# Nutritional Care Process in Hospitalized Patients with Obesity-Related Multimorbidity
###### Abstract
The guidelines used in this narrative review followed the Scottish Intercollegiate Guidelines Network (SIGN). These were classified into four categories: A, B, 0, and good practice points or expert consensus (GPP). Level A and B recommendations are based on solid evidence derived from biochemistry and physiology that have been applied to clinical settings. Recommendations based on existing Recommended Dietary Allowances (RDA) receive a level A classification. In contrast, recommendations based on Dietary Reference Intakes (DRIs) are assigned a level B classification. Many are supported by limited evidence, but they underwent a consensus process that resulted in a percentage of agreement (%). Qualification as a \"Strong\" consensus required >90% of votes. \"Consensus\" required between >75-90% of votes. A \"Majority\" agreement won >50-75% of votes. When the agreement was below 50% of the votes, there was no consensus [12; 13]. Hospital Factors That Alter Nutritional Status in Patients with Obesity-Related Multimorbidity (ORM)  
One of the most used nutritional strategies in managing individuals with ORM in community settings is the creation of an energy deficit ranging from 500 to 750 kcal/day to promote efficient and safe weight loss of approximately 0.5 to 1 kg per week [14]. However, admission to a hospital unit exposes individuals to a series of factors that lead to involuntary and excessive weight loss, which may contribute to the development of various forms of malnutrition. The use of hypocaloric diets is compounded by circumstances such as unappetizing food, prolonged fasting due to medical instructions, administrative procedures, pharmacological treatments, gastrointestinal surgeries, and the placement of drains or dialysis. All of these may cause alterations in nutrient absorption and/or metabolism, disturbances in fluid and electrolyte balance, and gastrointestinal symptoms such as decreased appetite, diarrhea, constipation, abdominal distension, early satiety,anorexia, dysgseusia, dysphagia, and mucositis, among others. In this way, the hospital environment fosters nutritional deficiencies and energy deficits that exceed current recommendations for individuals with ORM [15; 16]. Additionally, patients with ORM in critical condition or with a metabolic response to injury may present hypermetabolic states. In protein metabolism, proteolysis occurs, leading to significant losses of muscle mass--up to 2% of skeletal muscle per day in the ICU [17]--and loss of bone mass, which are associated with metabolic acidosis, sarcopenia, osteoporosis, frailty, fatigue, disability, and mortality [18; 19]. The excessive release of pro-inflammatory cytokines and cortisol leads to alterations in carbohydrate (CHO) metabolism due to the development of peripheral insulin resistance, resulting in hyperglycemia that increases the infection rate and delays wound healing [20; 21]. Regarding lipid metabolism, there is a decrease in lipoprotein lipase (LPL) activity--an enzyme that hydrolyzes triglycerides and breaks them down into free fatty acids and glycerol, releasing them into muscle and adipose tissue to later provide energy via beta-oxidation--potentially causing dyslipidemias, primarily hypoalphalipoproteinemia (low levels of high-density lipoprotein cholesterol [HDL]) and hypertriglyceridemia [20; 22]. As for micronutrient metabolism, deficiencies may occur due to increased requirements for vitamins and minerals, leading to profound depression of the immune system, increased risk of infections, and immunomodulation failure that perpetuates inflammation. Likewise, alterations in the antioxidant system, fluid and electrolyte balance, and acid-base equilibrium may also be present [21]. In addition, there may be altered drug assimilation, as sarcopenia obesity--commonly observed in patients with ORM and prolonged immobility--can reduce drug transport and pharmacokinetics, resulting in decreased pharmacotherapeutic success [20].