Obesity is a chronic metabolic disease. It is also the only chronic disease patients are routinely blamed for having.
That framing has a cost. Most people arrive in our office having tried repeatedly on their own — and having never been evaluated for why. No thyroid check. No review of the medication list for drugs that cause weight gain. No screening for sleep apnea or insulin resistance. The workup was never done.
More than a third of Texas adults meet the criteria for obesity. Very few have ever had one.
The drivers almost nobody checks
Before any conversation about medication, the question is what is driving the weight. Sometimes there is a specific, correctable answer sitting in plain sight.
Start with the medication list. A number of commonly prescribed drugs cause clinically meaningful weight gain, and in most cases a reasonable alternative exists inside the same class.
| Drug class | Commonly associated with weight gain | Alternatives often available |
|---|---|---|
| Diabetes medications | Insulin, glipizide, glyburide | Metformin, GLP-1 agonists, SGLT2 inhibitors |
| Antidepressants | Paroxetine, mirtazapine, amitriptyline | Bupropion, fluoxetine, sertraline |
| Antipsychotics | Olanzapine, clozapine, quetiapine | Aripiprazole, ziprasidone, lurasidone |
| Blood pressure | Atenolol, metoprolol, propranolol | ACE inhibitors, ARBs, calcium channel blockers |
| Seizure & mood stabilizers | Valproate, gabapentin, pregabalin, lithium | Topiramate, lamotrigine, zonisamide |
| Steroids | Prednisone and other long-course corticosteroids | Lowest effective dose; steroid-sparing agents |
| Antihistamines | Diphenhydramine, cyproheptadine | Loratadine, cetirizine, fexofenadine |
Beyond medications, four things are worth ruling out before anything else: hypothyroidism, polycystic ovary syndrome, obstructive sleep apnea — which drives weight gain as surely as weight gain drives it — and insulin resistance, which is measurable well before diabetes appears.
The numbers, and where they mislead
| Measure | Threshold | What it tells you |
|---|---|---|
| BMI 25.0–29.9 | Overweight | Treatment indicated at 27+ with a weight-related condition |
| BMI 30.0 + | Obesity | Treatment indicated regardless of other conditions |
| Waist circumference | Over 40 in (men) / 35 in (women) | Visceral fat — tracks cardiometabolic risk better than BMI |
| A1c 5.7–6.4% | Prediabetes | The window where progression is still preventable |
| Urine albumin-to-creatinine | Over 30 mg/g | Early kidney damage — routinely skipped |
BMI is a crude screen and it is wrong at both ends. It overstates adiposity in muscular people and understates it in older adults who have lost muscle. It is what insurers use to authorize treatment, so it is what determines access — but it should never be the only thing your physician looks at. Waist circumference and the metabolic labs tell you more about risk than the BMI does.
What treatment actually looks like now
Three tiers. They stack; they are not a sequence you have to fail your way through.
| Approach | What it involves | Typical weight reduction |
|---|---|---|
| Structured lifestyle program | Intensive, supervised nutrition and activity change with regular contact | 3–8% |
| GLP-1 receptor agonist | Weekly semaglutide, or daily liraglutide | 8–15% |
| Dual GIP/GLP-1 agonist | Weekly tirzepatide | 15–21%, dose-dependent |
| Metabolic surgery referral | Sleeve gastrectomy or gastric bypass | 25–30% |
The number that matters clinically is smaller than the number most people have in mind. A sustained 5 to 10 percent reduction meaningfully improves blood sugar, blood pressure, lipids, and sleep apnea. That is the threshold where the disease burden shifts — not the number on a goal-weight chart.
Two things about medication that get left out of the sales pitch. A meaningful share of the weight lost is lean muscle, which is why protein intake and resistance training are part of the prescription rather than an optional extra. And stopping reverses most of the benefit — these work like blood pressure medication, not like a course of antibiotics.
Why this is worth treating, beyond the weight
Obesity is the upstream driver of a long list of conditions we then treat individually and expensively: type 2 diabetes, hypertension, high cholesterol, obstructive sleep apnea, fatty liver disease, osteoarthritis, and cardiovascular disease.
The one that gets missed most often is the kidney. Obesity damages kidneys directly, through a distinct pattern of injury, and indirectly by driving the diabetes and hypertension that are the two leading causes of kidney failure in this country. If you carry excess weight and nobody has checked a urine albumin, that test is overdue — it detects damage years before a creatinine moves.
There is also a specifically Houston problem. Long summers, a large outdoor workforce, and heat that makes sustained outdoor activity genuinely unsafe for months at a time. Any activity plan built for a temperate climate will fail here by July. That is a planning problem, not a discipline problem, and it should be addressed in the plan.
What we do
Work the causes first. Thyroid, A1c or fasting glucose, a lipid panel, liver enzymes, kidney function with a urine albumin, and a genuine review of every medication you take for the ones that are working against you.
Treat obesity as the chronic disease it is, with the full range of options — structured lifestyle support, medication when it is indicated, and referral for metabolic surgery when that is the right answer.
Handle the coverage question directly, because it is usually the real barrier. Formulary status, prior authorization, and the Medicare and Medicaid rules that changed in 2026 are all part of the visit, not an afterthought left to you.
Monitor properly during dose escalation rather than only at twelve weeks — including kidney function, which matters more here than in a cooler climate.
And manage the conditions traveling alongside it, on one shared record, with the physician who knows the whole picture.
When to be evaluated
If your BMI is 30 or higher, or 27 or higher with diabetes, hypertension, high cholesterol, or sleep apnea. If sustained effort has not produced durable results. If you are gaining weight on a medication you need. If you have never had a thyroid, an A1c, or a urine albumin checked. Or if you are considering a GLP-1 and want a physician to assess candidacy, contraindications, and coverage rather than a website that will ship it after a form.
Most people have never had the workup. That is the appointment worth making — before the prescription, not instead of it.