Obesity and sleep disturbances: The “chicken or the egg” question

  • Author Footnotes
    # All the authors equally contributed to the manuscript.
    Gabriel Dias Rodrigues
    # All the authors equally contributed to the manuscript.
    Department of Physiology and Pharmacology, Biomedical Institute, Fluminense Federal University, Niterói, 24210-130, Brazil

    Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
    Search for articles by this author
  • Author Footnotes
    # All the authors equally contributed to the manuscript.
    Elisa M. Fiorelli
    # All the authors equally contributed to the manuscript.
    Department of Internal Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
    Search for articles by this author
  • Author Footnotes
    # All the authors equally contributed to the manuscript.
    Ludovico Furlan
    # All the authors equally contributed to the manuscript.
    Department of Emergency Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
    Search for articles by this author
  • Nicola Montano
    Corresponding author.
    Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy

    Department of Internal Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
    Search for articles by this author
  • Eleonora Tobaldini
    Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy

    Department of Internal Medicine, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
    Search for articles by this author
  • Author Footnotes
    # All the authors equally contributed to the manuscript.


      • Obesity and sleep disturbances are linked by a bi-directional causal-effect relation.
      • Sleep disturbances increase the risk of obesity and metabolic syndrome.
      • Obesity is a risk factor for several sleep disorders (such as Obstructive Sleep Apnea).
      • It is mandatory to investigate possible sleep disorders in obese patients.


      Obesity and sleep disturbances are common conditions in modern societies and accumulating evidence support a close bidirectional causal relationship between these two conditions.
      Indeed, from one side sleep loss seems to affect energy intake and expenditure through its direct effects on hormone-mediated sensations of satiety and hunger and through the influence on hedonic and psychological aspects of food consumption. Sleep deprived patients have been shown to experiment excessive daytime sleepiness, fatigue, and tiredness that, in a vicious circle, enhances physical inactivity and weight gain. On the other side, obesity is a well-known risk factor for several sleep disorders. This narrative review will discuss the main pathophysiological mechanisms that link sleep loss to obesity and metabolic syndrome with particular attention to the three most common sleep disorders (insomnia, obstructive sleep apnoea syndrome, restless leg syndrome).
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to European Journal of Internal Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • The GBD
        Obesity collaborators (2017) health effects of overweight and obesity in 195 countries over 25 years.
        N Engl J Med. 2015; 377: 13-27
        • Matsumoto T
        • Chin K
        Prevalence of sleep disturbances: sleep disordered breathing, short sleep duration, and non-restorative sleep.
        Respir Investig. 2019; 57: 227-237
        • Cizza G
        • Requena M
        • Galli G
        • de Jonge L
        Chronic sleep deprivation and seasonality: implications for the obesity epidemic.
        J Endocrinol Invest. 2011; 34: 793-800
        • Magee CA
        • Huang X-F
        • Iverson DC
        • Caputi P
        Examining the pathways linking chronic sleep restriction to obesity.
        J Obes. 2010; (2010)
        • Wolk R
        • Shamsuzzaman ASM
        • Somers VK
        Obesity, sleep apnea, and hypertension.
        Hypertension. 2003; 42: 1067-1074
        • Baran RT
        • Atar M
        • Pirgon Ö
        • et al.
        Restless legs syndrome and poor sleep quality in obese children and adolescents.
        J Clin Res Pediatr Endocrinol. 2018; 10: 131-138
        • Brum MCB
        • Dantas Filho FF
        • Schnorr CC
        • et al.
        Night shift work, short sleep and obesity.
        Diabetol Metab Syndr. 2020; 12: 13
        • Tobaldini E
        • Fiorelli EM
        • Solbiati M
        • et al.
        Short sleep duration and cardiometabolic risk: from pathophysiology to clinical evidence.
        Nat Rev Cardiol. 2019; 16: 213-224
        • Blüher M
        Obesity: global epidemiology and pathogenesis.
        Nat Rev Endocrinol. 2019; 15: 288-298
        • Montano N
        • Fiorelli E
        • Tobaldini E
        Sleep duration and the heart: I sleep, therefore I beat.
