GLP-1’s are proving themselves as medical phenoms. They have been in existence for many years in the treatment of diabetes. They have demonstrated themselves as capable of reducing cardiac events, lowering blood pressure, cholesterol, heart failure symptoms, and even strokes. They have shown themselves effective in reducing the kidney problems that diabetes can cause in the long run. And there’s even proof that they might be useful for treating childhood obesity. Ultimately, they may prove valuable for medical conditions we haven’t yet explored. In light of the budding awareness of the strong correlations between our obesogenic diets that are high in fats, sugars, and calories and a variety of diseases ranging from some cancers to musculoskeletal ones, GLP-1’s may be the super-duper drugs that have exploded the weight loss market.

However, if weight loss is a goal and semaglutides and other similar hormone-affecting drugs is your method then, young or old, male or female, preserving muscle mass is critical. As a female, especially, whether pre- or post-menopausal, preserving muscle mass is even more critical as rapid and large amounts of weight loss includes bone density loss, too. Muscle mass training enhances bone mass accrual IF…, and this is a big IF, the weights you lift are heavy enough to be deemed ‘intense’.

The American College of Sports Medicine recommends that, for health, people should do some kind of RT should be done at least twice a week but could be done 3 or more if the program allows for sufficient recovery between sessions. A 2/wk program should consist of at least one exercise for each body part – legs, core, upper body/arms; ideally, you do 2-3 exercises per body part but they do not have to be the same exact exercises. For example, a heel raise gets the calf muscle, a squat and lunge also get the calf muscle, but they also get the upper leg and core.

If you choose to do 3 sessions/wk, be sure to space them out with at least 36-48 hours between sessions. For a more athletic program, it’s not unusual to do 4 or more sessions/wk but intelligent design must be applied to avoid overuse and overtraining, and injury.

What Constitutes a Viable Resistance Training Program

In the realm of RT, there are many models to consider, each with 4 variables: frequency, intensity,  duration, and exercise type. Frequency we’ve already addressed. Duration is a function of how long you want to spend doing the exercises; some quick and dirty routines can last as short as 15 minutes or you can drag it out to an hour or more. But intensity and type are where special attention should be made when the training is being done to minimize loss of muscle and bone.

When discussing intensity, we’re talking about a percentage of your maximal ability. Most of us will never test our max so let’s use a common way of determining intensity: to volitional fatigue. That means that when you feel you can no longer do any more repetitions with good form and no compensations, you have reached volitional fatigue. It is very subjective and varies according to how you are feeling at the moment, including stressors outside the gym. Recognizing that many people with overweight and obesity have not been in the gym in a while or are not comfortable going to a gym, it may take a few sessions with modest weights to figure out what it really feels like to be fatigued at the end of a set of an exercise.

There’s no hard and fast rule but, if bone loss is one of your issues, either due to age, menstrual status, sedentary lifestyle, or poor diet, it is recommended that you try to fatigue in 10-12 repetitions; that corresponds to a heavy enough weight to provide a good stimulus for bone to accrue. With the understanding that most people who do not have RT experience won’t feel comfortable trying to achieve that kind of load/intensity, especially if they’d had any injuries or are prone to some, such as to the rotator cuffs in older adults, the process of ramping up to weights that can mitigate bone loss should be long, slow, and properly designed to reduce risks. See your local trainer….or call us at STEPS.

Exercise type, however, is where the message of RT in combination with drug-enhanced weight loss is most critical. While many people aspire to 6-pack abs (abdominals), that is an unreasonable goal, especially for those who have carried excess fat around their midsections or those who are older. Having a strong core – those muscles from the mid-thigh to the mid-thorax, front, sides, and back – is valuable but not essential for the average person. Having a functional core, on the other hand, is. A functional core is one where all the muscles know how to work together and have sufficient endurance and strength to allow you to perform activities of daily living, work, and recreation.

Exercise Selections and Options

Allow me to provide some specific exercise types that will strengthen muscles and bones that we all need in order to accomplish what a rapid weight loss system detracts from, especially for post-menopausal women.

Bone loss from the hips/upper femur, which contributes to falls and fractures in older people, can be countered with such exercises as a leg press machine, weighted squats, lunges, and step-ups.

