If you sat in on one of my follow-up visits, you might be surprised how far down the list the conversation about weight loss actually falls.
My assistant weighs every patient and records it before I ever walk into the room, so the number is always there in the chart. But after 25 years of these conversations, I've learned that spending much of the visit talking about that number is one of the least useful ways I can spend the time. It tells me almost nothing about whether a patient is actually getting healthier.
What the scale can't tell you
A patient can step on a scale and see a number go down and be in worse metabolic shape than they were three months earlier. I've watched it happen more times than I can count. They lost weight — but they lost it as muscle, and what's left behind is a body with a slower metabolism, less strength, and a higher fat percentage than before they started, even though the total number is lower.
I tell patients some version of the same thing almost every visit: I would rather you be a few pounds heavier and have that weight be muscle, than a few pounds lighter and have lost it from the tissue that's actually protecting your metabolic health.
That sentence usually gets a surprised look the first time. People come in trained to think lighter is always better. It isn't. Lighter-but-less-muscle is a worse outcome than heavier-but-preserved-muscle, almost every time I've seen it play out over the long term.
Why I send patients for DEXA scans between visits
The scale gives you one number. A DEXA scan gives you the truth underneath it — how much of your body is fat, how much is lean mass, and how that ratio is shifting over time. It's the difference between knowing the score of the game and actually watching the game.
I instruct my follow-up patients to get DEXA scans between visits precisely because the scale can hide the thing I actually care about. Two patients can lose the same ten pounds and walk into my office in completely different metabolic positions. Without a DEXA scan, I'm guessing. With one, I'm not.
This isn't about chasing a perfect number on a body composition report. It's about having real information instead of a proxy that too often points in the wrong direction.
What actually moves down my priority list, and what moves up
When a follow-up patient sits down, here's roughly the order of what I'm actually tracking:
- How is their energy, strength, and function changing
- What their body composition trend looks like, not just their total weight
- Whether they're preserving or losing muscle through the process
- How they're doing with the habits that protect lean mass — protein intake, resistance training
- And, further down the list than most people expect: the number on the scale
That ordering isn't arbitrary. It reflects what I've actually seen determine whether a patient stays healthy five and ten years out, versus what just looks good on a chart in the short term.
The habit I'd want every patient to build
If you're in any kind of weight loss process — surgical, medication-based, or otherwise — the scale is going to tempt you to treat it as the scoreboard. I'd ask you to resist that.
Ask what's happening underneath the number. Ask your provider about body composition tracking, not just weight tracking. The scale will tell you a story. It's usually not the whole story, and sometimes it's not even the right one.
Curious what a DEXA-informed approach to weight loss looks like in practice? [Reach out / subscribe / etc. — placeholder for your CTA.]