INTRODUCTION

Health and disease have always been matters of concern of the society. This resulted
in constant search for improvement in quality of living and maintenance of a healthy
society .In that process various concept on health, disease and treatment emerged, thereby the
practice of medicine got refined on scientific basis .The emergence of a biomedicine with the
advent of germ theory completely changed the outlook towards the health and disease and
effort in scientific investigation started finding correlation with material cause to every
diseases.

Understanding the causes of disease is the key to begin the process of finding
remedies that could cure them .Every medical system has its own model of identifying the
reason of disease. Based on those concept they develop models of treatment .Though all these
model divergent in nature, the goal of every medical system has been to provide rational
treatment to the diseases.

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 DEFINITIONS

HEALTH

1. “Health is a state of complete physical, mental and social wellbeing and not merely an
absence of disease or infirmity”. (WHO 1946)

2. “The condition of being sound in body, mind, or spirit, especially freedom from physical
disease or pain”. (WEBSTER)

3. “Health is a state dynamic balance of an individual’s ability to perform personally valued

roles and responsibilities , to deal and cope with physical, biological psychological and social
stresses and challenges throughout the life while continuing to maintain sense of wellbeing”

(ICN)

DISEASE

1. “Disease is a condition in which body health is impaired and performance of vital

function in the body is interrupted”.(WEBSTER)

2. “The condition of the body or some part of organ of the body in which its functions are
disrupted or deranged.”(OXFORD ENGLISH DICTIONARY)

3. A disease is a particular abnormal condition that negatively affects the structure or function
of part or all of an organism, and that is not due to any external injury.

4. According to Jennings (1986), “disease is demonstrable pathophysiology or

pathochemistry and is diagnosed by the demonstration of pathologic features”.

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CONCEPT OF DISEASE CAUSATION
There have been many attempts to define disease. Webster defines disease as “a condition in
which body health is impaired, a departure from a state of health, an alteration of the human
body interrupting the performance of vital functions”. From an ecological point of view,
disease is defined as maladjustment of human organism to the environment. From a
sociological point of view ,a disease is considered a social phenomenon, occurring in all
societies and defined and fought in terms of the particular cultural forces prevalent in the
societies. The concept of disease causation is clear from theories of disease causation ,
pathogenesis of disease and the iceberg phenomenon.

Concept of disease
causation

Theories Pathogenesis of disease Ice berg phenomenon

A).THEORIES OF DISEASE CAUSATION

OLD THEORIES;

1. Demonic / super natural theories

Religion, philosophy, medicine were integral part in the early part of civilization. It
was believed that sun, moon, and stars are capable of influencing human beings. Philosophy
accepted the influence of an in animated bodies such as sun, moon and stars on living
bodies. Thus a correlation between these health and disease was established in primitive
ages. One concept prevalent was that the evil spirit entering the body directly and pursuing
nefarious actions. Another concept was the evil spirit as a messenger of gods giving
warning in the forms of diseases. Some other concept was a human enemy with supernatural
powers, send evil spirits to harm others. Many cuneiform tablets contain prayers to certain

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gods asking for protection from demons, while others asked the gods to expel the demons
that invaded their bodies.

2. Punitive theory

The association of religion with the cure and treatment of sickness probably had
much to do with the evolution of what we may call the punitive theory of disease; the belief
that one’s attitude towards the deity was responsible as a cause of sickness .From a period
centuries prior to the Christian era down to the present time, there have been beliefs disease
as a punishment meted out by an outraged god for the sins of individual or the race. There
are recorded statements in biblical writings where in punishment is meted for a sin of
David, with devastating plague in which the whole nation suffered and which was stayed
only by David’s repentance and the making of a sacrifices .

3. Miasmatic theory

Miasmatic theory is based on the inference that the air arising from certain kinds of
ground, especially low, swampy areas, was a cause of disease. Certain places were thus
given a very evil reputation, because the ground was said to exude some invisible,
insensible vapour, called it miasm ,which produced disease.

The invention of miasma was really beginning to be a scientific medicine. People

were searching for a material and natural causes, instead finding shelter on god or a devil.
Rational thinking that something cannot come out of nothing was the basis of the concept.
The fact that malaria was prevalent in the vicinity of swampy land, and some evidence that
people who ventured out in these swampy places were more likely to get the disease.

