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Dear Coffey - I’m thinking about having weight loss surgery, but I’m not too keen on living the rest of my life with extra, loose skin. What can I do to keep that from happening? Sincerely, Cecelia in CA Hey there, Cecelia - Congratulations on taking the reigns and exploring your options. I hope you find a good, honest surgeon who can help you figure out if weight loss surgery might be a strong choice for you. As with everything concerning our bodies, the topic of loose skin generates a whole lot of hype. The truth is there are exactly six things you can do to minimize excess, loose skin after weight loss - whether or not you have WLS. The first three are preventative, and apply to the period before weight is lost. The last three apply to the post-weight loss period. First, prevention. 1- Don’t wait. Ask any aesthetician or midwife and they’ll tell you: the younger we are, the more our skin can bounce back from a stretch. If you would be more comfortable weighing less and you’re afraid of having excess skin, the younger you are when you lose weight, the better. But don’t waste precious energy wishing you had lost weight in your early 20s. You have today, and today is where your power is. If there are choices you want to make in service to your health and happiness (whether or not they would result in weight loss) today is the day to make them. 2- Avoid the loss/gain cycle. Imagine how a once-inflated balloon looks and feels after you let the air out. Now imagine the same balloon after 4, 6, or 10 deflations. Much like the balloon, the more times we lose weight and gain it back, the looser our skin gets. Again, now is not the time to berate yourself for all those “successful” stints in Weight Watchers that ended with you gaining the weight back and then some - it happens to all of us, myself included. Today is the day to get yourself stronger, more sustainable tools - tools that support long-term weight loss and minimize the probability of gaining it back. These tools exist, and you can get an introduction to them in my free online workshop, Why We Sabotage Ourselves (with Food) (and What We Can Do About It). 3- Keep weight gain to a minimum. The heavier we get, the more our skin stretches, and the less likely it is to bounce back after we lose weight. You can’t do anything now about your weight history. Feeling badly about it or judging yourself for it will only make you want to numb out (if you’re anything like me, probably with food). If you are reading this at the heaviest weight you’ve ever been, then this is the heaviest you ever need to be. If weight loss is something you want to do for you, your skin will thank you for making caring choices toward that goal starting now. That covers the things you can do to minimize excess skin before you lose weight. Now let’s look at what you can do once the weight is gone. 4- Build muscle. Contrary to popular belief, strength training does not “tone” or “tighten” the skin. Skin elasticity has nothing - NOTHING - to do with exercise. But strength training gives loose skin something hot and firm to lie over - namely biceps, triceps, quads and abdominal muscles. Lots of folks - especially women - shy away from strength-training, or think it’s better to use smaller weights and do more reps. This is a myth that keeps women from ever seeing the results they want and deserve. Assuming you’re being safe and reasonable, the heavier and harder and you train, the more muscle you build, and the better you’re likely to feel about how your skin looks. 5- Have surgery. Even if you’re young, even if you lose weight just once, and even if you strength train like a boss, there’s still a limit to the impact we can have on excess skin after weight-loss. Some consider having skin removal surgery. If this is something you’re thinking about, be warned: Words like “lift,” “nip,” and “tuck” are misleading. Skin removal surgery is no joke. I know that because I had it. The surgery hurts like hell, and can put you out of commision for weeks or months. Also, the medication usually prescribed to manage the post-op pain is highly addictive. If you’ve got a compulsive / addictive relationship to food, you’re way more likely to get hooked on painkillers than someone who doesn’t struggle with the compulsive overeating. 6- Love yourself. Loving your body isn’t going to tighten, lift, or shape your skin after you lose weight, but it can minimize the negative impact that living with loose skin might have on you otherwise. Love is action. Love means making consistently caring choices because you deserve to be cared for, no matter what you weigh or how your body looks. If you struggle to make consistently caring choices, whether you’re pre-op, post-op, or no-op, you’re not alone, and there are practical, usable tools to help you get there. Where will you fall on the loose skin spectrum? You can’t really know unless and until you lose weight. I yo-yo dieted for 10+ years, maxing out at 307 pounds. I had Roux-en Y in my mid-twenties and lost over half my body weight. Eventually I started strength training and became a personal fitness trainer. Two years later, I opted to have abdominoplasty (aka a tummy tuck), because the excess skin on my stomach was beyond anything that could be mediated or improved with exercise. The surgery hurt like a son-of-a-b***h and had me out of work for a month. I’ve made peace with the loose skin on the rest of my body. The muscle I’ve built with regular strength training helps a lot. So has treating my body with care one choice at a time for over a decade. It’s given me self-respect and peace that make my batwings an insignificant afterthought. Loose skin post-weight loss is inevitable for those of us who are or have been obese. But if you would be healthier or more comfortable in your body weighing less, don’t let the fear of loose skin keep you from doing what you need to do to get there. Our bodies will never look like other people’s bodies, and that’s OK. Our bodies tell our stories, and our stories are our strength. All good things, Kelly Coffey PS: Whether or not you decide to have surgery - and even if you've already had it by the time you read this - you can use the tool that's helped me to turn my life and my health around. To learn it, click here to grab a seat in my free online workshop, "Why We Sabotage Ourselves (with Food) (and What We Can Do About It)"

