Follow-up review. Three months in on Mounjaro, 14kg down, and I hear myself say “You’re doing so well.” You’re beaming - it’s the first time in years that you’ve been able to make a dent in the problem that’s plagued you since your 30s. You already knew the verdict on the scales, but what we really need to talk about is all the rest - muscles, bones, nutrition and mood.
When it comes to weight loss, few people look at anything beyond the scales before declaring success or failure. “Doing well” in this GLP-1 era has come to mean precisely one thing - the number on the scale has gone down - but what we mustn’t ignore is what's going on in the background.
Before I can confidently say “You’re doing well”, we need to dig a bit deeper.
Are you doing any resistance training currently, or has exercise dropped off along with your appetite?
What does a typical day’s eating actually look like now - are you surviving on half a red onion and a Snickers?
How’s your energy, your mood, your general drive - not just “am I eating less” but “do I still feel like myself”?
Any family history of osteoporosis, or personal risk factors for bone health?
None of this is me hunting for a reason to stop the medication, it’s me checking that we do everything right to optimise your GLP-1 results - and that is about more than just weight. It’s about muscle mass, bone density, metabolism for the future, nutrient deficiencies and coping with mental changes.
There’s a short list of things that don’t show up on the scales at all, and it’s better to name them properly than let you find out about them by accident:
Muscle loss - in the SURMOUNT-1 DEXA substudy(1), roughly a quarter of the weight tirzepatide patients lost was lean mass, not fat. That’s not a drug side effect so much as a feature of weight loss generally, whichever route gets you there
Bone density - weight loss itself adversely affects bone density, through reduced load-bearing and the nutritional shortfalls that tend to creep in with a calorie deficit
Micronutrient gaps - iron, B12, calcium, fibre, all quietly dropping before you notice, because mild deficiency looks exactly like “it’s been a long week” These can lead to fatigue, hair loss, constipation, even neurological deficits
The dopamine flattening - the reward buzz you used to get from food has been squashed - but it’s not just food-related. Some people feel calm. Some feel like something’s gone missing more broadly
Bloods aren’t helpful for most of this. This is less about testing and more about making sure the basics are actually in place, because the fix here isn’t a lab result, it’s behaviour change.
If there’s a genuine reason to suspect a nutritional deficiency given your symptoms (crushing fatigue, shortness of breath, paraesthesia, hair loss, restless legs, recurrent infections), then full blood count, iron studies, B12, folate, and vitamin D are reasonable and specific things to check
Otherwise, the more useful “test” is simply reviewing what a ‘typical day’ actually looks like, because that tells me more than a blood panel would at this stage AND it has the potential to head problems off before they would ever show up in your blood work. As with everything in medicine - prevention is way better than cure!
The scales are moving, but we need to keep a close eye on the lifestyle at the centre of it all. Right now you’re losing weight and - almost certainly - some muscle and bone density alongside it.
Both of these things are happening to most women in midlife, even those who aren’t losing weight. On a GLP-1, it’s amplified. This makes it even more important to pay attention to the basics.
Resistance training 2–3 times a week, with weight or repetitions increasing over time - this is the single biggest lever for protecting the muscle you’re currently losing alongside the fat.
Weight-bearing exercise for bone specifically - variety and short bursts matter more than duration; dancing, for what it’s worth, is one of the better options for this.
Calcium 700 micrograms and vitamin D 10 micrograms daily.
The latest guidance in terms of protein intake for those on GLP-1s is to aim for 1.0-1.5g/kg per day (based on Adjusted Body Weight2). It’s a lot, especially if your appetite is fractionally smaller than that of a gnat!
A bit of actual meal planning - protein, fibre, some colour on the plate - because appetite suppression this effective means you can go from nothing in the cupboard to genuinely under-fed without noticing, and “under-fed” produces the exact fatigue and hair thinning that gets blamed on everything except the gap in your diet.
Wherever you find your diet at the moment, aim for improvement, not perfection. Take small steps in the right direction until you get to where you want to be.
The mental side of things hits people differently. Some feel an overwhelming sense of calm and control - that was true for me. But for others, the dopamine-flattening effect can feel much heavier. This is worthy of an appointment in its own right.
The mental impact of GLP-1s is something we’ve talked about in our regular Tuesday Clinic - check it out here → 3 ways my brain changed on GLP-1s
“Doing well” on this medication doesn’t mean lighter at any cost - it should mean your muscles are being maintained, your bones are being protected, your plate is actually feeding you, and you still feel like yourself underneath the smaller number.
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