Disease Informatics

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					                                           Bill and Narayana

 Disease Informatics:
ICD-11 at the doorstep

             By: RP Deolankar
Presentation for 4th Nutraceutical Summit, WTC,
                 Mumbai, India
                Feb. 21-23, 2008
World Health Organization (WHO)
 provides a service which is designated
 as a Family of International
 Classifications (WHO-FIC)

  10th version of ICD (ICD-10) has
  a Chapter entitled “Endocrine
  nutritional and metabolic
One of such service is International
 Classification of Diseases (ICD)
Application of Statistics and
 Information Science to establish
 causes of morbidity

 The activity is being described as a
 part of “Disease Informatics”
             Disease Definition
The ICD has become the
 international standard diagnostic
 classification for all general
 epidemiological and many health
 management purposes.
In turn, ICD provided Diseases
"Let your food be your medicine and your
medicine be your food" Hippocrates
In short, most of the diseases could be
linked to food and lifestyle.

Endorsed by the Forty-third World Health
 Assembly (WHA) in May 1990
Disease Definitions are quantal
Domain of handpicked experts as described
 by media

 Severity of the disease triggered by
 the virus may be determined by the
 type of food had been eaten by the
    Scope for improvement
Severity of Disease: Diseases are
Holistic approach: Multiple
 morbidities interact
Throwing open portal to Doctors,
 Health Workers, Educationists
 and Spiritualists

 Dr. T. B. Ustun
    Scope for improvement in
        clinical research
 Multiple morbidity ►     What can be done?
  Multiple hypotheses
 Bayesian applications    As most of the
                           functional foods serve
                           as multiple remedy
                           and also could reduce
                           side effects of drugs,
                           create task force for
                           statistical methods in
                           this area
Objectives of the presentation
Discuss: How to use platform provided by
ICD-11 for
Defining the diseases with least error so
  that those are understood, prevented and
Identifying most of the targets to combat
  a cluster of diseases, understand spatial
  continuum through working on Disease
  Causal Chains and
Designing a holistic solution to the
  disease problem
    Health of an individual
= % Wellbeing + % Disease
Loosing the wellbeing is
 proportionally gaining the disease

  Wellbeing guards

  Good food
  Superb lifestyle
  Complementary Nutraceuticals
       Medical check-up

Revealing certain events in the health
 history of an individual

Three aspects of Medical Check-up
Attempt to hunt priors (Backend
Understand present (Current event)
Predict posteriors (Frontend events)
 Disease Causal Chain or Web
Events linked together
Chain could be reversed due to
Pruning the Frontends could
 stimulate branching in the chain


 Event   Event           Event
    Factors (Components)
    Drive events from backend to Prof. HC Kraemer
    Proxy, Overlapping, Independent,
     Mediators and Moderators
    Events could be modulated through
     altering factors
Factors are shown by arrows


Cause Effect Diagram
Components working together
It is not A + B
It is A + B + AB

                        Genes load the gun,
                  the environment pulls the trigger

                        Prof. Kenneth Olden

   Point to ponder: Why certain probiotics reverse viral diarrhea?
    Ancient Indian Model of
    Human Body Computer
Human = Somatic body + Vitality +
 Mind + Intellect + Bliss
Intellect (Central Processing Unit) +
 Self/ Ego (Software) + Memory (Free
 space, Pen Drive/ Hard Disk) + Mind/
 senses (Program) + Life history
  Human Microbial Organs
Gut Associated, Vagina Associated,
 Skin Associated etc (Eco-organs)
Being described as Human

     Prof. Stig Bengmark
      Clinical Research
To understand the disease of an
 individual, one has to understand
 human and his body computer and
 his associated organs also
    ICD-10 classification
Infectious and Parasitic Diseases
Endocrine, nutritional or
 metabolic diseases etc.
Infectious disease is not a
 nutritional disease
Nutritional disease is not an
 endocrine disease
One may have Infectious Disease
 + Nutritional Disease +
 Endocrine disease
i.e. Multiple morbidities but not
 the complex disease
Infection can happen due to
 endocrine abnormality and
 endocrine abnormality can
 happen due to malnutrition
Some component may occur as
 prior some component may occur
 as posterior
(Keshan disease: Selenium
 Deficiency + coxsackie virus B4)
What is neglected in ICD-10
Disease Causal Chain
Most of the traditionally
 established remedies (TER) alter
 disease causal chain
TER could alter some component
 of a sufficient cause of the
Disease definition might not
 regard that component
      Rothman and Greenland

