GLP-1 is not the key mediator of the health benefits of metabolic surgery

The identification of key factors accounting for the health benefits of metabolic surgery is a research priority, as it may help design a medical therapy mimicking this powerful surgical tool. Because of its well-known effects on glucose metabolism and appetite, amongst the several proposed factors, glucagon-like peptide-1 (GLP-1) has been the most extensively evaluated. A large number of association studies have been reported suggesting that the striking changes in GLP-1 after Roux-en-Y gastric bypass and sleeve gastrectomy play a role in the metabolic benefits associated with these surgical techniques. In this review article, we challenge this view. Studies in humans using the specific GLP-1 receptor antagonist exendin 9-39 or the nonspecific inhibitor of GLP-1 secretion octreotide, as well as data derived from genetically engineered mouse models, provide strong evidence that although GLP-1 retains its physiologic role, it is not the cause of the amelioration of glucose tolerance or sustained weight loss after Roux-en-Y gastric bypass or sleeve gastrectomy. It is unlikely that “medical metabolic surgery” will be based on a single component. Importantly, the scrutiny of GLP-1 as candidate has taught us studies beyond association are required to thoroughly assess whether any of the additionally proposed mediators should be part of the cocktail of factors that could medically mimic metabolic surgery.