Bone loss in the lumbar spine can be slowed with such exercises as weighted squats, lunges, step ups as well as deadlifts, bird dogs, and stability ball bridges or hip lifts. You can make the latter more demanding to achieve volitional fatigue by adding small arm and leg movements during the birddog and doing bridges with one leg rather than both.

Bone loss of the upper spine, which affects posture, especially potential dowagers humps in older adults – which is exacerbated in our texting and computer-based lifestyles –

Finally, wrist bones, which tend not to get much training beyond middle school for most females once PE coaches don’t make you do push-ups, are prone to breaking when falling. They are often the first markers of middle age women’s bone loss at the early stage of osteopenia should they experience a broken wrist from a fall. In fact, though, push-ups or some version of a chest press or bench press are some of the exercises that load the wrist and could help build bone IF loaded sufficiently. However, since the rotator cuff deteriorates with age, and is susceptible to injury from doing those very exercises that could help the wrist bones, it’s wise to train them with caution and avoid the volitional fatigue in 10-12 rep prescription. But it’s also wise to train the cuff muscles to minimize the risk of injury from any kind of RT even if you’re not intending to do these bone-enhancing exercises.

Note that each exercise for each segment of the body is done in a weight-bearing posture, even the chest/bench press. Even something as mundane as a plank in a push-up position constitutes a weight-bearing load capable of producing osteogenic forces that may build wrist bones’ strength.

While it is necessary to proceed with caution as you pursue a bone- and muscle-preserving workout regimen, to pre-condition the core and the rotator cuff muscles to avert injuries that might result from a RT program, within 4-6 weeks one will start to experience muscle mass changes. It could easily take a year or more to note any bone-building changes; first by some imaging technique or by falling and not breaking something, which we would recommend against trying. Ultimately, though, the effort to enhance lean tissue – bone and muscle – facilitates weight loss, fat loss, and quality of life. And, with the health upsides of GLP-1 meds, there’s a good chance that RT will even extend the health-years of your life.

Which is the main reason we all should be doing some RT in our lives.

Originally printed on STEPS Fitness blog. Reprinted with permission.

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Dr. Irv Rubenstein graduated Vanderbilt-Peabody in 1988 with a PhD in exercise science, having already co-founded STEPS Fitness, Inc. two years earlier — Tennessee’s first personal fitness training center. One of his goals was to foster the evolution of the then-fledgling field of personal training into a viable and mature profession, and has done so over the past 3 decades, teaching trainers across through country. As a writer and speaker, Dr. Irv has earned a national reputation as one who can answer the hard questions about exercise and fitness – not just the “how” but the “why”. 

Super-duper weight loss drugs (originally they were designed to help those with Type 2 diabetes, or T2D) like Ozempic, Wegovy, Mounjaro, et al. have swamped the marketplace because of their unique pharmacologic actions compared to their predecessors. Earlier weight loss drugs and over-the-counter concoctions (like coffee and other caffeine-derivatives, as well as smoking cigarettes, for example) simply sped up metabolism and boost energy. These, then, provided (ab-)users an artificial mechanism by which to burn calories and even avoid consuming calories since energy levels didn’t require them.

What makes these modern drugs so unique is their effects on hunger and appetite hormones. Essentially, they alter or disrupt hormone signaling that tell the gut to stop demanding food and/or the brain to feel satisfied with the food you’ve consumed, presumably before you overeat. That is, those appetite and hunger messages lead people to eat less without – we hope – causing permanent and as-yet-unknown effects on the endocrine system as a whole.

Caveat: while some of these drugs have a relatively long history due to their use in managing diabetes, 5-10 years on the market may not be sufficient to declare with absolute certainty that long-term impacts are not going to crop up.

The past couple of decades have given scientists and pharmaceutical companies greater understanding about the gut-brain connection. Hormones, which are signaling proteins that course throughout the body, often have multiple outlets and receptors that allow one metabolic process to influence or be influenced by another part of the body. One of the most common hormones that most of us have some awareness and understanding of is insulin.

