Nutritional Challenges and Strategies in Obese Critically Ill Patients with Gynecological Cancer: A Narrative Review

Critically ill obese patients with gynecological cancer represent a high-risk population with complex nutritional needs. Although excess adiposity may suggest adequate energy reserves, it often conceals sarcopenia, micronutrient deficiencies, and functional malnutrition, contributing to impaired wound healing, immune dysfunction, prolonged mechanical ventilation, increased susceptibility to infections, and adverse oncologic outcomes. Obesity-associated inflammation, insulin resistance, and tumor-driven catabolism further exacerbate metabolic stress and complicate nutritional management in the intensive care setting. Accurate nutritional assessment requires a multimodal approach incorporating body composition analysis, functional measures, and laboratory parameters, as conventional indices such as body mass index may underestimate nutritional risk. Nutritional support should be individualized and may include early enteral nutrition to preserve gut integrity, supplemental or total parenteral nutrition when gastrointestinal function is compromised, high-protein regimens, and targeted micronutrient replacement. Immunonutrition, including arginine, glutamine, omega-3 fatty acids, and nucleotides, has emerged as a promising strategy to modulate inflammation, enhance immune function, and support tissue repair. This narrative review summarizes current evidence regarding obesity-related metabolic dysfunction, nutritional assessment, enteral and parenteral nutrition, and immunonutrition in obese critically ill patients with gynecological cancer. It highlights the challenges associated with sarcopenic obesity and hidden malnutrition while providing a clinically relevant overview for intensivists, gynecologic oncologists, surgeons, and nutrition specialists. Early recognition of nutritional risk and implementation of individualized multimodal nutritional strategies may improve recovery and clinical outcomes. However, high-quality ICU-specific studies remain limited, and further prospective research is needed to establish evidence-based nutritional protocols and evaluate their impact on survival, treatment tolerance, and quality of life in this vulnerable population.