4. Humoral theory

The Greeks rejected the super natural theories and looked upon a disease as a natural
process. They advocated that the matter is made up of four elements; earth, air, fire and
water and these elements have the qualities of being cold, dry, hot and moist. With this
concept they hypothesized that these qualities are represented in the body by four humors –
phlegm, yellow bile, black bile, and blood. According to this theory, the equilibrium among
these humors characterizes health, and disequilibrium characterizes disease.

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MODERN THEORIES;

 Biomedical model

Biomedical model is based on the greek philosophy which describes the mind and
body to be two separate entities with mind representing the godly aspect and the body as a
separate machine, the malfunctioning of which can be recognised easily by observation.
Invention of circulation by William Harvey and German pathologist sir. Rudolf Virchow
reinforced the mechanistic philosophy. According to this model, dame is the pathological
or mechanical alteration in body function. The pathological process needs to be contained
or baited and body function has to be restored through medical measures to get cure.

 Germ theory of disease

Germ theory was proposed by Louis pastuer (1822-1895) and Robert Koch (1843-1910).
Germ theory of disease is the currently accepted scientific theory for many diseases. It states
that microorganisms known as pathogens or "germs" can lead to disease. These small
organisms, too small to see without magnification, invade humans, other animals, and other
living hosts. Their growth and reproduction within their hosts can cause disease. "Germ"
may refer to not just a bacterium but to any type of microorganism or even non-living
pathogen that can cause disease, such as protists, fungi, viruses, prions, or viroids. Diseases
caused by pathogens are called infectious diseases. Even when a pathogen is the principal
cause of a disease, environmental and hereditary factors often influence the severity of the
disease, and whether a potential host individual becomes infected when exposed to the
pathogen.
Robert Koch is known for developing four basic criteria (known as Koch's postulates)
for demonstrating, in a scientifically sound manner, that a disease is caused by a particular
organism. These postulates grew out of his seminal work with anthrax using purified
cultures of the pathogen that had been isolated from diseased animals.
Koch's postulates:
 The microorganism must be found in abundance in all organisms suffering from the
disease, but should not be found in healthy organisms.
 The microorganism must be isolated from a diseased organism and grown in pure culture.
 The cultured microorganism should cause disease when introduced into a healthy
organism.

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 The microorganism must be re-isolated from the inoculated, diseased experimental host
and identified as being identical to the original specific causative agent.
Thus, the emphasis has shifted from empirical causes of old theories to microbes of germ
theory. The disease model accordingly is;

Disease agent man disease

Limitation of germ theory;
The germ theory of disease has many limitations .For example, it is well known that not
everyone exposed to tuberculosis develop tuberculosis. The same exposure, however, in an
undernourished or otherwise susceptible person, may result in clinical cases. Similarly, not
everyone exposed to beta haemolytic streptococci develops acute rheumatic fever.
 Epidemiological triad
One of the most straightforward models of disease causation is the epidemiologic triad or
triangle, the traditional model for infectious disease. The triad consists of an external agent,
a susceptible host, and an environment that brings the agent and host together. In this
model, disease results from the interaction between the agent and the susceptible host, in an
environment that supports transmission of the agent from a source to that host.
The epidemiologic triad model is helpful when considering association and causation. The
triad consists of three factors - agent, host and environment. They interact in a variety of
ways that result in various states of health in an individual or a community.

Agent;

The agent is the microorganism that actually causes the disease in question. These may be
classified into:

A. Living or biological agents

E.g: anthropods, helminths, protozoa, fungi, bacteria, virus

B. non-living or inanimate agents

E.g. nutrient agents such as energy, protein, carbohydrate, fat, vitamins, minerals,
water, and fibre. Chemical agents include arsenic, alcohol, dust; stone etc. physical agents
include atmospheric pressure, humidity, mechanical force, radiation, light, electricity, etc.

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Host;

The agent infects the host, which is the organism that carries the disease. A host doesn’t
necessarily get sick; hosts can act as carriers for an agent without displaying any outward
symptoms of the disease. Hosts get sick or carry an agent because some part of their
physiology is hospitable or attractive to the agent.

