Disease Informatics: ICD-11 at the doorstep

1. 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

2. 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”

3. 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”

4. 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 definitions "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.

5. ICD-10 • 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 subject.

6. Scope for improvement • Severity of Disease: Diseases are quantitative • Holistic approach: Multiple morbidities interact • Throwing open portal to Doctors, Health Workers, Educationists and Spiritualists Dr. T. B. Ustun

7. 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

8. 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 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

9. Health of an individual • = % Wellbeing + % Disease • Loosing the wellbeing is proportionally gaining the disease Wellbeing guards Good food Superb lifestyle Complementary Nutraceuticals

10. Medical check-up • Revealing certain events in the health history of an individual Three aspects of Medical Check-up • Attempt to hunt priors (Backend events) • Understand present (Current event) • Predict posteriors (Frontend events)

11. Event Event Event Event Disease Causal Chain or Web • Events linked together • Chain could be reversed due to intervention • Pruning the Frontends could stimulate branching in the chain

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

13. 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?

14. 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)

15. Human Microbial Organs • Gut Associated, Vagina Associated, Skin Associated etc (Eco-organs) • Being described as Human Microbiome Prebiotics Probiotics Synbiotics Prof. Stig Bengmark

16. Clinical Research • To understand the disease of an individual, one has to understand human and his body computer and his associated organs also

17. ICD-10 classification • Infectious and Parasitic Diseases • Cancers • Endocrine, nutritional or metabolic diseases etc.

18. 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

19. Reality • 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)

20. 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 • Disease definition might not regard that component

21. 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.

22. 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

23. 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

24. 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

25. 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

26. Field testing of ICD-11 • Draft version of ICD-11 shall be field tested • What can be done? Participate in the field testing

27. 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

28. 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

29. 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

30. 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

31. Standard Terminology MeSH, Medical Subject Headings of NLM, NIH, USA Based on UMLS (Unified Medical Language System) Metathesaurus

32. 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

33. 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

34. Example of Disease Causal Chain; …follows Phytase (germinated grains) + Calcium + Vitamin D + Sun Exposure for Influenza prevention? Sania in Sun

35. Calcium deficiency as the front-end event due to Chelation by Phytic acid

36. Front end events of Reduced availability of Calcium

37. 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.

38. 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

39. 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," http://www.bmj.com/cgi/content/full/326/7379/12/b?etoc

40. Front end events of Vitamin D deficiency (Avitaminosis D syndrome, II)

41. 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

42. Front-end events of Vitamin D deficiency (Avitaminosis D syndrome, III) 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.

43. Epidemic influenza and vitamin D. Epidemiol Infect. 2006 Dec;134(6):1129-40 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

44. 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

45. 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

46. Indian Government Institute National 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

47. 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

48. 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

49. 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

50. Thank you