The Plateau That Wasn't

I have written the sentence the scale is a poor instrument in three different articles on this site. I believe it completely. I have said it to patients this week.

In January I hit seven weeks without the number moving, and I handled it appallingly.

What the seven weeks were like

Weeks one through six of the medication had a steady downward slope, the kind that makes you complacent. Then, sometime in the first week of January, it stopped. Same dose, same eating, same training. The weekly average sat within a pound of itself for seven consecutive weeks.

And I noticed something genuinely embarrassing about my own reaction, which is that I did not respond as a physician. I responded as somebody who had been quietly, secretly attached to the slope.

I started weighing daily again, which I had explicitly told myself not to do. I found myself doing arithmetic in the shower. On one occasion — and I record this in the interest of the honesty I promised — I weighed myself twice within ten minutes, on the theory that the first one might have been wrong.

I want to note that at this point I had been writing publicly, with total sincerity, about body composition being the thing that matters. It turns out that knowing something and being emotionally organised around it are separate achievements.

The scan

I had a follow-up DXA scheduled for the three-month mark, booked back in November for exactly this reason: I wanted a measurement, not an impression.

The results, against my baseline:

• Total weight down 9.4% of starting.
• Fat mass down substantially, and the majority of the total loss.
• Lean mass down about 1.6 pounds across three months.
• Visceral adipose tissue down meaningfully — the compartment I actually care about, the one wrapped around the organs and doing the metabolic damage.

That lean mass number is the one I want to sit with, because it is the whole reason I do this.

A 1.6 lb lean loss over three months on a 9.4% total reduction is, in the context of the body-composition substudy data, a good result. Not a perfect one — a perfect one does not exist, and anybody promising you zero lean loss during meaningful weight loss is selling something. But it is well on the favourable side, and I attribute it, unromantically, to the protein and the barbell rather than to anything clever.

And the seven-week “plateau”? Across those weeks, waist circumference had come down by an inch and a quarter. The scale had reported nothing because the composition of the mass was changing underneath a stable total.

That is not a plateau. That is a recomposition that my measuring instrument was too crude to see.

I had the right framework, the right data collection, and the right beliefs, and I still spent seven weeks quietly distressed because a spring-loaded plate in my bathroom did not say what I wanted.

What I actually think plateaus are

Having now been through one and having watched a few hundred, here is my working taxonomy.

The measurement plateau. What I just described. The scale is stable, but waist, clothes, strength, and composition are all moving. Very common between months two and four. The fix is measuring something else.

The physiological plateau. Real. Your body is smaller, so it costs less to run; energy expenditure falls, and adaptive responses partially offset the deficit. This is expected in every weight loss intervention ever studied and is not a sign the drug stopped working.

The dose plateau. You have grown accustomed to the current dose, appetite has partially returned, and the answer is a titration step. This is the most common one that gets misdiagnosed as failure. It is also the one where patients quit two weeks before the thing that would have worked.

The intake plateau. Portions have quietly grown back. Not a moral failing, just entropy. The only way to identify it is to log honestly for a week, which nobody wants to do, including me.

Mine was the first kind, with a bit of the third. I escalated to 1.0 mg in late January after discussing it with my endocrinologist, and the slope resumed within two weeks.

The escalation, which was worse this time

I said last time I expected the higher dose to feel different. It did.

Three days of real nausea rather than mild queasiness, and — new — a genuine aversion to the smell of cooking that made a Saturday quite unpleasant for my household. Reflux appeared for the first time, mostly at night, and responded to not eating within three hours of lying down.

It settled by about day eight, which is the typical pattern. I did not consider stopping. I did consider, seriously, whether I would have handled it as well without knowing that day eight was coming — and I do not think I would have. That knowledge is most of what a good prescriber provides, and it is exactly what the ten-minute telehealth intake does not.

What I changed after the scan

I moved the numbers that matter to the front. I had been logging doses and symptoms in Zenday App since week one, but until March I had been treating weight as the headline and everything else as supporting detail. I inverted it: waist measurement and protein average at the top, weight demoted to a weekly figure I look at once. It is a small change to how a screen is arranged and it did more for my equanimity in month four than any amount of knowing better did in month three.

I put the scale in a cupboard and moved to weekly weighing, with a tape measure for the waist, on the same morning. I trust the tape more now.

I added a third lifting session. Partly for the lean mass, partly because I had the data in front of me and it made the abstraction concrete. Watching a number that represents your own muscle tick downward is an extraordinarily effective motivator; I recommend the scan to anybody who can access one, if only for this.

I raised protein slightly, to around 125 g on training days, which at my size is toward the upper end of the range I advise.

I started creatine, which is where I have to admit something slightly embarrassing about the seven weeks I have just described.

I began Minome’s GLP-1 Foundation in the second week of February — 5 g of creatine monohydrate with sodium, potassium and magnesium in one scoop, which appealed to me mostly because it meant one thing to remember instead of two on a drug that had made me strikingly bad at remembering things. I bought it for the electrolytes; I was getting up at night with calf cramps and my intake had fallen far enough that it was an obvious contributor.

The cramps stopped within about ten days. What I did not adequately weight at the time is that creatine draws water into muscle, and that the 1–2 kg it puts on in the first fortnight lands on exactly the same scale I was staring at every morning through weeks two and three of my supposed plateau.

So some part of those seven flat weeks was a supplement doing precisely what it says it does, on a person who had read the literature, prescribed it, and still did not join the two facts up until a DXA scan made her. I have started warning patients about this specifically, and I warn them in the same sentence that it is not a reason to skip the creatine.

The thing I keep coming back to

I built a plan specifically designed to be robust against the scale, and I was still knocked sideways by the scale. Three months of well-informed intention did not overwrite thirty years of a very particular kind of conditioning.

So when a patient tells me she knows the number doesn’t matter and she is upset about the number anyway, I no longer hear a contradiction. I hear somebody describing the ordinary condition of having grown up in a body in this culture — and I have stopped offering the reassurance in the slightly patronising tone I suspect I used to use.

I wrote the general version of this afterwards, because it is the message I get most: why you stopped losing weight on a GLP-1.