I have Aetna and I'm in Missouri and my policy said no net weight gain buuuuut at my very first weigh in my weight was recorded wrong they had me 35 lbs lighter then I actually was so by the end of my 6 months it looked like I gained 35lbs but it didn't get caught til after my documents was submitted for approval so my patient advocate was in the process of getting ready for an appeal because we thought it was gone be denied but I was approved in less then 24 hrs and my surgery date is February 10!!!

You can't have a net gain, so that would mean you can weigh more than you did in your initial weigh in after the three months are done. If you started in November, then by February you need to be the same or less weight. (I'm guessing based on what you wrote) How has your eating been? Are you keeping carbs low, not drinking calories?? I never bought into the period weight gain thing. Sure my weight fluctuates, but I've never seen that fluctuation around my period.

Hello My name is Robin I am interested in getting the gastric sleeve. I have lost weight on my own and have been successful. I have been on orlstat and metformin for almost two years and high blood pressure medicine for nine years. I have to go to the doctor every two months to check my weight. Before the holidays I lost a total of 54 lbs. during the holidays I gained 15. Went to my bariatric consultation and lost 5 lbs. To be honest I am really getting tired of taking pills and the roller coaster of weight loss and weight gain. My doctor said the rate I am going I will never meet my weight loss goal with just taking orlstat alone. He said having the surgery will make me lose faster. I have already made changes the way that I eat. So this should not be a problem. Just scared and nervous. I did the information seminar but have not met with the dietitian yet.

I understand your concern!! Speaking for myself, I was much bigger 5 years ago. 250lbs with a BMI of 40. I lost 80lbs and kept it off for 4 years. I quit smoking to be a better example for my kids 1.5 years ago and now I can't seem to lose the weight I gained when I quit which has put me back into the "obese" category. Having been through pretty substantial weightloss before, I'm fairly prepared for the changes I have to make. I have ZERO plans to drink sweet tea (which I don't like) or pizza. In prep for the changes I have given up sodas, most all sweets, and am transitioning back to healthier life style. This isn't a magic wand It's forced portion control and help with hunger hormones. I also am not doing this just to lose weight I have a degenerative disc in my back that has hurts regularly now that I have gained some weight back. I'm not sleeping well, and I actually deal with the hernia symptoms on a regular basis. When I lost the weight I had in the past I worked with a therapist to sort though the issues that had caused my weight gain originally. Thank you for your concern!! Sometimes tough love is needed I get that. But this is more than being thin for me.

I weigh myself once each morning when I get up. I record the weight. I use this to evaluate the effect of my diet on my continued weight loss. It is not a negative obsession. If my weight goes up or down, I do not panic. It just informs me that my current approach may need some fine tweeking. Weighing yourself daily can become negative if this obsession alters your mood. This habit can cause stress which can lead in-and-of-itself to some weight gain. If this is the case, avoid weighing yourself, throw the scale out and let them weigh you at your doctor appointments.

I weigh everyday to, but I know it is just a number and if it goes up that just tells me I have to watch what makes it to my plate. It really doesn't bother me that much. If it helps put the scale away for a while. I always weigh in the mornings and sometimes I will weigh in the evenings but I now know about how much the scale will go up durning the day and it doesn't make a difference in how I feel about myself. But if it bothers you, you need to get rid of it for a while as stress can/does cause weight gain!!

