Dr.LipidDallas said:

The intervention that works is boring and well evidenced: resistance training two to three times a week at a genuine effort, protein at 1.4 to 2.0…

This is where I part company with the consensus forming above. I think this board over-worries about lean mass. Some lean loss is obligatory — you need less muscle to move a smaller body, and preserving mass you no longer need is not a health outcome. The question is whether strength and function held, and mine did.

RunnerRach said:

I lifted three times a week throughout and still lost lean mass.

Sharing my comprehensive lab data relevant to lean mass:

Protocol: Tirzepatide 10mg/wk, resistance training 5x/week, protein 1.5g/kg/day.

The improvements in lean mass are clearly reflected in these numbers. The inflammatory marker reduction (hsCRP) is particularly striking.

Dr.RaviCardio said:

I think this board over-worries about lean mass.

Dr.RaviCardio 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.

A narrower follow-up, since the general answer is now clear:

Whether resistance training and protein change the ratio or only the absolute amount?

Reporting back.

Follow-up: I dropped the cardio to two easy sessions and put the effort into three real lifting sessions. The scale slowed and the scan improved.