GLP-1 receptor agonists and dual GLP-1/GIP agonists achieve clinically meaningful weight loss in transplant candidates, enabling many to cross BMI thresholds for surgical eligibility. However, current transplant data focus primarily on weight reduction, glycated hemoglobin levels, and graft function rather than comprehensive physiologic markers. This distinction between 'access response' (meeting BMI criteria) versus 'reserve response' (improved body composition, muscle strength, and cardiopulmonary fitness) represents a critical gap in transplant medicine. The difference matters enormously for surgical outcomes. Major organ transplantation demands robust physiologic reserve for surviving immunosuppression, rehabilitation, and long-term graft maintenance. Simply achieving a lower BMI through pharmaceutical intervention may not translate to better surgical tolerance or recovery capacity. The authors propose monitoring lean muscle mass, frailty scores, handgrip strength, gait speed, and nutritional adequacy alongside weight changes. This framework challenges the transplant field's reliance on BMI cutoffs as proxies for surgical readiness. While incretin therapies show promise as bridges to transplantation, their success should be measured by comprehensive physiologic improvements, not just scale numbers.