胖的相反不是瘦-重度肥胖者減重暨代謝手術後之身體意象研究

Abstract

有鑑於重度肥胖者的外科減重手術恢復歷程有其特殊性（擔心復胖、急速瘦身的皮膚鬆弛、胃食道逆流、向旁人解釋外科減重經驗）、矛盾性（瘦下來雖變得健康卻又不適應瘦身後的自我、永無止境的身體意象追逐與失衡），本研究旨在探討因手術而面臨重大體態改變的重度肥胖者的術後經驗，以半結構深入訪談六位成人病人，並以反思性主題分析法探究其減重經驗以及身體意象看法如何的交互作用影響個人手術後恢復之歷程。 研究結果發現：六位受訪者主觀上在經歷縮胃手術後的恢復歷程對身體意象知覺包含下列主題：（一）一體兩面的矛盾性：面對手術後的生活改變與適應受到個人對此經驗的解讀影響，除了光鮮亮麗之外亦有哀悼、失落、心酸的一面；（二）來來回回的波動性：手術恢復歷程的情緒調適方式與外在環境交互作用影響減重路徑，恢復歷程並非直線性的過程，個體如何應用個人資源調節情緒轉化困境相當重要；（三）個體與外在系統互動的脈絡性：個人受家庭經驗、職場經驗、同儕經驗、性別經驗、來自社會對於肥胖的歧視以及對外科減重的偏見等建構起自我的瘦身過程的身體意象；瘦身過程中資源的取得、同儕陪伴、家人支持、宗教靈性的支持將有益於術後的恢復，並全面性地影響工作效能提升、社交壓力減輕、自尊提升、生活品質改善、原有疾病的好轉；（四）朝向健康與減重目標的堅持性：韌力經驗藉危機與轉機增進個人自我決定、提升動機、增加困難忍受力；減重手術不單是一時短時間的改變與更需要長時間的堅持與努力。 根據受訪者內容對此一恢復歷程的助人者建議為：（一）應整體性地考量以及尊重肥胖者的現象場，促進個人保護因子以發揮有助於促進復原進程，面對憂鬱、焦慮、身體意象、人格特質、人際相處、飲食衝動控制，避免以專業姿態再製肥胖者在社會中所遭遇的壓迫；（二）對於復胖者的態度應維護其尊嚴並維持良好醫病關係以助於個體整體的恢復（三）鼓勵個體善用各方資源（醫療、人際、社會、心理、靈性），而對手術本身賦予意義者，較能因應隨著手術連帶而來的次級失落與次級獲益。（四）鼓勵保持個體積極的態度，有助於促發機會帶來正向的影響，包含面對皮膚鬆弛、身體意象的轉變、手術後與親朋好友互動、自我概念的轉換與失落的調適；（五）手術前的決策時間與決策之完整性，能給予足夠的資訊與案例以供參考，並能理解恢復歷程的軸度發展。 根據上述結果，針對醫療人員與助人工作者及有意後續研究者，提出相關的建議以供參考。

The post bariatric-surgery recovery process for people with severe obesity demonstrates specificity and ambivalence. Participants’ weight will decrease, but they also face problems regarding regaining weight, stretched skin, and weight stagnation periods. Furthermore, patients need to understand the surgical process, and be able to explain their decision for undergoing surgical weight loss to those who might be quick to judge them. This study investigated the changes in body image and the bariatric surgery recovery experiences of people with obesity that underwent major physical appearance changes. In-depth, semi-structured interviews over four years were conducted with sixpatients who received bariatric surgery, and a reflexive thematic analysis was performed to explore their weight loss experiences and measure how their perception of their body image influenced their recovery process post-surgery. All six participants mentioned the following four themes: (A) Patients faced quandaries regarding the results of the surgery as well as worries about their expectations not being met. These quandaries included, pending side- effects, weight loss being too rapid to adjust to their new body image, and health concerns. The complexity of individuals with obesity should be comprehensively considered and respected. The promotion of personal protective factors is beneficial to the recovery process. In their daily lives they face: depression, anxiety, body-image problems, challenging personality traits, and dietary impulse control difficulties. They should not be stigmatized in the same way when in a professional setting. (B) Causes of fluctuating weight: The interaction between emotional adjustment and their external environment influenced the weight-loss path. The weight-loss path is like a roller-coaster. The recovery process is nonlinear, unpredictable, and sometimes they need to take risks and keep strong whilst enduring lots of different criticisms and concerns. For individuals who regain weight, their dignity should be preserved. Favorable doctor–patient relationships should be maintained to assist the overall recovery of the patients. (C) Interactions with external systems: Access to individual health and weight loss resources, peer companionship, family support, and religious support were beneficial to postoperative recovery. In addition, surgery comprehensively improved work efficiency, reduced social pressure, boosted self-esteem, upgraded the quality of life, and ameliorated existing diseases for individuals with obesity. Individuals who are encouraged to use different resources and give meaning to their surgery themselves are more likely to cope with secondary loss and secondary gain following surgery. (D) Persistently moving towards goals: The experience required tenacity and improved personal determination, enhanced motivation, and increased endurance to deal with difficulties during crises and opportunities. Positive attitudes should be encouraged, because they help to promote opportunities that bring desired results. These opportunities include facing stretched skin, transformation of body image, postoperative interaction with family and friends, transition in self-concepts, and adjustment for loss. Whilst there is a physical difference in appearance in patients as a result of the surgery, the psychological change may take longer. It takes time for their appetite to adjust and for patients to stop fearing overeating or using eating to fill up a void. For being overweight is intertwined with the whole identity of a patient. This study shows the importance of a continuous psychological evaluation in patients and the need for appropriate interventions even after weight loss.