        J. Am. Coll. Cardiol. 2019; 74: 1315-1316
        • Berry R
        • Quan S
        • Abreu AR
        • for the American Academy of Sleep Medicine
        The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications.
        American Academy of Sleep Medicine, Darien, IL2020 (version 2.6, www.aasmnet.org2020)
        • Watson N
        • Badr M
        • Belenky G
        Recommended amount of sleep for a healthy adult: a joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society.
        J Clin Sleep Med. 2015; 11: 931-952
        • Liu Y
        • Wheaton AG
        • Chapman DP
        • et al.
        Prevalence of healthy sleep duration among adults — United States, 2014.
        MMWR Morb Mortal Wkly Rep. 2016; 65: 137-141
        • Grandner MA
        • Patel NP
        • Gehrman PR
        • et al.
        Problems associated with short sleep: bridging the gap between laboratory and epidemiological studies.
        Sleep Med Rev. 2010; 14: 239-247
        • Irwin MR
        • Wang M
        • Campomayor CO
        • et al.
        Sleep deprivation and activation of morning levels of cellular and genomic markers of inflammation.
        Arch Intern Med. 2006; 166: 1756-1762
        • Sauvet F
        • Leftheriotis G
        • Gomez-Merino D
        • et al.
        Effect of acute sleep deprivation on vascular function in healthy subjects.
        J Appl Physiol. 2010; 108: 68-75
        • Hirshkowitz M
        • Whiton K
        • Albert SM
        • et al.
        National Sleep Foundation's updated sleep duration recommendations: final report.
        Sleep Heal. 2015; 1: 233-243
        • Di Lorenzo L
        • De Pergola G
        • Zocchetti C
        • et al.
        Effect of shift work on body mass index: results of a study performed in 319 glucose-tolerant men working in a Southern Italian industry.
        Int J Obes Relat Metab Disord J Int Assoc Study Obes. 2003; 27: 1353-1358
        • Canuto R
        • Garcez AS
        • Olinto MTA
        Metabolic syndrome and shift work: a systematic review.
        Sleep Med Rev. 2013; 17: 425-431
        • Tobaldini E
        • Cogliati C
        • Fiorelli EM
        • et al.
        One night on-call: sleep deprivation affects cardiac autonomic control and inflammation in physicians.
        Eur J Intern Med. 2013; 24: 664-670
        • Marshall NS
        • Glozier N
        • Grunstein RR
        Is sleep duration related to obesity? A critical review of the epidemiological evidence.
        Sleep Med Rev. 2008; 12: 289-298
        • Tobaldini E
        • Costantino G
        • Solbiati M
        • et al.
        Sleep, sleep deprivation, autonomic nervous system and cardiovascular diseases.
        Neurosci Biobehav Rev. 2017; 74: 321-329
        • Sauvet F
        • Drogou C
        • Bougard C
        • et al.
        Vascular response to 1 week of sleep restriction in healthy subjects. A metabolic response?.
        Int J Cardiol. 2015; 190: 246-255
        • Ralls FM
        • Grigg-Damberger M
        Roles of gender, age, race/ethnicity, and residential socioeconomics in obstructive sleep apnea syndromes.
        Curr Opin Pulm Med. 2012; 18: 568-573
        • Peppard PE
        • Young T
        • Palta M
        • et al.
        Longitudinal study of moderate weight change and sleep-disordered breathing.
        JAMA. 2000; 284: 3015-3021
        • Wing YK
        • Hui SH
        • Pak WM
        • et al.
        A controlled study of sleep related disordered breathing in obese children.
        Arch Dis Child. 2003; 88: 1043-1047
        • Pecori A
        • Buffolo F
        • Pieroni J
        • et al.
        Primary Aldosteronism and obstructive sleep apnea: casual association or pathophysiological link?.
        Horm Metab Res = Horm und Stoffwechselforsch = Horm Metab. 2020; 52: 366-372
        • Møller DS
        • Lind P
        • Strunge B
        • Pedersen EB
        Abnormal vasoactive hormones and 24-hour blood pressure in obstructive sleep apnea.
        Am J Hypertens. 2003; 16: 274-280
        • Sharma AM
        • Engeli S
        The renin-angiotensin system in obesity hypertension.