Insulin, cell receptors, and disease

Pumped out by the pancreas, insulin helps manage blood sugar, an essential substrate that feeds all of our organs, especially the brain. The digestive process breaks down carbohydrates into sugars that the blood stream then carries to organs for energy. Ever feel groggy or slower between meals? Well, that’s your brain saying ‘feed me…ideally, with sugars, or carbs’. Ever feel like your energy is waning on a long bike ride or hike? That’s your muscles demanding calories, especially sugar-based calories. The insulin signals drive both the sugar calories from those foods to their respective locales and even help pull stored glucose (a form of sugar) from glycogen stores (sugar formulations the body keeps around in case they’re needed like the liver) between feedings. When insulin is in short supply (as in Type 1 diabetes), sugar can’t enter cells.

However, without receptors on the surface and within the cells to allow insulin to do its job, it is neutered. These dysfunctional receptors are part of the process that leads to T2D: when insulin is unable to unlock the cells that have disabled receptors, the brain, heart, and other organs including muscles are deprived of energy.

A few digestive and appetite hormones have similar roles. Leptin, ghrelin, PYY, and the big kid on the block, glucagon-like peptide 1 (GLP-1) transmit signals of fullness, satiety, and hunger to and from the gut and brain. Without operative receptors, however, some of these signals get disrupted. Obesity itself, regardless of original causality, be it genetics, diet, or lifestyle, is one of those disruptors. With obesity, some of these hormones fail to signal when you are sated or over-signal that you continue to be hungry. GLP-1 works by messaging the digestive system that you are sated. Therefore, for those who cannot get that feeling, GLP-1 receptor agonists – these super-duper drugs – help reduce food intake by reducing appetite…and increasing weight loss.

All drugs have side effects

One of the oldest drugs which originally came from willow tree bark is aspirin. Well-known and long used to reduce fevers, manage headaches, and more recently thin blood for those folks at risk for potentially-fatal blood clots such as after lower-extremity surgery or certain cardiac conditions, can also lead to excessive bleeding in the event a closed-head injury or gastric ulcers due to its effect on the stomach lining.

Semaglutide and liraglutide, two of the main GLP-1 drugs out there, have been found to reduce food obsessions leading to calorie restriction but, oddly, have been correlated with reducing other addictive obsessions from gambling to sex to alcohol and other drugs. (1) Interestingly, in combination with bimagrumab, semaglutides “led to superior fat mass loss while simultaneously preserving lean mass despite reduced food intake”. (2)

However, a disconcerting unintended consequence of these weight loss meds is that “the potential health benefits of diet-induced weight loss are thought to be compromised by the weight-loss-associated loss of lean body mass, which could increase the risk of sarcopenia (low muscle mass and impaired muscle function)”. (3)  Any time you diet, some of the weight you lose, after initial water weight, is lean tissue – muscle mass and, if rapid and extensive weight is lost, bone mass. A meta-analysis of 18 well-controlled studies that included over 1300 subjects confirmed that these kinds of drugs, which were originally designed to help those with T2D, contribute to loss of muscle mass; metformin, another T2D drug, on the other hand, does not. (4)

Some studies show that, “compared with persons with normal weight”, those with obesity have substantial muscle mass to support and transport their bodies, but poor muscle quality, that is more fatty infiltration generally from lack of a training stimuli. Somehow, though, the “diet-induced weight loss” reduction of muscle mass happens “without adversely affecting muscle strength”. This maintenance of muscle mass that accompanies weight loss improves overall physical function, likely due to the loss of fat mass which otherwise is a drag on performance. While it is recommended, and is very vogue, to encourage a high protein intake – of 1.2 – 2.0 grams/kg of body weight vs the RDA recommendation of 0.8 g/kg – to preserve lean body and muscle mass during weight loss, apparently this does not improve muscle strength; and it could have “adverse effects on metabolic function” if kidney problems are an issue or become one.

