Treating, Masking, or Mismeasuring? A Measurement-First Reframing of GLP-1 Receptor Agonists Across the Eating-Disorder Spectrum

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and the dual GIP/GLP-1 co-agonist tirzepatide are increasingly prescribed for obesity and type 2 diabetes in populations enriched for binge-spectrum eating pathology. A recurring controversy asks whether these agents treat eating pathology or merely mask it. This critical narrative review argues that, posed as a simple binary, the question is under-specified, and reframes it around three problems. The central is a measurement problem: several intended effects of GLP-1 RAs are scored as improvement by eating-disorder instruments, creating a diagnostic blind spot. In the one disorder where a weight-acting drug has been tested against a placebo, efficacy on weight coincided with no effect on the psychological core—the dissociation that confounds measurement during GLP-1 RA therapy. The second is a phenotype problem: because BED subtypes already moderate response to drug versus psychological treatment, an agent acting on appetite and reward should not act uniformly, though this remains a hypothesis. The third concerns the post-discontinuation trajectory, and a therapy–harm asymmetry emerges across the spectrum. A factorial, phenotype-stratified trial with disorder-core endpoints and drug-free follow-up could resolve these questions; meanwhile, prudent practice combines uncontaminated pre-treatment screening, monitoring not reliant on confounded self-report, discontinuation planning, and integration with psychological care.