        J Renin Angiotensin Aldosterone Syst. 2001; 2: S114-S119
        • Mavanji V
        • Billington CJ
        • Kotz CM
        • Teske JA
        Sleep and obesity: a focus on animal models.
        Neurosci Biobehav Rev. 2012; 36: 1015-1029
        • Sinton CM
        • Fitch TE
        • Gershenfeld HK
        The effects of leptin on REM sleep and slow wave delta in rats are reversed by food deprivation.
        J Sleep Res. 1999; 8: 197-203
        • Lin L
        • Faraco J
        • Li R
        • et al.
        The sleep disorder canine narcolepsy is caused by a mutation in the hypocretin (orexin) receptor 2 gene.
        Cell. 1999; 98: 365-376
        • Funato H
        • Tsai AL
        • Willie JT
        • et al.
        Enhanced orexin receptor-2 signaling prevents diet-induced obesity and improves leptin sensitivity.
        Cell Metab. 2009; 9: 64-76
        • Blanco-Centurion CA
        • Shiromani PJ
        Beneficial effects of regular exercise on sleep in old F344 rats.
        Neurobiol Aging. 2006; 27: 1859-1869
        • Al Khatib HK
        • Harding S V
        • Darzi J
        • Pot GK
        The effects of partial sleep deprivation on energy balance: a systematic review and meta-analysis.
        Eur J Clin Nutr. 2017; 71: 614-624
        • Farooqi IS
        • Jebb SA
        • Langmack G
        • et al.
        Effects of recombinant leptin therapy in a child with congenital leptin deficiency.
        N Engl J Med. 1999; 341: 879-884
        • Rihm JS
        • Menz MM
        • Schultz H
        • et al.
        Sleep deprivation selectively upregulates an amygdala-hypothalamic circuit involved in food reward.
        J Neurosci. 2019; 39: 888-899
        • Jordan AS
        • McSharry DG
        • Malhotra A
        Adult obstructive sleep apnoea.
        Lancet (London, England). 2014; 383: 736-747
        • Young T
        • Skatrud J
        • Peppard PE
        Risk factors for obstructive sleep apnea in adults.
        JAMA. 2004; 291: 2013-2016
        • Malhotra A
        • White DP
        Obstructive sleep apnoea.
        Lancet (London, England). 2002; 360: 237-245
        • Shinohara E
        • Kihara S
        • Yamashita S
        • et al.
        Visceral fat accumulation as an important risk factor for obstructive sleep apnoea syndrome in obese subjects.
        J Intern Med. 1997; 241: 11-18
        • Schwartz AR
        • Patil SP
        • Laffan AM
        • et al.
        Obesity and obstructive sleep apnea: pathogenic mechanisms and therapeutic approaches.
        Proc. Am. Thorac. Soc. 2008; 5: 185-192
        • Mayer P
        • Pépin JL
        • Bettega G
        • et al.
        Relationship between body mass index, age and upper airway measurements in snorers and sleep apnoea patients.
        Eur Respir J. 1996; 9: 1801-1809
        • Schwartz AR
        • Patil SP
        • Squier S
        • et al.
        Obesity and upper airway control during sleep.
        J Appl Physiol. 2010; 108: 430-435
        • Isono S
        Obesity and obstructive sleep apnoea: mechanisms for increased collapsibility of the passive pharyngeal airway.
        Respirology. 2012; 17: 32-42
        • Imayama I
        • Prasad B
        Role of leptin in obstructive sleep apnea.
        Ann Am Thorac Soc. 2017; 14: 1607-1621
        • Zhu B
        • Shi C
        • Park CG
        • et al.
        Effects of sleep restriction on metabolism-related parameters in healthy adults: a comprehensive review and meta-analysis of randomized controlled trials.
        Sleep Med Rev. 2019; 45: 18-30
        • Ip MSM
        • Lam B
        • Ng MMT
        • et al.
        Obstructive sleep apnea is independently associated with insulin resistance.
        Am J Respir Crit Care Med. 2002; 165: 670-676
        • Ohga E
        • Tomita T
        • Wada H
        • et al.
        Effects of obstructive sleep apnea on circulating ICAM-1, IL-8, and MCP-1.
