Obese Patients in Critical Care: Nutritional Support Through Enteral and Parenteral Routes

  • Magdalini Kyriakopoulou
  • Stavrina Avgeropoulou
  • Anastasia Kotanidou
  • Foteini Economidou
  • Antonia Koutsoukou
Reference work entry


As the obese population is globally increasing, it is nowadays quite common for these patients to be admitted in the intensive care unit. Management of obese patients in the critical care setting is challenging, as routine elements of nursing care, diagnostic and therapeutic interventions, as well as nutritional support can be quite complicated. Determination of energy requirements by means of predictive equations is not accurate, and indirect calorimetry – although few times available or feasible – remains the gold standard. Hypocaloric feeding with high protein provision is recommended for the nutritional support of the obese critically ill patient. This approach has demonstrated positive nutritional and clinical outcomes, avoiding the deleterious effects of overfeeding and minimizing lean body mass loss. Pharmaconutrition may be considered in the context of potential activity on the low-grade inflammatory state seen in obesity. Monitoring is the last integral part of the nutritional plan and is directed towards detection of complications (associated with obesity or improper feeding) and assessment of its therapeutic efficacy.


Obese Patient Intensive Care Unit Patient Whey Protein Enteral Nutrition Ideal Body Weight 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

List of Abbreviations


Actual body weight


Adjusted body weight


American society of parenteral and enteral nutrition


Body mass index


Blood urea nitrogen


Enteral nutrition




Ideal body weight


Indirect calorimetry


Intensive care unit








Lean body mass


Lean body weight


Medium-chained triglycerides




Nonalcoholic fatty liver disease


Nitrogen balance


Nonprotein calories


Parenteral nutrition


Polyunsaturated fatty acids


Resting energy expenditure


Society of critical care medicine


Tumor necrosis factor-a




Urinary urea nitrogen


Carbon dioxide production


Oxygen consumption




  1. Agarwal E, Ferguson M, Banks M, Bauer J, Capra S, Isenring E. Nutritional status and dietary intake of acute care patients: results from the nutrition care day survey 2010. Clin Nutr (Edinburgh, Scotland). 2012;31(1):41–7. doi:10.1016/j.clnu.2011.08.002.CrossRefGoogle Scholar
  2. Akinnusi ME, Pineda LA, El Solh AA. Effect of obesity on intensive care morbidity and mortality: a meta-analysis. Crit Care Med. 2008;36(1):151–8. doi:10.1097/01.CCM.0000297885.60037.6E.CrossRefPubMedGoogle Scholar
  3. Alpert MA, Hashimi MW. Obesity and the heart. Am J Med Sci. 1993;306(2):117–23.CrossRefPubMedGoogle Scholar
  4. Amato P, Keating KP, Quercia RA, Karbonic J. Formulaic methods of estimating calorie requirements in mechanically ventilated obese patients: a reappraisal. Nutri Clin Pract. 1995;10(6):229–32.CrossRefGoogle Scholar
  5. Anderegg BA, Worrall C, Barbour E, Simpson KN, Delegge M. Comparison of resting energy expenditure prediction methods with measured resting energy expenditure in obese, hospitalized adults. JPEN J Parenter Enter Nutr. 2009;33(2):168–75. doi:10.1177/0148607108327192.CrossRefGoogle Scholar
  6. Angulo P. Nonalcoholic fatty liver disease. N Engl J Med. 2002;346(16):1221–31. doi:10.1056/NEJMra011775.CrossRefPubMedGoogle Scholar