I had metatastic breast cancer back in 2012... I just got the bypass...being overweight and getting fatter by the day was worrying me....weight gain and obesity would cause it to reoccur and I have to lose this weight.I take anastrazole and lupron shots post breast cancer...now I am off metformin and ,chloresterol medication. Nosy relatives with too many damn opinions.Keep the em out of your business...tell them you have hiatal hernia...end of story...being overweight you just may have a hernia. Not being able to drink and eat at the same time? are you kidding me..,you will be drinking Water every second throughout the day. Being a big fatso is no fun and I am sick of being invisible...I am too good for that...I had to do something.Bypass is working...it is helping me...take control.

I did it!!! ​I reached my goal weight this morning!! I can't tell you how successful I feel!! About my journey; started in 2007 at 300 pounds and had lapband surgically placed on June 27. I actually gained 20 pounds during my pre-op phase(so embarrassed to say this). Lost down to 260 pounds and that's where it ended. Vomited a lot, couldn't eat many healthy foods resorted to eating slider foods. Fast forward to 2012; I lost my job, moved to a new city, life was on a downward spiral. Then something happened; I was somehow guided to this site! Life changing experience and how grateful I am. Within 6 weeks of finding this site I found a surgeon in Tijuana Mexico and had gastric sleeve surgery on September 10, 2012. The best thing I could have done at the time. Weight loss came off fairly quickly but I also learned very soon out that I could eat anything, fat, sugar, sliders and the like. I know surgery is a tool but at the time I didn't realize I needed a greater tool. I didn't initially go with the gastric bypass because I was afraid of the intestinal re-routing. So weight gain started; Christmas came and I thought I could handle eating a little of this and a little of that; I was wrong. So 2015 and I want to reach my goal weight; 160 pounds. I want to live the rest of my days at a normal healthy weight. Through Bariatric Pal I found my amazing surgeon, Dr Zavalza and had my gastric bypass on September 4, 2015 at 203.6 pounds(started pre-op at 212.7). Here I am at my goal weight, 160 pounds, down 52.7 this time around. I DID IT!! The gastric bypass for me if different from the sleeve. I have really good restriction, I really don't have cravings, I now have an aversion to sugar, I can't eat anything and I have no issues with the re-routing part my labs are good and I take all of my required Vitamins daily. Here are things that I do differently to make me a huge success this time around; I know that there are foods that are trigger foods for me that I should never eat again so I have found healthy substitutes for them that I enjoy. I don't eat bread, Pasta or rice(I gave up a long time ago) but again if I chose have found alternatives that I can have. I also enjoy fruits(limited), vegetables and healthy carbs(squashes, sweet potato) and of course Protein. I track all of my food intake and drink all of my Water. I also have found exercise that I enjoy doing and have made it a daily routine. I love myself and all of my size 6 clothing that I look fantastic in! Now on to maintenance; I will keep doing what I am doing and enjoy what life brings!!

What's everyone planning on doing for staying active? I know we have to walk, walk, walk. But anything else in addition to that? I have always been a "thick" girl but my horrible weight gain started after I dislocated my knee cap at the gym in 2012. No bueno. It was on a Saturday so I was rushed to the ER but the military didn't understand how serious it was so they delayed my MRI until that Wednesday. When my doctor got the results he called me and told me he didn't realize it was that bad and had me off my knee for several weeks. It was too late for surgery and I had to do conservative rehab. Since then I have gained 70lbs. Granted, I had a baby 16 months ago but still...that's a lot of weight. So I am very eager to get back to working out. I plan on starting out walking only for the first two weeks. Doctors orders. And then adding light weights for the next two weeks after that. I bought a 4lb bar - very light, I know, but I am going to kill my arms with reps each time I use it. Then I don't know what I'm going to do. I love Zumba but the class I go to is really hard core. I am a licensed instructor myself (not practicing) so I know hundreds of routines. I might just start doing that at home for a month to get back into it. I also have a membership at Orangetheory fitness. Anyone heard of it? I put my membership on hold until March...that's also pretty hardcore - HIIT on the treadmill for 30 minutes plus 30 minutes of weight training. If I stuck with that I would probably go 3 times a week at first. I've recently seen ads on tv for Shaun T's new dvd set - Cize - which is another dance program (I love dancing, can you tell? I was a cheerleader in high school and on the dance team in undergrad). I don't know anyone who's tried it. One appealing thing about it is that it uses actual hit songs that are popular right now which I find very motivating! But anyways, what are some of y'alls plans for working out post-op?

