Dr.NateNeph said:

Bone density monitoring on lean mass: DEXA bone density at baseline and month 12.

My endo's protocol for lean mass plateau: if weight loss stalls for 6+ weeks at current dose, we go through this checklist before titrating up:

1. Food diary review — is intake creeping up?
2. Protein check — minimum 100g/day
3. Activity audit — steps + resistance training
4. Sleep quality — poor sleep kills GLP-1 efficacy
5. Stress/cortisol management

Only after addressing all of these do we increase the dose. Often fixing one lifestyle factor restarts progress without needing more medication.

marcus_mpls said:

Right, and protein targets should be set on a reference weight rather than current weight.

This is exactly what I could not find anywhere else. Adding it to my notes with a link back to this thread.

Dr.NateNeph said:

Bone density monitoring on lean mass: DEXA bone density at baseline and month 12.

Physical therapist weighing in on lean mass. I work with bariatric and metabolic patients daily.

The resistance training evidence is critical here:

The Lundgren 2024 JAMA paper[1] showed that structured resistance training preserved 73% more lean mass in GLP-1 patients vs medication alone. When discussing lean mass, we MUST include the exercise component.

My minimum prescription: 3x/week compound movements (squat, deadlift, press, row), progressive overload, 7-10K steps/day, and 1.2-1.6g protein/kg/day.

lucas_SP_BR said:

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

Back pain as a lean mass side effect: not from the medication itself, but from rapid body composition changes. Losing 48 lbs shifts your center of gravity and your core muscles need time to adjust.

Physical therapy has been essential. Core strengthening exercises (planks, dead bugs, bird dogs) daily for 10 minutes have eliminated my lower back pain. Your body is literally relearning how to carry itself.

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