The current best practices in malnutrition screening and assessment, estimation of energy needs for patients with obesity, the risks and management of sarcopenic obesity, the value of tailored nutrition recommendations, and the emerging role of immunonutrition are the main topics of this review, which was developed after a panel discussion with an international group of experts in the care of patients with obesity in the critical care setting. Due to underlying comorbidities, immunological factors including inflammation, and changes in energy expenditure and other aspects of metabolism, patients admitted to the intensive care unit (ICU) increasingly appear overweight and obesity that requires specialized nutrition considerations. Despite growing evidence, there are still significant gaps in understanding the complicated dietary needs of obese intensive care unit (ICU) patients. Due to a lack of validation and varied factors impacting nutrition status in this population, available malnutrition screening, and evaluation techniques are limited in patients with obesity. Estimates of energy and protein needs in people with obesity are similarly complex, as they may comprise estimates based on ideal, actual, or modified body weight. Evidence on the benefits of immunonutrition for obese patients is limited; however, in patients who are hemodynamically stable in the intensive care unit, the presence of inflammation that affects immune function may imply a role in these nutrients. All doctors who deal with the difficult cases of critically ill patients who are obese need education on optimal nutrition practices and the consideration of factors like weight stigma and bias that affect the administration of care. Individualized therapy that considers the whole person is essential for the success of current dietary regimens for these patients, as they may be affected by factors such as preexisting comorbidities, altered metabolism, and persistent stigma. Research is needed to determine whether or not existing recommendations and evidence for nutrition therapy can be successfully implemented with obese populations, particularly in serious illnesses.