A 45-member modified Delphi consensus: screen for eating disorders before GLP-1 receptor agonist prescribing, and generally avoid these agents in active anorexia and bulimia nervosa

The consensus recommends assessing all individuals for a current or past eating disorder before initiating GLP-1 receptor agonists, using a brief 3-5 question screening tool, implemented in settings where these agents are prescribed, including primary care. No guidelines or clear recommendations previously existed for this intersection of GLP-1 receptor agonists and eating disorders; this study is the first to establish screening as a routine pre-prescribing step through structured consensus. The main screening recommendation reached 94.7% consensus, with the brief-tool and primary-care sub-recommendations at 89.5% and 94.7%; those who disagreed cited lack of equitable access to follow-up for positive screens and the time burden in primary care.

The consensus states that GLP-1 receptor agonists should generally be avoided in individuals with active eating disorders, particularly anorexia nervosa, atypical anorexia nervosa and bulimia nervosa with marked dietary restraint and/or significant weight suppression, and that clinicians should proceed cautiously in those with a past history of these disorders. It converts risk signals previously scattered across case reports and population data into an actionable, risk-aware prescribing recommendation, and notes that obesity does not preclude an eating disorder diagnosis. This item reached 100% consensus; experts emphasized it should not be read as an absolute contraindication across all eating disorder presentations and should be applied with individualized assessment of symptom profile, illness severity, nutritional status and treatment context.

The consensus recommends monitoring all individuals receiving GLP-1 receptor agonists for physical and psychological signs of an eating disorder, tailoring monitoring intensity to baseline screening results and emerging risks such as extreme appetite loss, and tracking variables including eating disorder psychopathology, weight loss rate, nutrition, hunger/satiety, vital signs, mood and quality of life. It turns monitoring from a general caution into a stratified variable list, and proposes signals such as weight loss beyond what is expected for a given agent, typically more than 1-2 pounds per week, as possible indicators of developing eating disorder symptoms. The main monitoring recommendation reached 84.2% consensus, the stratified-monitoring sub-recommendation 97.4% and the variable list 86.8%; 15.8% disagreed, citing insufficient research on new-onset eating disorder prevalence and added prescriber burden.

The consensus sets research priorities: epidemiological studies comparing users with non-users, regulatory studies and policies to enhance prescribing safety, and clinical trials of GLP-1 receptor agonists in binge eating disorder assessing safety, efficacy and psychological outcomes. It translates the evidence gaps behind the clinical recommendations into concrete designs, including longitudinal cohorts, case-control studies, electronic medical record reviews, validation of brief screening tools, a national prescription register, and binge eating disorder trial outcomes such as food noise and maladaptive dietary restriction. The epidemiology and binge eating disorder trial recommendations both reached 100% consensus and the regulatory recommendation 91.9%; the national register sub-recommendation had the lowest consensus at 73.7%, with concerns about feasibility, privacy and data quality.

The consensus addresses individuals considered for or receiving GLP-1 receptor agonists for obesity or other metabolic indications, across settings where these agents are prescribed, particularly primary care and remote prescribing. For clinicians it offers an operational framework of pre-treatment screening, risk-stratified monitoring, standardized educational materials and concurrent evidence-based psychotherapy, and states that these agents should generally be avoided in active anorexia nervosa, atypical anorexia nervosa and bulimia nervosa with marked dietary restraint and/or significant weight suppression. For researchers it sets executable priorities: longitudinal cohorts, case-control studies and electronic medical record reviews comparing users with non-users, validation of brief screening tools in this population, a national prescription and outcome register, and binge eating disorder trials incorporating food noise, maladaptive dietary restriction, physiological and laboratory measures. The authors note the recommendations focus on GLP-1-based medications, and that novel non-GLP-1 weight-loss compounds will need separate study.

The consensus rests on expert opinion rather than new empirical data; the authors note the panel was not representative of all experts, participants had varying levels of involvement across stages, and no standardized Delphi consensus threshold exists, so the 70% threshold may have affected the strength of agreement. Existing literature on GLP-1 receptor agonist-related eating disorder risk is largely case reports, and the population-level signal comes from a retrospective cohort study indicating that individuals with obesity and a prior mental health diagnosis were twice as likely to develop an eating disorder within two years of starting a GLP-1 receptor agonist, with the highest incidence for anorexia nervosa, which the authors call preliminary. Validation of screening tools in this population, operationalizing eating disorder risk criteria, and distinguishing therapeutic appetite suppression from emergent eating disorder symptoms remain open questions. The recommendations may change as new evidence emerges, and the role of non-GLP-1 weight-loss compounds is still to be examined.