This topic is about someone who has an ileostomy due to colonic dysmotility and is struggling to maintain a healthy weight. They are experiencing weight loss, have a low BMI, and are considered borderline malnourished. They need to gain weight before an upcoming surgery, or it might be postponed. Here are some helpful insights and advice for managing this situation:

1. **Assess and Treat Underlying Causes**
- Check for thyroid issues, Addison’s disease, and lactose intolerance.
- Request a full nutrition panel to check levels of vitamins and minerals like B-12, A, D, E, K, iron, and zinc.
- Work with a dietitian who understands ostomies.

2. **Manage Output**
- Although emptying the bag four times a day is moderate, if the output is liquid, try thickening it with foods like bananas, applesauce, oatmeal, sweet potatoes, white bread, rice, pasta, pumpkin, and squash.
- Consider anti-motility medications like Loperamide or Lomotil, but discuss the appropriate dosage with your doctor.

3. **Increase Calorie Density, Not Volume**
- Add healthy fats to meals, such as olive oil, avocado oil, or canola oil. Use mayonnaise, creamy sauces, and smooth nut butters.
- Choose energy-dense proteins like eggs, tender meats, fish, tofu, and cheese. Cook with oil and add gravy or cheese sauce.
- Opt for low-fiber carbs that can also help slow output, such as white rice, pasta, peeled potatoes, and oatmeal.
- Temporarily include extra sugar or desserts to help restore weight quickly.

4. **Structured Eating Pattern**
- Eat 5–7 small meals or snacks daily instead of three large meals. Eat slowly and chew well.
- Avoid drinking large amounts of fluids with meals. Stop fluids 30 minutes before eating and wait 30–60 minutes after eating before drinking again. Sip fluids steadily between meals to stay hydrated.

5. **Oral Nutrition Supplements**
- Use supplements like Ensure Plus, Boost Plus, Resource 2.0, or Fresubin between meals, not as meal replacements.
- Mix with lactose-free or plant-based milks if whole milk increases output.

6. **Hydration Strategy**
- Use Oral Rehydration Solutions (ORS) instead of plain water and sip continuously outside of "no-fluid" windows.
- Include hydrating foods like soups, smoothies, yogurt, and ripe fruit in your diet.

7. **Exercise and Muscle Maintenance**
- Engage in light strength training while increasing protein intake to help convert calories into muscle mass.
- Aim to consume some protein every four hours, with convenient options like cheese or meat and cheese crackers.

8. **Practical Tips from Others**
- Keep the bag empty to prevent leaks at night if eating late.
- Track which foods thicken or loosen output and log meals to identify personal patterns.
- If shakes and diet adjustments fail and malnutrition worsens, discuss the possibility of temporary TPN or tube feeding with your healthcare provider.

9. **Long-term Outlook and Encouragement**
- Many people report that weight gain resumes months after surgery once hydration, diet, and medications are optimized.
- Focus on overall health, and gradual weight gains of 0.5–1 kg per month are common once the right regimen is found.