Finally, while both endurance exercise, if performed at pretty high intensities such as stair climbing or cycling with high resistances, and resistance training (RT) at moderate to heavy loads “help preserve” lean tissue during a weight loss regimen, only intensive and consistent RT improves muscle strength. This is why researchers are so heavily promoting RT as a way to prevent the inevitable loss of muscle and to restore the low-quality muscle that people with obesity have to a more functional variety. (3)

The mechanisms for these drugs’ effects on lean tissue are under investigation. One group of researchers has determined that the combination of these drugs actually protects against muscle atrophy. The biochemistry is irrelevant here. What might be more relevant is the customary fact that rarely are these drugs prescribed together. So, while they might prevent this adverse effect, it will require more study before they are co-prescribed. (5) There is evidence that shows that oral semaglutide, when prescribed for T2D patients, does help with weight loss and, even alone, does not lead to substantial loss of muscle mass. (6)

Weight loss vs Muscle loss: Inevitable or Preventable?

As we discussed above, any significant amount of weight loss is accompanied by muscle and even bone loss, especially if done quickly over a short period of time. This could be diet-related, disease- or medical treatment-related (think: during chemo or radiation for cancer), or even, shockingly, exercise-related. Yes, if someone engages in intensive and long-duration cardio training such as running or biking, and weight loss occurs, so, too, does muscle loss. (Real News, Nov 2024)

Why? It’s pretty simple: unless sufficient calories are consumed to compensate for the excess energy output, the body becomes very efficient by discarding muscles that are not used in the training (REAL News – Dec. 2024) or simply allowing unused muscle fibers, like the bigger, stronger, more powerful fast-twitch fibers, to atrophy since neural stimulation is withheld. Even young athletes on a hypo-caloric diet designed for weight loss lose muscle mass unless they’re on a significantly-elevated protein intake diet. (7)  Sadly, too, weight loss of 5% or more is accompanied by bone density loss! (REAL News – December 2018)

With studies showing that GLP-1’s can lead to 15 – 24% weight loss, they can be accompanied by 10%, or ~6 kg, of muscle mass loss. (8) Sergeant et al (2019) found in over half of the studies included in their meta-analysis of the same year, the proportion of muscle loss was somewhere between 20% and an astounding 50% of the total weight lost! (9) A more recent study by Bikou et al. confirmed that, while extremely effective for fat loss, these meds can cause up to 40% of the weight lost being lean mass. (10)

All of these researchers concluded that, with intensive RT, not only can patients reduce the muscle loss, they can maintain muscle mass to reduce weight re-gain should they stop taking the medications.

Takahashi et al (11) demonstrated that vitamin D supplementation, and possibly vitamin B12, but not vitamins A, B6, C, and E, might correlate with with the loss of lean tissue in older adults with T2D. Thus, in addition to a vigorous RT program, getting in extra D could reduce the atrophy that accompanies weight loss.

Nunn et al., in a study of diet-induced mouse obesity, found that blocking a particular muscle cell receptor that is known to interfere with muscle growth – ActRII – while being treated with a semaglutide medication preserves muscle mass. It actually induced an almost 10% increase in lean mass!However, this is what you might call a proof of concept study and has not yet been approved for humans taking a GLP-1 drug. (12)

Some studies have found that muscle mass loss does not deteriorate as much in patients with T2D as one might expect. (6) The Japanese subjects experienced substantial health benefits over the 24 months they used a combination of liraglutide and semaglutide, affirming Klausen et al.’s (1) finding. Too, Gurjar et al. found that “drug repositioning” with liraglutide might be the answer to weight-loss-induced muscle loss, at least in mice. (13)

There is a new kid on the block in Phase 3 studies – a combination drug of Amylin + two GLP-1 drugs – semaglutide and cagrilintide – that offers comparable weight loss while helping to “preserve the reduction in energy expenditure” which could help maintain weight loss in the long run. (14)  This could be the game-changer what with all these super-duper drugs that are helping people lose weight, especially for those who are older, more likely to have blood sugar control issues such as T2D, and may already have suffered age-related sarcopenia. However, for all patients who are taking these GLP-1’s, the basic prescription still holds, whether or not it totally reverses years of sedentary living or age-related muscle loss, and that’s RT using loads greater than body weight.

Check out part 2, If You’re Using GLP-1 Meds for Weight Loss, Then You Gotta Do Weight Lifting

Originally printed on STEPS Fitness blog. Reprinted with permission.