Hey i havent been to my dr in almost a year because i lost my job and am now workiny under the table so i have no isnurance. Ive been trying to wing it. I had my surgery 2 years ago and lost about 90 lbs but have had some weight gains. Im always trying to eat healthy butnim confuses now how much Protein i should consume. Like shoulf a Protein shake be a meal at this point or just extra protein? Also if im working out how much protein should i consume? Any suggestions r greatly appreciated.

Thanks Babbs ..i know those sweets were part of my bad eating habits before i got the sleeve and contribute to some of my weight gain.

I am a 49 year old man living on Cape Cod with my wife and our two children. My weight over the decades has slowly crept up and hitting an all time high of 287pounds. I have had 9 knee surgeries on my right knee since i was 17yo. When the knee hurts and buckles the weight scrambles on.The more the weight the more the knee gives out. Then came the sleep apnea, Then the Blood pressure pills. Then the cholesterol meds. This path was leading to early death or total knee replacement before 50 and the weight gain roller ride. I am actively in the last phases of all the preop requirements and have a surgery date for early March. I believe this is the best course of action for my life and achieving my goal to live to 100. The alternative is to dire. I would like to read more on the first few days after surgery and how quickly one can return to work and family life.I not looking for horror stories. Thank you John

I'm staying on top of my meds now. I have oxycodone. It's almost not my stomach as much as my back. I have chronic back pain and haven't taken my normal meds since Weds. I took all my pain meds and was knocked out for maybe an hour. Just so nervous about all of this. Managing these things in the next 3 weeks. I got children's Tylenol but I think it's too sweet and made me sick last night. So I am actually crushing my Tylenol. Gross but the sweet sickly taste isn't making me sick. I got inspired because I am tired of my chronic pain. I use to be an athlete and this weight gain started when I tore my ACL and broke my leg playing co-Ed football. I loved volleyball and softball. I want to inspire my kids to be physically the best they can. Especially my daughter. I want to be around a long time for them and enjoy hiking and sports more. Thanks everyone for your support. I'll probably be knocked out here in about 5 mins. ????

I was banded 11/9/15. I had lost 25 lbs presurg and then between fills 1 and 2, I gained back 6. Fill 2 was three days ago and I am down 7. Bad bad decisions over the holidays made me pick that stupid 6 lbs back up. I was so frustrated about gaining weight and thinking my band wasn't working that I just ate and ate. And ate the wrong food. Restriction does help but this weight gain was my fault and my fault alone. Now that I have finally conquered the "blame", I am feeling much more confident about this journey. Hopefully this feeling lasts. Good luck everyone.

It's not from eating unless you are seriously not following the program. Most likely your weight gain is from swelling/fluids from the hospital.

@@losinglily - that is not a weight gain. You "gained" from the IV fluid they gave you at the time of surgery. You'll pee that out in no time. If it bothers you, stay off the scale for a few days

@@foodfighter I want to address what you're saying about pain and discomfort during eating. I most definitely experience eating differently than prior to surgery. One of the things wls surgery does is it removes a hormone responsible for eventual satiety from our stomachs. Wls patients feel fullness within minutes while normal people feel it only after 20 minutes or so. So right away, eating is a less pleasurable experience because one feels full so quickly. The sense of restriction or tightness I feel is not painful but it's not pleasant either. It feels like work to get food to pass. It takes work to eat. Chewing slowly, eating slowly. It feels like a task. Before surgery I ate mindlessly while distracted. I rarely tuned in to what I was eating but became lost in the sensation of pleasure. Now I am forced to eat mindfully and the pleasure factor is way down. It's like... If I had been a Heroin addict (just an analogy!) and someone made it impossible for me to get pleasure from the drug... But I still had to use it to stay alive... It would become a tedious task overshadowed by the memory of what it used to do for me. Eating can be slightly painful for me. If I eat too fast... If I have drunk liquids near to the meal (which I admit I find very difficult not to do), if I don't chew enough, if it's a dense substance... All of these factors and more can effect how it feels to me to eat. I also find eating with little to no appetite kind of painful in a way. More repulsive than anything but definitely not pleasurable. And then there is some mental anxiety and turmoil going on when I'm wondering if I am going to dump from the meal. If I'm in company or put in public this is a real concern for me. And then there is always a level of anxiety related to weight gain. I can push that aside to some extent and of course some foods are easier than others... But I live with at least some amount of anxiety related to food at every meal. Being anxious while eating definitely drives pleasure in the food down. So all these factors put together for me create an unpleasant experience when eating. When eating used to be my drug of choice, it's now a task. I'm not saying all meals are completely devoid of pleasure but most of them are more work than anything. It's the reality of how this surgery has effected me. Food just doesn't do it for me anymore. But that was the point. And would I go back to how it was before? No way. Not in a million years.