        J Appl Physiol. 2003; 94: 179-184
        • Börgel J
        • Sanner BM
        • Bittlinsky A
        • et al.
        Obstructive sleep apnoea and its therapy influence high-density lipoprotein cholesterol serum levels.
        Eur Respir J. 2006; 27: 121-127
        • LeBlanc ES
        • O'Connor E
        • Whitlock EP
        • et al.
        Effectiveness of primary care–relevant treatments for obesity in adults: a systematic evidence review for the U.S. Preventive Services Task Force.
        Ann Intern Med. 2011; 155: 434
        • Araghi MH
        • Chen YF
        • Jagielski A
        • et al.
        Effectiveness of lifestyle interventions on obstructive sleep apnea (OSA): systematic review and meta-analysis.
        Sleep. 2013; 36: 1553-1562
        • Dixon JB
        • Schachter LM
        • O'Brien PE
        • et al.
        Surgical vs conventional therapy for weight loss treatment of obstructive sleep apnea: a randomized controlled trial.
        JAMA. 2012; 308: 1142-1149
        • Patil SP
        • Ayappa IA
        • Caples SM
        • et al.
        Treatment of adult obstructive sleep apnea with positive airway pressure: an American academy of sleep medicine systematic review, meta-analysis, and GRADE assessment.
        J. Clin. Sleep Med. 2019; 15: 301-334
        • Tomfohr LM
        • Ancoli-Israel S
        • Loredo JS
        • Dimsdale JE
        Effects of continuous positive airway pressure on fatigue and sleepiness in patients with obstructive sleep apnea: data from a randomized controlled trial.
        Sleep. 2011; 34: 121-126
        • Riemann D
        • Baglioni C
        • Bassetti C
        • et al.
        European guideline for the diagnosis and treatment of insomnia.
        J Sleep Res. 2017; 26: 675-700
        • Cappuccio FP
        • Taggart FM
        • Kandala N-B
        • et al.
        Meta-analysis of short sleep duration and obesity in children and adults.
        Sleep. 2008; 31: 619-626
        • Wu Y
        • Zhai L
        • Zhang D
        Sleep duration and obesity among adults: a meta-analysis of prospective studies.
        Sleep Med. 2014; 15: 1456-1462
        • Chan WS
        • Levsen MP
        • McCrae CS
        A meta-analysis of associations between obesity and insomnia diagnosis and symptoms.
        Sleep Med Rev. 2018; 40: 170-182
        • Singareddy R
        • Vgontzas AN
        • Fernandez-Mendoza J
        • et al.
        Risk factors for incident chronic insomnia: a general population prospective study.
        Sleep Med. 2012; 13: 346-353
        • Henst RHP
        • Pienaar PR
        • Roden LC
        • DE Rae
        The effects of sleep extension on cardiometabolic risk factors: a systematic review.
        J Sleep Res. 2019; 28: e12865
        • Phillips B
        • Hening W
        • Britz P
        • Mannino D
        Prevalence and correlates of restless legs syndrome: results from the 2005 National Sleep Foundation Poll.
        Chest. 2006; 129: 76-80
        • Allen RP
        • Picchietti DL
        • Garcia-Borreguero D
        • et al.
        Restless legs syndrome/Willis-Ekbom disease diagnostic criteria: updated International Restless Legs Syndrome Study Group (IRLSSG) consensus criteria–history, rationale, description, and significance.
        Sleep Med. 2014; 15: 860-873
        • Lin S
        • Zhang H
        • Gao T
        • et al.
        The association between obesity and restless legs syndrome: a systemic review and meta-analysis of observational studies.
        J Affect Disord. 2018; 235: 384-391
        • De Vito K
        • Li Y
        • Batool-Anwar S
        • et al.
        Prospective study of obesity, hypertension, high cholesterol, and risk of restless legs syndrome.
        Mov Disord. 2014; 29: 1044-1052
        • Allen RP
        • Picchietti D
        • Hening WA
        • et al.
        Restless legs syndrome: diagnostic criteria, special considerations, and epidemiology. A report from the restless legs syndrome diagnosis and epidemiology workshop at the National Institutes of Health.
