severity, daytime sleepiness, and cardiometabolic risk markers. Some benefits appear to occur without substantial weight loss, suggesting additional mechanisms such as improved ventilatory stability, reduced rostral fluid shift, enhanced upper-airway neuromuscular responsiveness, and lower systemic inflammation. We therefore propose expansion, rather than replacement, of the current disease model by pairing airway therapies with structured lifestyle and metabolic risk modification from the time of diagnosis. This integrated, whole-person approach has the potential to improve quality of life, enhance treatment durability, and reduce long-term cardiovascular and metabolic complications. Aligning funding models, implementation pathways, and research priorities with this framework could help shift OSA care from device dependent nocturnal symptom control toward sustained health gains across the life course.