Heat stress results from the animal's inability to dissipate sufficient heat to maintain homeothermy. Environmental factors, including ambient temperature, radiant energy, relative humidity, and metabolic heat associated with maintenance and productive processes, contribute to heat stress. The focus of this article is to identify environmental and metabolic factors that contribute to excessive heat load, describe how disruption of homeothermy alters physiologic systems of the cow, and discuss nutritional modifications that help to maintain homeostasis or prevent nutrient deficiencies that result from heat stress. Changes in diet are needed during hot weather to maintain nutrient intake, increase dietary nutrient density, or to reestablish homeostasis. Formulation for adequate nutrient intake is challenging because of the competition between nutrient density and other needs for the cow, including energy density and adequate dietary fiber. Lower DMI during hot weather reduces nutrients available for absorption, and absorbed nutrients are used less efficiently. An excess of degradable dietary protein is undesirable because of energy costs to metabolize and excrete excess N as urea. Optimizing ruminally undegraded protein improves milk yield in hot climates. Mineral losses via sweating (primarily K) and changes in blood acid-base chemistry resulting from hyperventilation reduce blood bicarbonate and blood buffering capacity and increase urinary excretion of electrolytes. Theoretical heat production favors feed ingredients with a lower heat increment, such as concentrates and fats, whereas forages have a greater heat increment. Improved dietary energy density and the lower heat increment associated with the inclusion of dietary fat must be coupled with limitations to fat feeding to avoid ruminal and metabolic disorders. Numerous nutritional modifications are used for hot weather feeding; however, many need further investigation to achieve specific recommendations.