        Sleep Med. 2003; 4: 101-119
        • Wang GJ
        • Volkow ND
        • Logan J
        • et al.
        Brain dopamine and obesity.
        Lancet (London, England). 2001; 357: 354-357
        • Innes KE
        • Selfe TK
        • Agarwal P
        Restless legs syndrome and conditions associated with metabolic dysregulation, sympathoadrenal dysfunction, and cardiovascular disease risk: a systematic review.
        Sleep Med Rev. 2012; 16: 309-339
        • Ozdas S
        • Oner RI
        Influence of obesity surgery on restless leg syndrome.
        J Coll Physicians Surg Pak. 2019; 29: 309-312
        • Lin S-W
        • Chen Y-L
        • Kao K-C
        • et al.
        Diseases in patients coming to a sleep center with symptoms related to restless legs syndrome.
        PLoS One. 2013; 8: e71499
        • Winkelman JW
        • Redline S
        • Baldwin CM
        • et al.
        Polysomnographic and health-related quality of life correlates of restless legs syndrome in the Sleep Heart Health Study.
        Sleep. 2009; 32: 772-778
        • Bianchi MT
        • Goparaju B
        • Moro M
        Sleep apnea in patients reporting insomnia or restless legs symptoms.
        Acta Neurol Scand. 2016; 133: 61-67
        • Silva C
        • Peralta AR
        • Bentes C
        The urge to move and breathe - the impact of obstructive sleep apnea syndrome treatment in patients with previously diagnosed, clinically significant restless legs syndrome.
        Sleep Med. 2017; 38: 17-20
        • Sateia MJ
        International classification of sleep disorders-third edition highlights and modifications.
        Chest. 2014; 146: 1387-1394
        • Aurora RN
        • Kristo DA
        • Bista SR
        • et al.
        The treatment of restless legs syndrome and periodic limb movement disorder in adults–an update for 2012: practice parameters with an evidence-based systematic review and meta-analyses: an American Academy of Sleep Medicine Clinical Practice Guideline.
        Sleep. 2012; 35: 1039-1062
        • Ohayon MM
        • Roth T
        Prevalence of restless legs syndrome and periodic limb movement disorder in the general population.
        J Psychosom Res. 2002; 53: 547-554
        • Szentkirályi A
        • Stefani A
        • Hackner H
        • et al.
        Prevalence and associated risk factors of periodic limb movement in sleep in two German population-based studies.
        Sleep. 2019; 42
      1. Publications Office of the European Union (2017) Sixth European Working Conditions Survey – Overview report (2017 update). Luxembourg.

        • Pietroiusti A
        • Neri A
        • Somma G
        • et al.
        Incidence of metabolic syndrome among night-shift healthcare workers.
        Occup Environ Med. 2010; 67: 54-57
        • Liu Q
        • Shi J
        • Duan P
        • et al.
        Is shift work associated with a higher risk of overweight or obesity? A systematic review of observational studies with meta-analysis.
        Int J Epidemiol. 2018; 47: 1956-1971
        • Zhang Q
        • Chair SY
        • Lo SHS
        • et al.
        Association between shift work and obesity among nurses: A systematic review and meta-analysis.
        Int J Nurs Stud. 2020; 112103757
        • O'Brien VM
        • Nea FM
        • Pourshahidi LK
        • et al.
        Overweight and obesity in shift workers: associated dietary and lifestyle factors.
        Eur J Public Health. 2020; 30: 579-584
        • Tanikawa Y
        • Kimachi M
        • Ishikawa M
        • et al.
        Association between work schedules and motivation for lifestyle change in workers with overweight or obesity: a cross-sectional study in Japan.
        BMJ Open. 2020; 10e033000
        • Morgan PJ
        • Collins CE
        • Plotnikoff RC
        • et al.
        Efficacy of a workplace-based weight loss program for overweight male shift workers: the Workplace POWER (Preventing Obesity Without Eating like a Rabbit) randomized controlled trial.
        Prev Med (Baltim). 2011; 52: 317-325
        • Lubkin M
        • Stricker-Krongrad A
        Independent feeding and metabolic actions of orexins in mice.
        Biochem Biophys Res Commun. 1998; 253: 241-245