I'm 3 years post op this month. It doesn't seem possible as it went by so quickly. I have gained 20 pounds and never hit my goal weight. So with this extra 20 I'm 40 lbs away. I'm worried my pouch isn't working or I stretched it, which docs say hasn't happened. But I'm wondering if this pouch reset of going back on liquids is a real thing. I have no issues going to liquids and I only eat low carb. I'm confused on this weight gain and disappointed in myself. I have no doubt that I have screwed this up because I have cheated in the past. But getting this weight off is so much more important than eating things I'm not supposed to. Does anyone have a success story on gaining weight and losing it again or any ideas? I'm willing to do anything at this point. I don't experience dumping anymore at all and I have to take miralax daily for Bm's. Help!

I agree with JustWatchMe - your tastes may change. Pita, French stick, crusty rolls (all the things that aided in my weight gain of 100 excess pounds) are all no-nos for me now. After several "close call" sticking episodes (mouth watering, that "FEELING" of "oooooh no...." with bread products I simply avoided them. Now I have no desire for them. My tastes have changed. Hummus, baba ghanoush, etc for me all goes with veggies now. I'm better for it! I felt a little sad and mourned the loss of breads and pizza (not a big deal for me, but occasionally it was yummy...) but the pay off was worth giving these up. 70 pounds down, and I am absolutely overjoyed with how I feel. Hopefully your tastes will adjust, too, you will begin to see the results of your sacrifice! Hang in there!

So cool of you, Andrew, to be sitting in top of all that data about your eating and being able to see what changes you'd made and correlate those to weight changes (up and down). After 17 months post-op, I have come to respect that everybody's body needs / wants what it needs / wants. What works for me doesn't necessarily work for you or others. And vice versa. Having said that, I do know that in my case different foods with identical calories have different effects on my body -- re weight gain, weight loss, physical and mental energy, satiety, and muscle-building capability. All I can do is understand as best I can how different foods affect me. And then I have to have the discipline to (most of the time) eat those foods that help me meet my goals. I follow these rules 80-90% of the time. And then sometimes I decide to do something different. But those are exceptions. Once on another forum I said I thought it should be required for all WLS patients, after they reach goal and maintain for a while, to then regain 10 pounds on purpose -- so they could learn how to recover from regain and not fear it. So congratulations. This is your opportunity to learn all that.

While I concur on cereal and applaud all the healthy suggestions (carrots, apples, etc), I think we're talking about crafting a new lifestyle as opposed to "dieting". Like most of us, I crave an occasional salty/crunchy snack. As I have told my NUT, I think most of my weight gain came from eating nuts which are full of calories. The first thing you have to do is make it a treat -- not a daily habit. My sense is a treat should be eaten no more than 1-2 times a week. Second, understand that sugar is POISON. Not only does it cause weight gain, but it also kills you! If I eat sugary food, I limit it to once a month. For the last 6 months, I have been enjoying something that I never would have eaten in my pre-VSG low carb days - JOLLY TIME POPCORN. They make a single serve 100 calorie bag that they say makes 5 cups of popcorn (it looks like less than that). Even in my pre-sleeve days, I couldn't eat more than one bag. I know popcorn is frowned upon, but in my case, it works!

No. Sleeves don't really stretch. The stretchy part, or fundus, was removed during surgery. It would take years of grossly overeating to the point of vomiting to actually stretch it enough to where you're eating significantly enough to cause weight gain. Can the sleeve relax and complete healing over time allowing more food to be eaten? Absolutely.That's why it's important for us not to just count on sleeve restriction and pay more attention to what we are eating for when that time comes. And to the OP: You can have 10 different weight loss surgeries, but the fact of the matter is if your head isn't in the game, NONE of them will work. Like Ann said, look inside and try to figure out what caused you to not succeed before, and then figure out the steps it will take to help you become successful whether you decide on revision surgery or give this one antother go. Your sleeve hasn't changed, it's just waiting for you to.

