Disease Informatics:ICD-11 at the doorstep

By: RP DeolankarPresentation for 4th Nutraceutical Summit, WTC,

Mumbai, IndiaFeb. 21-23, 2008

Bill and Narayana

WHO

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 diseases”

ICD

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 DefinitionThe ICD has become the

international standard diagnostic classification for all general epidemiological and many health management purposes.

In turn, ICD provided Diseases definitions

"Let your food be your medicine and your medicine be your food" HippocratesIn short, most of the diseases could be linked to food and lifestyle.

ICD-10

Endorsed by the Forty-third World Health Assembly (WHA) in May 1990

Disease Definitions are quantalDomain 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 subject.

Scope for improvementSeverity of Disease: Diseases are

quantitativeHolistic approach: Multiple

morbidities interactThrowing open portal to Doctors,

Health Workers, Educationists and Spiritualists

Dr. T. B. Ustun

Scope for improvement in clinical research

Multiple morbidity ► Multiple hypotheses

Bayesian applications

What can be done?

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 byICD-11 for Defining the diseases with least error so

that those are understood, prevented and reversed

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 + % DiseaseLoosing the wellbeing is

proportionally gaining the disease

Wellbeing guards

Good foodSuperb lifestyleComplementary Nutraceuticals

Medical check-up

Revealing certain events in the health history of an individual

Three aspects of Medical Check-upAttempt to hunt priors (Backend

events)Understand present (Current event)Predict posteriors (Frontend events)

Disease Causal Chain or WebEvents linked togetherChain could be reversed due to

interventionPruning the Frontends could

stimulate branching in the chain

Event

Event

EventEvent

Factors (Components)Drive events from backend to

frontendProxy, Overlapping, Independent,

Mediators and ModeratorsEvents could be modulated through

altering factors

Cause Effect Diagram

EventEvent

Factors are shown by arrows

Prof. HC Kraemer

Components working together

It is not A + BIt is A + B + AB

Point to ponder: Why certain probiotics reverse viral diarrhea?

Genes load the gun,the environment pulls the trigger

Prof. Kenneth Olden

Ancient Indian Model of Human Body Computer

Human = Somatic body + Vitality + Mind + Intellect + Bliss (Panchakosha)

Intellect (Central Processing Unit) + Self/ Ego (Software) + Memory (Free space, Pen Drive/ Hard Disk) + Mind/ senses (Program) + Life history (Data)

Human Microbial Organs

Gut Associated, Vagina Associated, Skin Associated etc (Eco-organs)

Being described as Human Microbiome

Prof. Stig Bengmark

PrebioticsProbioticsSynbiotics

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 DiseasesCancersEndocrine, nutritional or

metabolic diseases etc.

Triviality

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

RealityInfection 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-10Disease Causal ChainMost of the traditionally

established remedies (TER) alter disease causal chain

TER could alter some component of a sufficient cause of the disease

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 complexNeeds group effort to understandNeeds modern tools of information

science to studyYet can have simple solutions

ICD-11

Membership is open to all who are willing to register

Members can back their suggestions with appropriate evidence

Members can participate in online debate over proposed changes in disease definition

What can be done?

Register as a member, Form Disease Informatics Groups

Systematic reviews: Basis of ICD-11

Practice of combining the results of a number of studies (scientific, clinical and public health) that address a set of related research hypothesis

• What can be done?

Participate in Cochrane collaboration

What is Cochrane Collaboration?

It is a global network of dedicated volunteers for providing reliable source of evidence in health care. Evidence is in the form of Systematic reviews based on meta-analysis

What can be done? Register our interest in nutraceuticals and functional foods, form Cochrane review group

Professor Archibald Leman Cochrane

Field testing of ICD-11

Draft version of ICD-11 shall be field tested

What can be done?

Participate in the field testing

Standardization of terminology

ICD-11 website shall provide linkage for standardization of terminology

What can be done?

Find out methodology so that world understands our terminology

Examples of Indian termsSimple 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 Libraryshould 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

MeSH, Medical Subject Headings of

NLM, NIH, USA

Based on UMLS (Unified Medical

Language System) Metathesaurus

Standard Terminology

Standardization of Data Processing

ICD-11 website shall provide linkage for standardization of Data Processing

More and more Bayesian Approach would appear in Disease Informatics

What can be done?

Develop user friendly software

Standardization of Research ICD-11 website

shall provide linkage for standardization of research

More and more Good Practice Protocols would be asked for

What can be done?

Develop standard courses in Health Research, Project Management Software, Infrastructure and Equipment 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 Calcium due to IP6)

Sub-clinical deficiency in subjects taking calcium deficient diets

Rickets in children where component cause is calcium deficiency

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

Dr.Narayana Kochupillai

Founder faculty member of the Department of Endocrinology, Metabolism & Diabetes at the AIIMS, INDIA

"Based on our clinical experience and limited studies, we believe vitamin D deficiency is widespread in northern India," http://www.bmj.com/cgi/content/full/326/7379/12/b?etoc

Front end events of Vitamin D deficiency

(Avitaminosis D syndrome, II)

Front end events Backend event

Autoimmune diseases

Vitamin D deficiency

Type 1 diabetes

Heart Disease

Osteoporosis

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 HolickBoston University

Front-end events of Vitamin D deficiency

(Avitaminosis D syndrome, III)

Front-end event Back-end event

Epidemic Influenza (Driving factors to be investigated)

Vitamin D deficiency

Cannell JJ, Vieth R, Umhau JC, Holick MF, Grant WB, Madronich S, Garland CF, Giovannucci E. Epidemic influenza and vitamin D. Epidemiol Infect. 2006 Dec;134(6):1129-40 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 Dec;134(6):1129-401. Cannell JJ, Atascadero State Hospital, CA2. Vieth R, Mount Sinai Hospital, Canada3. Umhau JC, NIH4. Holick MF, Boston University5. Grant WB, SUNARC, CA6. Madronich S, National Center for Atmospheric Research, CO7. Garland CF, University of California San Diego8. Giovannucci E., Harvard School of Public Health, Boston

All authors are from different institutes

Disease definition challengedAuthor’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 CalciumRich in Vitamin DRich in ProteinUseful in lead detoxification

Indian Government InstituteNational Centre for Disease Informatics and Research at Bangalore, India

Multi-disciplinary

Multi-centric

Surveillance

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

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

Disease Informatics: Phytates driving from the back-end

to Influenza, Encephalitis, Hepatitis, Anemia at the front-end

Read the Basics of Disease Informatics

DIG for Disease Informatics Group. Part I Part II

Disease Informatics: Host factors simplified

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