  7. Aubier M, Murciano D, Lecocguic Y, Viires N, Jacquens Y, Squara P, Pariente R. Effect of hypophosphatemia on diaphragmatic contractility in patients with acute respiratory failure. N Engl J Med. 1985;313(7):420–4. doi:10.1056/NEJM198508153130705.CrossRefPubMedGoogle Scholar
  8. Bistrian BR. Clinical use of a protein-sparing modified fast. JAMA. 1978;240(21):2299. doi:10.1001/jama.1978.03290210081040.CrossRefPubMedGoogle Scholar
  9. Burge JC, Goon A, Choban PS, Flancbaum L. Efficacy of hypocaloric total parenteral nutrition in hospitalized obese patients: a prospective, double-blind randomized trial. JPEN J Parenter Enter Nutr. 1994;18(3):203–7.CrossRefGoogle Scholar
  10. Choban PS, Dickerson RN. Morbid obesity and nutrition support: is bigger different? Nutr Clin Pract. 2005;20(4):480–7. doi:10.1177/0115426505020004480.CrossRefPubMedGoogle Scholar
  11. Choban PS, Burge JC, Scales D, Flancbaum L. Hypoenergetic nutrition support in hospitalized obese patients: a simplified method for clinical application. Am J Clin Nutr. 1997;66(3):546–50.PubMedGoogle Scholar
  12. Choban P, Dickerson R, Malone A, Worthington P, Compher C. A.s.p.e.N. Clinical guidelines: nutrition support of hospitalized adult patients with obesity. JPEN J Parenter Enter Nutr. 2013;37(6):714–44. doi:10.1177/0148607113499374.CrossRefGoogle Scholar
  13. Cynober L. Some laboratory measurement of response to nutrition clinical studies. In: Sobotca L, editor. Basics in clinical nutrition. 3rd ed. Prague: Galen; 2004. p. 285–6.Google Scholar
  14. De Oliveira EP, Orsatti FL, Teixeira O, Maestá N, Burini RC. Comparison of predictive equations for resting energy expenditure in overweight and obese adults. J Obes. 2011;2011:534714. doi:10.1155/2011/534714.CrossRefPubMedPubMedCentralGoogle Scholar
  15. Dickerson RN, Drover JW. Monitoring nutrition therapy in the critically ill patient with obesity. JPEN J Parenter Enter Nutr. 2011;35(5 Suppl):44S–51. doi:10.1177/0148607111413771.CrossRefGoogle Scholar
  16. Dickerson RN, Rosato EF, Mullen JL. Net protein anabolism with hypocaloric parenteral nutrition in obese stressed patients. Am J Clin Nutr. 1986;44(6):747–55.PubMedGoogle Scholar
  17. Dickerson RN, Boschert KJ, Kudsk KA, Brown RO. Hypocaloric enteral tube feeding in critically ill obese patients. Nutrition (Burbank, Los Angeles County, Calif). 2002;18(3):241–6.CrossRefGoogle Scholar
  18. Elamin EM. Nutritional care of the obese intensive care unit patient. Curr Opin Crit Care. 2005;11(4):300–3.CrossRefPubMedGoogle Scholar
  19. Finfer S, Chittock DR, Su SY-S, Blair D, Foster D, Dhingra V, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360(13):1283–97. doi:10.1056/NEJMoa0810625.CrossRefPubMedGoogle Scholar
  20. Fisher WR. Hypertriglyceridemia in diabetes. An approach to management. The Journal of the Florida Medical Association. 1991;78(11):747–50.PubMedGoogle Scholar
  21. Frankenfield DC, Rowe WA, Smith JS, Cooney RN. Validation of several established equations for resting metabolic rate in obese and nonobese people. J Am Diet Assoc. 2003;103(9):1152–9. doi:10.1053/jada.2003.50575.CrossRefPubMedGoogle Scholar
  22. Griesdale DEG, de Souza RJ, van Dam RM, Heyland DK, Cook DJ, Malhotra A, et al. Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data. CMAJ Can Med Assoc J. 2009;180(8):821–7. doi:10.1503/cmaj.090206.CrossRefGoogle Scholar
