Kwashiorkor Research Shows Prime Healthcare's Cases Must Be Off Base

What does Antidote really know about kwashiorkor?

Not much, to be honest.

We hadn't even heard of it until last year when California Watch wrote about it, underscoring how rare it is in the United States and how odd it is that 1,000 adult cases of kwashiorkor would suddenly appear at Shasta Regional Medical Center in Redding, California.

Shasta's owner, Prime Healthcare, says that it has to bill Medicare for kwashiorkor when doctors there find someone with a protein deficiency. This prompted Antidote to do a little searching in the medical literature for kwashiorkor and its manifestations.

I kept coming across the name of Dr. Michael Krawinkel at the University of Giessen's Institute of Nutritional Sciences in Germany. He has been cited frequently in the literature for work on malnutrition and, specifically, kwashiorkor. He wrote a paper in 2003 titled "Kwashiorkor is still not fully understood." So I asked him to enlighten me. He was so surprised to hear that anyone had tried to diagnose adults with kwashiorkor that he didn't quite know what to say.

"To my knowledge, the term  ‘kwashiorkor' has been used exclusively for severely malnourished children since its first description in 1935 by Cicely Williams," he wrote Antidote.

So what about adults? They must have the capacity to be undernourished, too, right?

Yes, but undernourished does not equal kwashiorkor. Krawinkel said that true under-nutrition in adults would be defined as having a body-mass index (BMI) that is two standard deviations under the median for a typical healthy person. He said that someone with a BMI that low "can be accompanied by edema and ascites" meaning a distended belly and fluid in the abdomen, "but, I would not use the term ‘kwashiorkor' for this condition."

But what would make Krawinkel apply the term kwashiorkor to an adult? Even if an adult were undernourished and had a swollen belly, Krawinkel would still want to rule out all other possible causes of the swelling, meaning problems with "severe anemia, nephrotic syndrome, protein-losing enteropathy, and heart failure," he wrote.  

And then, with those factors excluded, he would look for "high levels of oxidative stress indicators in the respective patient." This means that these patients would have an imbalance of pro- and antioxidative substances in their bodies.

So I asked Krawinkel, "Can a person who is overweight and eating a normal diet develop kwashiorkor?" He answered, "No."

Then, I asked, "Is protein deficiency the defining characteristic of kwashiorkor or is there another defining characteristic?" He answered, "Protein deficiency is not the defining cause of kwashiorkor but oxidative stress is most relevant, according to the literature."

Getting back to the Jethro Tull Problem outlined by Antidote last week, this appears to be more evidence either that Prime has found an interesting way to work the Medicare billing system or that Medicare's billing codes have a disconnect from reality.

Related Posts:

Is Prime Healthcare Playing Medicare Like a Flute? Three Questions to Consider

Prime Healthcare's Jethro Tull Problem: Medicare Billing for Obscure Diagnoses

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Photo credit: Steve Evans via Flickr