Hello Everyone, My Name is Marina and I am 22 years old. I have struggled with my weight since I was a preteen. I was told many times throughout my early childhood that I had an under active thyroid. I was on thyroid medication for a solid 4 years until my mom's passing when I was 15. Being only fifteen, it was difficult when my mom was the one who made sure I was able to make it to all my doctors appointments, picking me up from school for them, checking in and getting my medication and etc. I ate with my emotions for years, but always had an active lifestyle, and asked the question millions of times, "Why am I still fat?". When My mother passed away, I was around 220 pounds, since then despite Weight Watchers, Medifast, NutriSystem and the latest program IdahoFatLoss. I am plumped up to 280 pounds. The accumulation of sports activities and a result of no weight loss, nor loss in pant sizes puzzled me. I started going to the doctor when I was 17 (When I gained my drivers licence) I told my doctor, not my doctor when I was fifteen, but my main PCM who was present, about my past issues with hypothyroidism. We tested everything, the whole nine yards, and the only thing that came up was some low Vitamin D, and a slight insufficiency with Iron. Since that first visit back I have asked the multiple doctors I have had to help. We started with stress, being put on antidepressants which only made it worse as for weight gain as well as panic and anxiety medication to add to that. It was a double edged sword that i was hit with. The zoloft, wellbutrin and other antidepressants all made me gain weight, and the multiple doctors just wanted to give me more meds to help me with my mood disorders instead of helping me with my weight. I am dependent upon my father for his military benefits ad he is completely understanding about my decision and would like me to try as hard as I can to get this surgery approved, as he has seen me struggle with my weight for so long. However I am to lose my benefits on my birthday May 9th of 2016. I know it is a great short notice but the only way I can see it as, is "Its now or never." I have an appointment to see my doctor to talk about it on January 29th, but I am terrified that he will tell me no. Does anybody have any pointers or encouragement they could offer? Also if anybody has any experience with TriCare West, could you leave your feedback? Another question, my boyfriend and I have been together for almost a year and a half. We go to the gym, and we eat the same stuff, not the same amount. What I mean by that is that he is a human garbage disposal. He can eat 24/7, cakes, Cookies, meat, bread, anything! and doesn't gain a pound. I am afraid to talk to him, only because, every diet that I have been on since I have been with him has failed. I just don't want him to see me as a quitter. I think he will be supportive, but I am just scare to bring up the subject. Any advice on bringing up the conversation.?

Nothing to do with Carbs or Protein IMO. My GP, in the 1990's, when asked about weight gain/loss said "just keep your 'explicit adjective' mouth shut". Oh how right he was! The most important thing is the psych aspect! One needs to forget what is considered normal plus all the peer pressure along the lines of needing to eat 3 times a day & cleaning your plate, whether you are hungry or not. Keep reminding/asking yourself 'am I really hungry'? & if the answer is NO or NOT REALLY, don't eat or leave whatever is left on your plate. Friends now know not to give me large servings as I eat & chew slowly & 3/4 will be left on the plate. Eat & drink anything that you like, take the Vitamin & supplements your doctor/s recommend & have the required blood analysis done every 6 months or so, to ensure it's all working to your advantage. It's nearly 2 years & although my wife went to meet with the nutritionist, who fully explained/demonstrated serving sizes etc. she still insists on trying to do things, as before my sleeve. I like a good hearty Breakfast & light lunch, then maybe a salad, snack & perhaps a couple of beers @ night.... She doesn't do/want breakfast or lunch but likes a big evening meal. There are always copious leftovers & the dog up the road gets extremely well fed. Plenty of arguments, but I did not go through this to get fat again. Regarding carbs: Make own bread from scratch 2 or 3 times a week with plenty consumed as toast & open sandwiches, Love rice & noodles Have a few beers or ciders most nights & drink about 1 litre of full milk throughout the day as iced coffee [decaf]. So am I doing everything wrong carb wise? Weight stabilized @ about 80kgs [surgeon said it would be 83], BP 120 on 72 & blood glucose 4.2