  23. Hogue CW, Stearns JD, Colantuoni E, Robinson KA, Stierer T, Mitter N, et al. The impact of obesity on outcomes after critical illness: a meta-analysis. Intensive Care Med. 2009;35(7):1152–70. doi:10.1007/s00134-009-1424-5.CrossRefPubMedGoogle Scholar
  24. Honiden S, McArdle JR. Obesity in the intensive care unit. Clin Chest Med. 2009;30(3):581–99. doi:10.1016/j.ccm.2009.05.007. x.CrossRefPubMedGoogle Scholar
  25. Hurt RT, Frazier TH, McClave S a, Cave MC. Pharmaconutrition for the obese, critically ill patient. JPEN J Parenter Enter Nutr. 2011;35(5 Suppl):60S–72. doi:10.1177/0148607111413775.CrossRefGoogle Scholar
  26. Kahokehr AA, Sammour T, Wang K, Sahakian V, Plank LD, Hill AG. Prevalence of malnutrition on admission to hospital – acute and elective general surgical patients. e-SPEN Eur e-J Clin Nutr Metab. 2010;5(1):e21–5. doi:10.1016/j.eclnm.2009.11.001.CrossRefGoogle Scholar
  27. Kee A-L, Isenring E, Hickman I, Vivanti A. Resting energy expenditure of morbidly obese patients using indirect calorimetry: a systematic review. Obes Rev. 2012;13(9):753–65. doi:10.1111/j.1467-789X.2012.01000.x.CrossRefPubMedGoogle Scholar
  28. 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? JPEN J Parenter Enter Nutr. 2011;35(5 Suppl):36S–43. doi:10.1177/0148607111413776.CrossRefGoogle Scholar
  29. Liu KJ, Cho MJ, Atten MJ, Panizales E, Walter R, Hawkins D, Donahue PA. Hypocaloric parenteral nutrition support in elderly obese patients. Am Surg. 2000;66(4):394–9. discussion 399–400.PubMedGoogle Scholar
  30. Marik PE, Zaloga GP. Gastric versus post-pyloric feeding: a systematic review. Crit Care (Lond, Engl). 2003;7(3):R46–51. doi:10.1186/cc2190.CrossRefGoogle Scholar
  31. Marik PE, Zaloga GP. Immunonutrition in critically ill patients: a systematic review and analysis of the literature. Intensive Care Med. 2008;34(11):1980–90. doi:10.1007/s00134-008-1213-6.CrossRefPubMedGoogle Scholar
  32. Marques MB, Langouche L. Endocrine, metabolic, and morphologic alterations of adipose tissue during critical illness. Crit Care Med. 2013;41(1):317–25. doi:10.1097/CCM.0b013e318265f21c.CrossRefPubMedGoogle Scholar
  33. McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enter Nutr. 2009;33(3):277–316. doi:10.1177/0148607109335234.CrossRefGoogle Scholar
  34. 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. JPEN J Parenter Enter Nutr. 2011;35(5 Suppl):88S–96. doi:10.1177/0148607111415111.CrossRefGoogle Scholar
  35. McClave SA, Martindale RG, Kiraly L. The use of indirect calorimetry in the intensive care unit. Curr Opin Clin Nutr Metab Care. 2013;16(2):202–8. doi:10.1097/MCO.0b013e32835dbc54.CrossRefPubMedGoogle Scholar
  36. Mehta NM, Bechard LJ, Dolan M, Ariagno K, Jiang H, Duggan C. Energy imbalance and the risk of overfeeding in critically ill children. Pediatr Crit Care Med. 2011;12(4):398–405. doi:10.1097/PCC.0b013e3181fe279c.CrossRefPubMedPubMedCentralGoogle Scholar
  37. Metheny NA, Stewart BJ, McClave SA. Relationship between feeding tube site and respiratory outcomes. JPEN J Parenter Enter Nutr. 2011;35(3):346–55. doi:10.1177/0148607110377096.CrossRefGoogle Scholar
  38. Moghissi ES, Korytkowski MT, DiNardo M, Einhorn D, Hellman R, Hirsch IB, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care. 2009;32(6):1119–31. doi:10.2337/dc09-9029.CrossRefPubMedPubMedCentralGoogle Scholar
