A panel discussion with an international group of experts in the care of obese patients in the critical care setting evaluated best practices in malnutrition screening and assessment, estimation of energy needs for obese patients, the risks and management of sarcopenic obesity, the importance of tailored nutrition, and the role of immunonutrition.
Patients in the ICU are often overweight and/or obese, with obesity rates reported between 28.2% and 36%. These patients require individualised nutrition considerations as they may suffer from comorbidities, inflammation, and changes in energy expenditure and other aspects of metabolism. There is a significant knowledge gap in recognising and managing the nutritional needs of obese patients in the ICU. Current malnutrition screening and assessment tools lack validation and heterogeneous factors that impact the nutrition status of obese patients. Estimations of energy and protein demands are complex in this patient group and may include estimations based on ideal, actual, or adjusted body weight. In addition, there is very little evidence on the role of immunonutrition in obese patients. Hence, nutritional deficiencies and malnutrition are often underdiagnosed in patients who are overweight or obese.
There is a need for educational efforts for clinicians who care for complex cases of obese critically ill patients. In addition, specific strategies should be outlined to ensure optimal nutrition for this patient population while ensuring that biases and weight stigma do not impact care delivery.
The American Society for Parenteral and Enteral Nutrition (ASPEN), the Society of Critical Care Medicine (SCCM), and the European Society for Clinical Nutrition and Metabolism (ESPEN) provide recommendations for this patient population, recommending an individualised approach to nutritional care in patients with obesity. However, the 2019 ESPEN guidelines do not recommend any specific tool to be used in critically ill patients and simply state that every critically ill patient staying for more than 48 h in the ICU should be considered at risk for malnutrition. Similarly, the ASPEN and SCCM guidelines do not address screening and assessment practices for obese patients in the ICU.
There is a need to focus on the individual needs and requirements of obese patients. A customised approach that considers preexisting comorbidities, altered metabolism, and chronic stigma should be used. There is also a need for additional research to determine the applicability of current guidelines for nutrition therapy in obese patients in the critical care setting.
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