PedsEndoPhilly 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…

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.

One thing that is still open after newstart_MO’s answer:

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

Dr.PeteFamMed said:

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: Food…

Dr.PeteFamMed 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.

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.

KevinCompounds said:

Dr.PeteFamMed said: ...the muscle loss concern with lean mass...

Agreed on the ranges, with the condition that a single DEXA is not a measurement, it is one draw from a distribution. Hydration status moves the lean compartment by a kilogram or more between scans, so any comparison of scans done at different times of day or different hydration states is noise.

If somebody has the primary source to hand I would rather cite it than paraphrase it.