  39. Montejo J. Immunonutrition in the intensive care unit. A systematic review and consensus statement. Clin Nutr. 2003;22(3):221–33. doi:10.1016/S0261-5614(03)00007-4.CrossRefPubMedGoogle Scholar
  40. Mudge AM, Ross LJ, Young AM, Isenring EA, Banks MD. Helping understand nutritional gaps in the elderly (HUNGER): a prospective study of patient factors associated with inadequate nutritional intake in older medical inpatients. Clin Nutr (Edinburgh, Scotland). 2011;30(3):320–5. doi:10.1016/j.clnu.2010.12.007.CrossRefGoogle Scholar
  41. Oliveros H, Villamor E. Obesity and mortality in critically ill adults: a systematic review and meta-analysis. Obesity (Silver Spring, Md). 2008;16(3):515–21. doi:10.1038/oby.2007.102.CrossRefGoogle Scholar
  42. Port AM, Apovian C. Metabolic support of the obese intensive care unit patient: a current perspective. Curr Opin Clin Nutr Metab Care. 2010;13(2):184–91. doi:10.1097/MCO.0b013e328335f1e6.CrossRefPubMedPubMedCentralGoogle Scholar
  43. Pressoir M, Desné S, Berchery D, Rossignol G, Poiree B, Meslier M, et al. Prevalence, risk factors and clinical implications of malnutrition in French Comprehensive Cancer Centres. Br J Cancer. 2010;102(6):966–71. doi:10.1038/sj.bjc.6605578.CrossRefPubMedPubMedCentralGoogle Scholar
  44. Rao Z, Wu X, Liang B, Wang M, Hu W. Comparison of five equations for estimating resting energy expenditure in Chinese young, normal weight healthy adults. Eur J Med Res. 2012;17(1):26. doi:10.1186/2047-783X-17-26.CrossRefPubMedPubMedCentralGoogle Scholar
  45. Reeds DN. Nutrition support in the obese, diabetic patient: the role of hypocaloric feeding. Curr Opin Gastroenterol. 2009;25(2):151–4. doi:10.1097/MOG.0b013e32831ef1e4.CrossRefPubMedGoogle Scholar
  46. Rice TW. Obesity in acute lung injury: the “weight” is over. Chest. 2007;131(2):333–4. doi:10.1378/chest. 06-2584.CrossRefPubMedGoogle Scholar
  47. Talpers SS. Nutritionally associated increased carbon dioxide production. Excess total calories vs high proportion of carbohydrate calories. Chest J. 1992;102(2):551. doi:10.1378/chest.102.2.551.CrossRefGoogle Scholar
  48. Vincent J-L, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H, et al. Sepsis in European intensive care units: results of the SOAP study. Crit Care Med. 2006;34(2):344–53.CrossRefPubMedGoogle Scholar
  49. Walker RN, Heuberger RA. Predictive equations for energy needs for the critically ill. Respir Care. 2009;54(4):509–21.PubMedGoogle Scholar
  50. Whitlock G, Lewington S, Sherliker P, Clarke R, Emberson J, Halsey J, et al. Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies. Lancet. 2009;373(9669):1083–96. doi:10.1016/S0140-6736(09)60318-4.CrossRefPubMedGoogle Scholar
  51. Xavier Pi-Sunyer F. Obesity guidelines-full report, NHLBI. NHLBI. (nd).Google Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Magdalini Kyriakopoulou
    • 1
  • Stavrina Avgeropoulou
    • 1
  • Anastasia Kotanidou
    • 2
  • Foteini Economidou
    • 3
  • Antonia Koutsoukou
    • 1
  1. 1.ICU, 1st Department of Respiratory Medicine, Medical School, National and Kapodistrian University of AthensSotiria HospitalAthensGreece
  2. 2.First Critical Care Department, Medical SchoolNational and Kapodistrian University of Athens, Evangelismos General HospitalAthensGreece
  3. 3.First Critical Care Department, Medical School, National and Kapodistrian University of Athens, Evangelismos General HospitalAthensGreece

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