COA_Karl 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…

Filing a mild objection. Mild because I might be wrong; an objection because nobody has addressed the case that does not fit. 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.

Dr.CardioMD said:

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

Dr.CardioMD 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.

mike.trainer_LA said:

I think this board over-worries about lean mass.

Back pain as a lean mass side effect: not from the medication itself, but from rapid body composition changes. Losing 59 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.

Following on from PedsEndoPhilly — and this may be the naive question:

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

Closing the loop on my own question.

Second scan under matched conditions came back with the lean number nearly a kilogram higher than the first, so a chunk of what I panicked about was hydration. Strength numbers were up throughout.