Metabolic Support of the Obese Intensive Care Unit Patient

  • Sanit Wichansawakun
  • Dong Wook Kim
  • Lorraine S. Young
  • Caroline M. ApovianEmail author
Part of the Nutrition and Health book series (NH)


As the prevalence of obesity has increased, the number of obese patients admitted to ICUs has also increased. Nutritional assessment and support is a key element in the proper management of critically ill obese patients. Estimating caloric requirements of critically ill obese patients with predictive equations is challenging, as most of these equations were developed for the nonobese population. Currently, indirect calorimetry remains the gold standard for estimating energy requirements. Hypocaloric feeding is recommended for most critically ill obese patients. It is intended to reduce nonprotein calorie infusions while maximizing protein sparing. The caloric goal should not exceed 60–70 % of energy requirements, with a daily intake of at least 2.0–2.5 g/kg ideal body weight of protein required. This hypocaloric feeding regimen will prevent complications of overfeeding, such as hyperglycemia and fluid retention, while preserving lean body mass and promoting steady controlled weight loss. Further investigations are needed for clinical use of pharmaconutrients in critically ill obese patients, though some experimental studies have shown positive results. Those listed above may be considered in the nutritional treatment of critically ill obese patients.


Obesity Critical illness Nutrition support Hypocaloric feeding 


  1. 1.
    NHLBI Obesity Education Initiative. The practical guide identification, evaluation, and treatment of overweight and obesity in adults [Internet]. NIH publications. 2000.
  2. 2.
    Ogden CL, Carrol MD, Flegal KM. Prevalence of obesity in the United States 2009–2010. NCHS Data Brief. 2012.Google Scholar
  3. 3.
    Ogden CL, Carrol MD, Curtin LR, et al. Prevalence of overweight and obesity in the United States, 1999–2004. JAMA. 2006;295(13):1549–55.CrossRefPubMedGoogle Scholar
  4. 4.
    Wang Y, Beydoun MA. The obesity epidemic in the United States—gender, age, socioeconomic, racial/ethic, and geographic characteristics: a systemic review and meta-regression analysis. Epidemiol Rev [Internet]. 2007 [cited 2007 Jan 25];29:6–28.Google Scholar
  5. 5.
    Oliveros H, Villamor E. Obesity and mortality in critically ill adults: a systematic review and meta-analysis. Obesity [Internet]. 2008 [cited 2008 Jan 17];16:515–21. doi: 10.1038/oby.2007.102.
  6. 6.
    McClave SA, Kushner R, Van Way CW, Cave M, DeLegge M, Dibaise J, et al. Nutrition therapy of the severely obese, critically ill patient: summation of conclusions and recommendations. J Parenter Enteral Nutr. 2001;35:88s–96. Scholar
  7. 7.
    Hurt RT, Frazier TH. Obesity. In: Mueller CM, Kovacevich DS, McClave SA, Miller SJ, Schwartz DB, editors. The A.S.P.E.N. adult nutrition support core curriculum. 2nd ed. USA: ASPEN; 2012.Google Scholar
  8. 8.
    Port AM, Apovian C. Metabolic support of the obese intensive care unit patient: a current perspective. Curr Opin Clin Nutr Metab Care [Internet]. 2010 [cited 2010 Mar];13(2):184–91. doi: 10.1097/MCO.0b013e328335f1e6.
  9. 9.
    Arabi YM, Dara SI, Tamim HM, Rishu AH, Bouchama A, Khedr MK, et al. Clinical characteristics, sepsis interventions and outcomes in the obese patients with septic shock: an international multicenter cohort study. Critical Care [Internet]. 2013;17(R72):1–13.
  10. 10.
    Martino JL, Stapleton RD, Wang M, et al. Extreme obesity and outcomes in critically ill patients. Chest. 2011;140:1198–206.CrossRefPubMedCentralPubMedGoogle Scholar
  11. 11.
    Paolini JB, Mancini J, Genestal M, et al. Predictive value of abdominal obesity vs. body mass index for determining risk of intensive care unit mortality. Crit Care Med. 2010;38:1308–14.PubMedGoogle Scholar