Environment;

Outside factors can affect an epidemiologic outbreak as well; collectively these are referred
to as the environment. The environment includes any factors that affect the spread of the
disease but are not directly a part of the agent or the host. For example, the temperature in a
given location might affect an agent’s ability to thrive, as might the quality of drinking
water or the accessibility of adequate medical facilities.

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  Theory of multifactorial causation.

This theory of multifactorial causation was put forth by Pettenkofer Munich (1819-
1901), which de-emphasizes the Germ theory.

As a result of advances in public health, it is now well recognized that many diseases
are neither caused by an organism nor could they be prevented by the traditional methods of
isolation, immunization, improvement in sanitation. These diseases are predisposed by
many factors (social, economic, cultural, genetic, and psychological) contributing to its
occurrence, especially in case of modern diseases of civilization like coronary heart disease,
various type of cancer, many types of diabetes, COPD, mental illness etc.

It is now known that most of these factors (excess of fat and salt intake, smoking, lack
of physical exercise, junk foods, and obesity) are so much linked to lifestyle and human
behaviour that they are considered as “risk factors”, in the web of causation of disease.

Risk factors:

1. Modifiable factors
Smoking, hypertension, elevated serum cholesterol, physical activity, obesity,
etc.
2. Unmodifiable factors
Age, sex, race, family history, and genetic factors.
The risk factors can be modified by intervention or eliminated, thereby reducing
the possibility of occurrence of the disease. This is called ‘primordial prevention’.
3. Risk groups
These are group of individual who are exposed to, or associated with, the risk
factors and, therefore, they are at high risk of mortality and morbidity, either
because of constitution or of the environmental physically, biologically, or
socioculturally. These are the people who require identification and health care
services most. This is known as risk approach. Risk groups depending upon the
situation includes:
 Physical situation:
Poor living condition, overcrowding and lack of sanitation
 Biological situation:
1. Age wise (LBW newborns, infants, toddlers, elderly )

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 2. Sex wise ( female in reproductive age )
3. Physiological state ( pregnancy and malnutrition )
4. Genetic factors ( strong family history )mh
 Sociocultural situation:
Socioeconomic class, lifestyle, habits, beliefs, customs, tradition, etc.

 Web of Causation

This model of disease causation was suggested by McMahon and Pugh. The web of
causation considers all the predisposing factors of any type and their complex
interrelationship with each other. This model is ideally suited in the study of chronic
diseases, where disease agent is not known but is an outcome of interaction of multiple
factors. The web of causation does not imply that the disease cannot be controlled unless all
the multiple causes or chains of causation or at least a number of them are appropriately
controlled or removed. This is not a case. Sometimes removal or elimination of just only
one link or chain may be sufficient to control disease, provided that link is sufficiently
important in the pathogenetic process.

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  Wheel theory

As medical knowledge advanced, an additional aspect of interest that came into play
is the comparative role of “genetic” and “environmental” (i.e., extrinsic factors outside the
host) factors in causation of disease. To explain relative contribution of genetic and
environmental factors, the “wheel” theory was postulated. This theory visualizes human
disease in the form of a wheel, which has a central hub representing the genetic component
and the peripheral portion representing the environmental component. The environmental
component has three spokes representing three components namely the social, biological, and
physical components of the environment. To maintain health, one has to exercise regularly
and take adequate rest, follow personal hygiene, eat nutritionally balanced diet, abstain from
the abuse of drugs and alcohol, take care of one’s mental well-being, and develop social skills
to interact in a positive manner within the society.

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B). PATHOGENESIS OF DISEASE

It means the evolution of a disease process in an individual, from its early stage to final
stage of recovery or death, in the absence of any intervention such as prevention or
treatment. This differs from disease to disease and from person to [Link] involves two
phases;

 Pre-pathogenesis phase

This phase refers to the period before the onset of disease. During
this phase, interaction is taking place among the three component of epidemiological triad
namely agent, host, and environment. Each representing the angle of triangle respectively.

As long as there is equilibrium among these three interacting factors, as long the
person will be healthy. Once the equilibrium is distributed, disease process starts. In other-
words, potentially we are all in pre pathogenesis phase of many diseases, both
communicable and non- communicable.

