Dr.LeslieOBGYN said:

The mechanism that matters here is not stomach emptying, it is central.

Agreed, though "tolerable" needs defining. A dose you tolerate by eating almost nothing is not tolerated, it is being paid for somewhere else — usually in lean mass, sometimes in adherence three months later.

Worth separating that from semaglutide, which this thread keeps folding into the same question. They behave differently and the advice does not transfer.

mike_nyc said:

Agreed on the ranges, with the condition that a single DEXA is not a measurement, it is one draw from a distribution.

Bookmarking. The distinction being drawn above is the one nobody else makes. Printing the relevant bit and taking it with me.

Dr.LeslieOBGYN said:

The mechanism that matters here is not stomach emptying, it is central.

Pushing back on Dr.LeslieOBGYN here. The trial means are being read too generously in this thread. STEP populations were selected, supported, and titrated by protocol, and the real-world curves are consistently a few points worse. That difference is not noise, it is what happens when you remove the study infrastructure.

Worth separating that from semaglutide, which this thread keeps folding into the same question. They behave differently and the advice does not transfer.

Correct me if the detail matters more than I have assumed.

MikeFit_NJ said:

Two DEXA scans eleven months apart: down 24kg total, of which the scan says 6kg was lean.

MikeFit_NJ said:

...the muscle loss concern with lean mass...

This is a legitimate and well-studied concern. Let me put some numbers on it:

In STEP 1, approximately 39% of weight lost was lean mass. However, the Lundgren 2024 study showed that structured resistance training reduced this to ~25% lean mass loss.

Context matters: at BMI 35+, you're carrying excess lean mass to support the extra weight. Losing some lean mass is expected and not inherently harmful if you maintain adequate muscle function through exercise.

The solution isn't avoiding the medication — it's combining it with proper exercise and protein intake.

Moderator note: good thread. Keeping it here rather than moving it, because the question is general enough to be useful.