  12. 12.
    Cave MC, Hurt RT, Frazier TH, Matheson PJ, Garrison RN, McClain CJ, McClave SA. Obesity, inflammation, and the potential application of pharmaconutrition. Nutr Clin Pract [Internet]. 2008 [cited 2008 Feb 1];23:16–34. doi: 10.1177/011542650802300116.
  13. 13.
    Breen HB. Lipid oxidation and nitrogen balance in critically ill obese patients. Nutr Clin Pract [Internet]. 2005 [cited 2005 Feb 1];20:98–102. doi: 10.1177/011542650502000198.
  14. 14.
    Vachharajani V, Vital S. Obesity and sepsis. Intensive Care Med [Internet]. 2006 [cited 2006 Aug 31];21:287–95. doi: 10.1177/0885066606290670.
  15. 15.
    Mizock BA. Alterations in fuel metabolism in critical illness; Hyperglycemia. Best Pract Res Clin Endocrinol Metab. 2001;15(4):533–51.CrossRefPubMedGoogle Scholar
  16. 16.
    Langouhe L, Perre SV, Thissen S, Gunst J, Hermans G, D’Hoore A, et al. Alterations in adipose tissue during critical illness: an adaptive and protective response. Am J Respir Crit Care Med [Internet]. 2010 [cited 2010 May 4];182:507–61. doi: 10.1164/rccm.200909-1395OC.
  17. 17.
    Malone AM. Permissive underfeeding: its appropriateness in patients with obesity, patients on parenteral nutrition, and non-obese patients receiving enteral nutrition. Curr Gastroenterol Rep. 2007;9:317–22.CrossRefPubMedGoogle Scholar
  18. 18.
    Kushner RF, Drover JW. Current strategies of critical care assessment and therapy of the obese patient (hypocaloric feeding): what are we doing and what do we need to do? J Parenter Enteral Nutr [Internet]. 2011 [cited 2011 Aug 1];35:36s–43. doi: 10.1177/0148607111413776.
  19. 19.
    Cutts ME, Dowdy RP, Ellersieck MR, Edes TE. Predicting energy needs in ventilator-dependent critically ill patients: effect of adjusting weight for edema or adiposity. Am J Clin Nutr. 1997;66:1250–6.PubMedGoogle Scholar
  20. 20.
    Wooley JA, Frankenfield D. Energy. In: Mueller CM, Kovacevich DS, McClave SA, Miller SJ, Schwartz DB, editors. The A.S.P.E.N. adult nutrition support core curriculum. 2nd ed. USA: ASPEN; 2012.Google Scholar
  21. 21.
    Frankenfield D, Hise M, Malone A, Russell M, Gradwell E, et al. Prediction of resting metabolic rate in critically ill adult patients: results of a systematic review of the evidence. J Am Diet Assoc. 2007;107:1552–61.CrossRefPubMedGoogle Scholar
  22. 22.
    Oliveira EP, Orsatti FL, Teixeira O, Maest N, Burini RC. Comparison of predictive equations for resting energy expenditure in overweight and obese adults. J Obes [Internet]. 2011 [cited 2011 May 24];2011:1–5. doi: 10.1155/2011/534714.
  23. 23.
    Palghi A, Reed JL, Greenburg I, et al. Multidisciplinary treatment of obesity with a protein-sparing modified fast: results in 668 outpatients. Am J Public Health. 1985;75(10):1190–4.CrossRefGoogle Scholar
  24. 24.
    Hurt RT, Frazier TH, McClave SA, Cave MC. Pharmaconutrition for the obese, critically ill patient. J Parenter Enteral Nutr [Internet]. 2011 [cited 2011 Aug 31];35:60s–72s. doi: 10.1177/0148607111413775.
  25. 25.
    Kaafarani H, Shikora A. Nutritional support of the obese and critically ill obese patient. Surg Clin North Am. 2011;91:837–55.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Sanit Wichansawakun
    • 1
  • Dong Wook Kim
    • 2
  • Lorraine S. Young
    • 3
  • Caroline M. Apovian
    • 2
    Email author
  1. 1.Department of Medicine, Section: Clinical Nutrition and ObesityThammasat University HospitalKlongluangThailand
  2. 2.Endocrinology, Diabetes, Nutrition, and Weight ManagementBoston Medical Center (Boston University School of Medicine)BostonUSA
  3. 3.Endocrinology Diabetes and NutritionBoston Medical CenterBostonUSA

Personalised recommendations