Surgery can be effective tool in effort to lose weight

Rabbi Nat Ezray’s decades of struggle with weight began early. He joined Weight Watchers in the fifth grade. In the 30 years to come, he would lose and gain weight several times over, each time gaining a bit more until his 5-foot-6-inch frame carried 280 pounds.

“I felt hostage to it,” Ezray said, “and powerless in the face of it, even though I did diet after diet.”

Before undergoing gastric bypass surgery, Rabbi Nat Ezray carried as much as 280 lbs on his 5-foot-6-inch frame. “I felt hostage to it ... even though I did diet after diet,” he said. Video: Stanford Hospital & Clinics

He had tried to keep fit, jogging and playing racquetball. But his body was breaking down. He developed sleeping problems, high blood pressure, high cholesterol, acid reflux and diabetes–all issues very common in people who are seriously overweight. Still, while he would often lose the extra pounds, he would regain them.

In 2002, when he was just 42, he had a heart attack. His cardiologist told him, “You’re one of the brightest, most motivated people I’ve met, but I just don’t think you can lose this weight on your own.”

Ezray fit a profile shared by many. His face-off with weight was years long and, in spite of his best efforts, the weight he lost always came back. In recent years, as the rabbi of Congregation Beth Jacob, Ezray was managing a demanding schedule that wholly filled his days.

Still, Ezray tried, even after doctors inserted stents in his heart to open up blocked arteries. For a second time, he tried a liquid diet. He continued to see a counselor to talk about the role of food in his emotional life. And, finally, he investigated a suggestion his cardiologist had made years earlier—to have his gastrointestinal system surgically altered.

A physician friend recommended Ezray see John Morton, MD, director of bariatric surgery at Stanford Hospital & Clinics. Bariatrics, from a Greek word meaning weight, refers to the study, prevention and treatment of obesity. Morton’s treatment and research focus also includes minimally invasive surgery as well as evidence-based studies on surgical outcomes. His interest in weight and its health impacts dates back to high school, when he saw what many pounds of extra weight did to his best friend.

Not a quick fix

What Morton tells anyone interested in gastric surgery is that it is “no magic bullet… We can’t operate our way out of the obesity problem. It’s part and parcel of a lifestyle change. These surgeries are simply tools.” At Stanford, Morton said, “We don’t want to shoehorn anybody into a specific operation. You have to take into consideration the risks and benefits.”

When prospective patients come to Stanford to discuss bariatric surgery, they face a set of hurdles designed to test their motivation and discipline. They must attend an information seminar to learn about the surgery and the most successful methods to reach and maintain their weight loss goals. They must be evaluated by a psychologist and a nutritionist. They are also required to lose 10 percent of their weight before surgery.

Norbert von der Groebenbariatric

Ezray has lost some 70 pounds since the operation two years ago.

Stanford also follows the bariatric surgery guidelines established by the U.S. National Institutes of Health. That organization recommends surgery for people with a body mass index of 40 or more and for people with a BMI of 35 who also have serious health issues related to their weight, such as type-2 diabetes and high blood pressure.

BMI is a way of comparing height to weight. Clinical guidelines set out a BMI of 25 to 29 as overweight. Anything over that is considered obesity. Someone who is 5 feet 4 inches tall and weighs 204 pounds (BMI 35) will be a candidate for surgery if those obesity-related health issues are present.

Weight is not the only measure. It matters where it is. Abdominal fat has the most negative impact on health.

Ezray was also concerned about the risks of surgery. “I did all the research,” he said. He learned that Stanford’s bariatric surgery program is the only one in northern California recognized by the American College of Surgeons as a Level 1A Center for Excellence. Morton has performed more than 1,000 bariatric surgeries, with no serious post-surgical complications. Those complications can often happen, Morton told Ezray, “because patients haven’t been properly screened or prepared.”

Morton has also made it a priority to keep his clinical team together, to build the collective experience.

“The more cases you do, the better you are,” he said. “We have also researched where problems can occur and created protocols to prevent those. For us, patient safety is first.”

Choices to be made

One of the most frequently performed bariatric surgeries, the gastric bypass, first appeared in the mid-1960s. Now surgeons, staple off all but a small portion of the stomach and connect that directly to the intestines. That reduces caloric absorption and reduces exposure to hormones that physicians suspect influences appetite and blood sugar.

The bypass has shown to have the most immediate effect. Other approaches reduce the stomach’s size but do not involve the intestine, and are reversible. The weight loss associated with those surgeries is less.

About 70 percent of the bariatric surgeries at Stanford are the gastric bypass. After considering his options, Ezray chose that one and had the procedure two years ago. Even before the surgery, however, he had examined what his prior stumbling blocks were and figured out how to address them. One thing he did, he said, was to approach food mindfully, “to sit down when I eat and really value it. I loved that the surgery would slow me down and I would appreciate taste and texture.”

He would also make his exercise time as high a priority as possible, “part of a true devotion to health being first on my list,” he said.

He was home about four days after the surgery and recovered quickly, he said. His high blood pressure and cholesterol levels dropped so he didn’t need to take as much medication. He no longer needs diabetes medication. The positive impact on type-2 diabetes of surgery-assisted weight loss was first documented in the 1990s.

A life renewed

Stanford has a comprehensive after-care program. After surgery, patients are seen five times for check-ups in their first year, and then annually. The bariatric surgery program also organizes a support group for patients to see them through the changes in their lives.

Ezray had lost some 70 pounds and is down to 190 pounds; he wants to lose a few more. Otherwise, he could not be happier. The people who helped him at Stanford “were very kind and compassionate,” he said.

He is still not eating certain foods: no red meat or ice cream or alcohol, and almost no processed foods. He rises early several days a week to stretch and do 45 minutes on his elliptical exercise machine; frequently he adds weight training to develop his core muscles.

And now, as he talks with people in his congregation, they’ll often be walking with him. “I had a lot of energy before, but boy, do I have a lot of energy now!” Ezray said. “I didn’t realize how much energy it took to fight the daily fight with food.”

His congregation gave him great support when he told them about his surgery, he said. “I didn’t realize how much anxiety people felt about my health.”

And he has realized something else. “I don’t have to hold on to the fear that I was going to die young,” he said. “I feel like I’ve been given a second chance.”

Sara Wykes is a writer for the Stanford Hospital & Clinics communications office.

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