Agent factors;

A disease agent is defined as a substance, living or non -living or a force, the

excessive presence or relative lack of which initiates the diseases process. The disease
agents are broadly classified into the following groups:

1. Physical agents: heat, cold, radiation, noise, atmospheric pressure, humidity, etc.

2. Chemical agents: urea, uric acid, bilirubin, ketones, calcium oxalates, dust, gas,
fumes, metals, or allergens.

3. Biological agents: viruses, Rickettsiae, bacteria, fungi, protozoa, etc.

4. Mechanical agents: friction, force, injury, sprain, accidents etc.

5. Nutrition agents: nutrients like proteins, fats, carbohydrates, vitamins, minerals and
water etc.

Host factors:

1. Age-certain diseases are peculiar in certain age group, example, measles and
diphtheria among the children, hypertension, and diabetes among the middle-aged.

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 2. Sex – certain diseases like lung cancer and coronary heart diseases are common among
men and rheumatic arthritis, hyperthyroidism, diabetes, and obesity are common
among women.
3. Ethnicity – sickle cell anemia is more frequent among the Negroes. Thalassemia is
common among people of the Mediterranean region.
1. Occupation – this not only determine income but also the health hazards arising out of
the occupation.
2. Literacy Level – the higher the literacy level, the lower is incidence of the disease.
3. Income – this is the factor determining standard of living and influences the development
of disease. Lower socioeconomic status predisposes for infectious diseases and higher
status for non -communicable diseases.
4. Marital status –cancer of cervix is common among the married women than the
unmarried women. Similarly, STDs and HIV are common among unmarried than among
married persons.
5. Nutritional status – poor nutritional status makes a person more vulnerable to infectious
diseases.
6. Life style factors – Like smoking, alcoholism, drug abuse, lack of exercise ,multiple
sexual partnership ,etc. favour the development of diseases.

Environmental Factors;
These are classified into physical, biological, and sociocultural environment.
*physical environment: air, water, soil, food etc..
*biological environment: plants, animals, insects, rodents, microbes etc…
*sociocultural environment: it includes factors like exposure to stressful situations such as
death or divorce of the parents, desertion, loss of employment, birth of handicapped child,
etc, which produce feelings of anxiety ,tension ,anger ,depression, frustration etc..

 pathogenesis phase
The pathogenesis phase begins with the entry of the disease agent in the susceptible
human host. The further events in the pathogenesis phase are clear cut in the infectious
disease i.e. .the disease agent multiplies and induces tissue and physiological changes , the
disease progresses through a period of incubation and later through early and late
pathogenesis. The final outcome of the disease may be recovery, disability, or death. The

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pathogenesis phase may be modified by interventions such as immunization and
chemotherapy.
The infection may be clinical or sub-clinical, and when it is subclinical, the person will not
have recognizable signs and symptoms but spread disease agent to others, acting as a
carrier, as in typhoid and diphtheria. When a person develops clinical signs and symptoms,
he is called clinical case. Pathogenesis has two distinct phases;

 Preclinical phases
During this period, the parasites lodges, multiplies, and starts the disease process in
the host but the symptoms and signs are neither felt by the prospective patients, nor are they
apparent to the doctor on clinical examination. Incubation period may, thus, be defined as
the length of the time, reckoned from the point of entry of the parasite into the host, till the
clinical manifestation of the disease.

 Clinical phases
The disease become clinically manifested in this phase. The severity of
illness in an individual again depends on agent, host, and environment.
In chronic diseases, the early pathogenesis phase is less dramatic. This phase in chronic
diseases is referred to as presymptomatic phase. During the presymptomatic phase, there is
no manifest disease. The pathological changes are essentially below the level of “clinical
horizon”. The clinical stage begins when recognizable signs or symptoms appear.

C). ICEBERG PHENOMENON OF DISEASE

According to this concept, Disease in a community may be compared with an iceberg.

When a piece of ice allowed to float on water, a small portion is visible and major portion
is submerged in the water. The floating tip of the iceberg represents what the physician
sees in the community, i.e. clinical cases (Diagnosed case, symptomatic case or clinically
apparent case).It includes sub-clinical cases & carriers

The vast submerged portion of the iceberg represents the hidden mass of disease, i.e.
latent, in apparent, pre symptomatic and undiagnosed cases and carriers in the community.
The “waterline” represents the demarcation between apparent and in apparent disease.