Sufficient and component cause model
(Button is not sufficient cause to
 switch on or switch off the bulb)
Sufficient causal mechanisms > 1

         Three sufficient causes of disease.
To summarize the background

Diseases are complex
Needs group effort to understand
Needs modern tools of
 information science to study
Yet can have simple solutions
 Membership is open       What can be done?
  to all who are
  willing to register      Register as a
 Members can back         member, Form
  their suggestions        Disease Informatics
  with appropriate         Groups
 Members can
  participate in online
  debate over
  proposed changes
  in disease definition
  Systematic reviews: Basis of

 Practice of             • What can be done?
  combining the
  results of a number      Participate in
  of studies               Cochrane
  (scientific, clinical    collaboration
  and public health)
  that address a set
  of related research
        What is Cochrane
 It is a global        What can be done?
  network of             Register our
  dedicated              interest in
  volunteers for         nutraceuticals and
  providing reliable     functional foods,
  source of evidence     form Cochrane
  in health care.        review group
  Evidence is in the
  form of Systematic
  reviews based on

                         Professor Archibald Leman Cochrane
   Field testing of ICD-11
Draft version of   What can be done?
 ICD-11 shall be
 field tested        Participate in the
                     field testing
Standardization of terminology

ICD-11 website    What can be done?
 shall provide
 linkage for        Find out
 standardization    methodology so
 of terminology     that world
                    understands our
 Examples of Indian terms
Simple term: Ama = Dysbiotics
 (Products of dysbiosis)
Complex term: Vata = Body
 constitution described as Low
 density of the body +
 Ectomorphy + More gaseous +
 Less muscle + High body motility
 + Linear body shape etc
                 Traditional Knowledge Digital Library
                 should be made available to ICD-11
 Confusion due to local dialect
Kanjika (Indian functional food,
 also abbreviated as Kanji), a
 probiotic food, is a lactic fermented
 product where lactic fermentation
 is the terminal step in food
 processing and is prepared from
 raw material of plant origin and
 devoid of dairy product
Kanji is also used for porridge that
 is confusing
 Confusing terms (Continued)
Umbil is similar to kanjika but
 contains lactic fermented milk as
 an ingredient or cooked plant
 material may be combined with
 lactic fermented dairy product
Umbil is also used in place of
 Kanjika by some people
Standard Terminology

MeSH, Medical Subject Headings of

Based on UMLS (Unified Medical
Language System) Metathesaurus
     Standardization of Data

 ICD-11 website        What can be
  shall provide          done?
  linkage for
  standardization of    Develop user
  Data Processing       friendly software
 More and more
  Approach would
  appear in Disease
  Standardization of Research
 ICD-11 website        What can be done?
  shall provide
  linkage for           Develop standard
  standardization of    courses in Health
  research              Research, Project
 More and more         Management Software,
  Good Practice         Infrastructure and
  Protocols would be    Equipment
  asked for             Management, Store and
                        Inventory Management,
                        Archive Management,
                        Document Management
                        and GLP, GCP, GCLP,
                        GMP etc
Example of Disease Causal
     Chain; …follows

                Phytase (germinated grains) +
                Calcium + Vitamin D + Sun Exposure
                for Influenza prevention?
 Sania in Sun
 Calcium deficiency as the front-end
event due to Chelation by Phytic acid
Front end events of Reduced
   availability of Calcium
Front end events                      Backend event
No deficiency in subjects taking
calcium sufficient diet               Calcium deficiency
                                      (reduced availability of
Sub-clinical deficiency in subjects
taking calcium deficient diets        Calcium due to IP6)
Rickets in children where
component cause is calcium

Osteomalacia / osteoporosis in
elderly where component cause is
calcium deficiency

Degradation of vitamin D in the
liver due to calcium deficiency
Front end events of Degradation of
       vitamin D in the liver

John M Pettifor. Nutritional rickets: deficiency of vitamin D, calcium,
or both? Am J Clin Nutr 2004; 80(suppl): 1725S–9S.
Front end events of Vitamin D deficiency
     (Avitaminosis D syndrome, I)
   D: Finally, a vitamin makes the grade.
   Several new studies suggest that the
   so-called sunshine vitamin (because it’s
   produced in skin exposed to sunlight)
   may protect against cancer. One study
   showed that as blood levels of vitamin D
   go up, women’s breast cancer risk goes
   down. Another found that fairly large
   amounts of vitamin D lowered the risk
   for pancreatic cancer by about 40%.

