“The concerns you have and had when we met earlier this year to get you started are multifaceted and multidimensional. So in my typical blunt but honest- and knowledgeable – manner, let me address them here in some detail.

First, you are a post-menopausal female. The immediate loss of muscle mass with the decline of estrogen, in a recent study, showed that the loss of muscle mass cannot be substantially altered with a weight training program when compared to pre-menopausal women. Some studies have shown, in 2-3/wk for 12-24 wks, that post-menopausal women generally gain 1-2.5 kg of muscle which is 2.2 -5.5 lbs. Had we measured you – which would have required a skinfold body fat test or even a scale that I have – we would have had a baseline but…..

Second, you had years of sedentary living contributing to body fat gain that possibly contributed to the stroke but definitely inspired you to use a GLP-1 drug to lose weight. During those years, as you gained weight/fat, you did gain muscle, especially in the legs and hips to hold you up, but the quality of that muscle was deficient vs in that of a healthy, young person. Think of steak – lean vs marbled. With weight gain, esp after menopause, you were marbled, with muscle that had what’s called ‘fatty infiltration’: there but not real high quality. Any body fat assessment would have shown you, even after substantial weight loss, to have even less muscle than before you took the meds. Why? Because your legs and hips didn’t need it to hold up a larger body. So…

Add to all these physiological realities the loss of weight due to the meds. Up to  40% -50% of rapid weight loss, by drugs or diet, is lean muscle mass. What did you lose from start to now? If 40 lbs, consider the prospect that 16-20 of those pounds were muscle.

Then let’s talk the stroke. I don’t remember the details but during the time you were laid up, and from the time you started pt to get some function back, you were losing muscle mass. Even now, while you can ambulate, you can’t fully push off with the legs to move fast or up stairs. That’s not only neurological; it’s neuromuscular.

All this to say, you came here with a severe deficit and to gain muscle as a female, as an older female, as a person who had lost muscle from life, disease, and medications, is a long, slow, and nominal prospect. Furthermore, which would you prefer – more muscle mass or better gait and function? To build muscle, you need to work the shit out of the lower body. Would you safely get to your car after a leg-burning exercise routine? Because you’re not able to build substantial muscle mass in the upper body/arms to notice an increase in lean mass but you can readily build strength via neurological reconditioning – the way most women at any age gain muscle strength unless you’re built solid as an athlete. Are you able to do heavy squats, lunges, step ups, dead lifts, even leg presses to build muscle…safely? Not just orthopedically but cerebrovascularly?

I’m including a link to an article that might help you appreciate the challenges you face in this regard. Note page 2946, column titled Hypertrophy. This lists credible studies on this issue. As you can see, in some strength programs women gained as little as 0.1 kg whereas others gained, on average, 4 kg. All the studies were pretty small so this type of meta-analysis gives more credible results. Note on the bottom of the mean change in hypertrophy among all studies is 4.8%. That’s pretty low especially starting from a low baseline of older women’s muscle mass.

Finally, reading the Discussion, you can see that overall the message is bleak:

These fndings may provide explanation to our main results, since the included protocols had similar intensities and volume (being that the majority of studies were performing between 8 and 12 repetitions with an intensity of around 60% of 1RM). Another meta-analysis [59] which evaluated the training frequency of RT programs on gains in muscular strength has concluded that increased frequency is linked to increases in strength. However, when age groups were analyzed, only young adults seemed to beneft from increased RT frequency, while older adults did not. However, the results of this latter study only took into account measures of strength and not muscle mass. Nevertheless, evidence of a dose–response relationships in the elderly (taking into account both male and female) exists, suggesting that 2 sessions per week, performing 2 to 3 sets of 8 exercises, is effective in promoting strength and to modify muscle morphology [60]. The suggested protocol almost overlaps the mean reported data present in Table 1, which could explain the homogeneity of the results regarding lean body mass improvements observed across the retrieved studies.

It is important to note that increased muscle mass does not necessarily imply a causal relation with strength improvements [61] since the mechanisms responsible for strength development and muscle hypertrophy are diferent in nature [62, 63]. For example strength improvements as a result of increased neural drive are observed well before muscle hypertrophy as the result of increased motor unit fring rate or agonist–antagonist co-activation [62], while muscle hypertrophy is mainly stimulated by metabolic stress and mechanical tension which then activate intracellular pathways inducing muscle growth[63]. Although not a primary outcome of this review, as reported in Table 2, increases in strength were also observed for bench press, chest press, leg press and knee extension exercises. The small efects highlighted by the meta-analytic synthesis, seem to be in line with the most recent scientifc evidence, since as a consequence of aging, increased anabolic resistance, diminished muscle regeneration, impaired muscle activation and a reduction of the number of motor units are frequently observed [64]. However, precisely for these reasons it is important to engage postmenopausal and elderly women in RT programs, in order to improve muscle mass and strength, to reduce the risk of injury, and improve quality of life during the aging process [65].”

So you exercise to function better, maintain as much muscle as possible in the face of aging and weight loss, and put your exercise energies to work on being healthier, fitter, stronger, but not at the expense of injury, stroke, or death.

Whew…