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Dr. Irv Rubenstein graduated Vanderbilt-Peabody in 1988 with a PhD in exercise science, having already co-founded STEPS Fitness, Inc. two years earlier — Tennessee’s first personal fitness training center. One of his goals was to foster the evolution of the then-fledgling field of personal training into a viable and mature profession, and has done so over the past 3 decades, teaching trainers across through country. As a writer and speaker, Dr. Irv has earned a national reputation as one who can answer the hard questions about exercise and fitness – not just the “how” but the “why”. 

References

1. Mette Kruse Klausen et al. The role of glucagon‐like peptide 1 (GLP‐1) in addictive disorders. Br J Pharmacol. 2022 Feb; 179(4): 625–641. Published online 2022 Feb 2. doi: 10.1111/bph.15677)

2. Nunn et al. Antibody blockade of activin type II receptors preserves skeletal muscle mass and   enhances fat loss during GLP-1 receptor agonism. Mol Metab. 2024 Feb:80:101880. doi: 10.1016/j.molmet.2024.101880. Epub 2024 Jan 11.

3. Cava et al. Preserving Healthy Muscle during Weight Loss. Adv Nutr. 2017 May 15;8(3):511-519. doi: 10.3945/an.116.014506. Print 2017 May.

4. Ida et al. Effects of Antidiabetic Drugs on Muscle Mass in Type 2 Diabetes Mellitus. Curr Diabetes Rev. 2021;17(3):293-303. doi: 10.2174/1573399816666200705210006.

5. Xiang et al. GLP-1RA Liraglutide and Semaglutide Improves Obesity-Induced Muscle Atrophy via SIRT1 Pathway. Diabetes Metab Syndr Obes. 2023 Aug 15:16:2433-2446. doi: 10.2147/DMSO.S425642. eCollection 2023.

6. Uchiyama et al. Oral Semaglutide Induces Loss of Body Fat Mass Without Affecting Muscle Mass in Patients With Type 2 Diabetes. J Clin Med Res. 2023 Jul;15(7):377-383. doi: 10.14740/jocmr4987. Epub 2023 Jul 31.

7. Mettler et al., Increased Protein Intake Reduces Lean Body Mass Loss during Weight Loss in Athletes. Medicine & Science in Sports & Exercise 42(2):p 326-337, February 2010. DOI: 10.1249/MSS.0b013e3181b2ef8e

8. Locatelli et al. Incretin-Based Weight Loss Pharmacotherapy: Can Resistance Exercise Optimize Changes in Body Composition? Diabetes Care. 2024 Apr 30:dci230100. doi: 10.2337/dci23-0100.

9. Sergeant et al. A Review of the Effects of Glucagon-Like Peptide-1 Receptor Agonists and Sodium-Glucose Cotransporter 2 Inhibitors on Lean Body Mass in Humans. Endocrinol Metab (Seoul). 2019 Sep;34(3): 247-262. doi: 10.3803/EnM.2019.34.3.247.

10. Bikou et al. A systematic review of the effect of semaglutide on lean mass: insights from clinical trials. Expert Opin Pharmacother. 2024 Apr;25(5):611-619. doi: 10.1080/14656566.2024.2343092. Epub 2024 Apr 18.

11. Takahashi et al. Vitamin Intake and Loss of Muscle Mass in Older People with Type 2 Diabetes: A Prospective Study of the KAMOGAWA-DM Cohort. Nutrients. 2021 Jul 8;13(7):2335. doi: 10.3390/nu13072335

12. Nunn et al. Antibody blockade of activin type II receptors preserves skeletal muscle mass and enhances fat loss during GLP-1 receptor agonism. Mol Metab. 2024 Feb:80:101880. doi: 10.1016/j.molmet.2024.101880. Epub 2024 Jan 11.

13. Gurjar et al. Long-acting GLP-1 analog liraglutide ameliorates skeletal muscle atrophy in rodents. Metabolism. 2020 Feb:103:154044. doi: 10.1016/j.metabol.2019.154044. Epub 2019 Dec 5.

14. From online lecture on Medscape: https://www.medscape.org/viewarticle/1001688_4