   The Top 10 health stories of 2006, from
   the Harvard Health Letter
                              Founder faculty member of the
                              Department of Endocrinology,
                              Metabolism & Diabetes at the
                              AIIMS, INDIA

    Dr.Narayana Kochupillai

"Based on our clinical experience and
limited studies, we believe vitamin D
deficiency is widespread in northern India,"
Front end events of Vitamin D
(Avitaminosis D syndrome, II)

  Front end events   Backend event

  Autoimmune      Vitamin D
  diseases        deficiency
  Type 1 diabetes

  Heart Disease

The UV Advantage: The Medical Breakthrough
That Shows How to Harness the Power of the
Sun for Your Health by Michael F. Holick. I
Books /Marvel, New York

 Prof. Michael Holick
 Boston University
  Front-end events of Vitamin D
 (Avitaminosis D syndrome, III)

        Front-end event                  Back-end event

        Epidemic Influenza Vitamin D
        (Driving factors to deficiency
        be investigated)

Cannell JJ, Vieth R, Umhau JC, Holick MF, Grant WB, Madronich S, Garland CF,
Giovannucci E. Epidemic influenza and vitamin D. Epidemiol Infect. 2006
Aloia JF, Li-Ng M. Re: epidemic influenza and vitamin D. Epidemiol Infect. 2007
Oct;135(7):1095-6; author reply 1097-8.
Epidemic influenza and vitamin D.
Epidemiol Infect. 2006
1.   Cannell JJ, Atascadero State Hospital, CA
2.   Vieth R, Mount Sinai Hospital, Canada
3.   Umhau JC, NIH
4.   Holick MF, Boston University
5.   Grant WB, SUNARC, CA
6.   Madronich S, National Center for Atmospheric Research, CO
7.   Garland CF, University of California San Diego
8.   Giovannucci E., Harvard School of Public Health, Boston

All authors are from different institutes
Disease definition challenged
Author’s remark in the conclusion section:

Is influenza infection a sign of vitamin D
deficiency as much as Pneumocystis carinii
pneumonia is a sign of AIDS?

       J. J. Cannell
Nutraceutical for Influenza
Prevention on the basis of
        the DiCC
 Calcium Irrigated, UV
  Irradiated Mushrooms

 Rich in Calcium
 Rich in Vitamin D
 Rich in Protein
 Useful in lead detoxification
Indian Government Institute
National Centre for Disease Informatics
and Research at Bangalore, India


  Healthcare: Eleventh Five Year Plan (2007-2012) by Ministry
  of Health and Family Welfare, Government of India, New Delhi
Proposed Title-adjuncts for Nutraceutical Journals

     Disease Path Speed Breakers
     Causal Chain Quenchers
     Sufficient Cause Crackers
     Reversal of Disease Chronicle
     Simple Solutions to Disease Clusters
     Back-End Targets for Nutraceuticals
     Disease Informatics for Nutraceutical Development
      Learn more about DiCC
Disease Informatics: Phytates driving from the back-end
to Influenza, Encephalitis, Hepatitis, Anemia at the front-end

 Supercourse : Epidemiology, the Internet and Global Health,
               Lecture no. 30331

    Disease informatics for setting up Disease definition, drawing
    Disease Causal Chain / Web, marking Risk Events, Backend and
    Frontend Events, and Health Problem Solutions

    Rajendra P Deolankar BMJ.COM, 30 May 2006
 Read the Basics of Disease

DIG for Disease Informatics Group.
 Part I Part II
Disease Informatics: Host factors

Supercourse : Epidemiology, the
 Internet and Global Health,
 Lecture no. 25371, 25381 and 28921

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