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 Epidemiologist is concerned with Hidden portion of iceberg whereas clinician is
concerned with tip of iceberg.

Screening is done for Hidden portion of iceberg whereas diagnosis is done for tip of
iceberg. Iceberg phenomenon of disease is not shown by rabies, tetanus and measles.

NATURAL HISTORY OF DISEASE

The natural history of disease is the course a disease takes in individual people from its
pathological onset ("inception") until its eventual resolution through complete recovery or
death. The inception of a disease is not a firmly defined concept. The natural history of a
disease is sometimes said to start at the moment of exposure to causal agents. Knowledge of
the natural history of disease ranks alongside causal understanding in importance for disease
prevention and control.

This is refers to the progression of a disease in an individual over time, in the absence of
treatment. For example, untreated infection with HIV causes a spectrum of clinical problems
beginning at the time of seroconversion and terminating with AIDS and usually death. It is
now recognized that it may take 10 years or more for AIDS to develop after seroconversion.

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Natural history of disease provides crucial insights into disease occurrence, disease severity
(clinical services, public health programs), disease treatment, and disease prevention.

DEATH

EXPOSURE HOST DISABILITY

DISEASE

RECOVERY

STAGES OF NATURAL HISTORY OF DISEASE

 Susceptibility Stage:

Susceptibility refers to the pre-exposure period in the natural history of disease, in which the
individual in the population is vulnerable or at risk (i.e., susceptible) to acquire the infection
and/or amenable to get exposed to and be harmed by a health determinant. During this stage,
the individual in the population does not have the disease nor the infection; only the risk
factors are present. For example, a healthy person having unprotected sex in a population
where Chlamydia infections are present is in the susceptibility stage. Susceptibility of an
individual depends mostly on host factors, both inherited and learned or otherwise acquired
and embodied. The susceptibility stage ends with effective exposure.

 Sub-Clinical Stage:

In this stage, the etiological factors (e.g., infectious agent, risk behaviours, environmental
toxins) are present in the body and are causing pathological changes, but there are not yet any
discernible signs or symptoms.

For example, a person whose smoking habits have produced certain non-reversible
pathological changes in lung tissue is in the sub-clinical stages of lung cancer. This concept
was first expressed by Jacob Henle, in the mid-19th century, in terms of communicable

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disease: "The symptoms of disease do not appear directly after the entry of the contagious
agent but rather after a certain period, which varies in the different contagions “.

Incubation Periods;

In infectious diseases, the sub-clinical stage is known as the incubation period. This period
can be short (e.g. influenza, 1-2 days), intermediate (e.g. chicken pox, 2-3 weeks) or extended
(e.g. acquired immunodeficiency syndrome (AIDS), up to 15 years or longer).

In non-infectious diseases, the sub-clinical stage is known as the latent period or induction
period. This phase can be as short as seconds, as with a hypersensitivity reaction or toxic
reaction, or as long as decades, such as with the time between exposure to a carcinogen and
progression of a resulting tumour to a size that causes signs or symptoms .For example,
following the atomic bomb blast in Hiroshima, the latent period for the development of
leukemia was from 2 to 12 years, with a peak at 6 to 7 years, with the effective exposure.

 The clinical stage :

It is refers to the period of time at the onset of signs or symptoms of the disease. Ideally, a
diagnosis is made as soon as the clinical stage appears, but for a variety of reasons, this does
not always happen. Host factors, access to care, geography, and social factors, to name a few,
can all influence the time of diagnosis.

The expression of the clinical stage of the disease varies in the population. It can range from
mild signs and symptoms, to moderate symptoms, or to severe expression of illness. For
example, one individual may be seriously ill with an upper respiratory tract infection,
whereas a second individual exposed to the same source of infection and to the same extent,
may experience only mild symptoms. This is due to a difference in host factors such as the
nutritional status of the individual. It is important to note that depending on the condition,
certain individuals and segments of the population will not experience this stage of the
natural history of the disease; either it never progresses past the sub-clinical stage or
preventive measures are applied at an earlier stage.

When thinking about sub-clinical versus clinical stages of disease, it is useful to recall the
iceberg metaphor, since there are important implications for public health. Consider
poliomyelitis, which manifests itself primarily sub-clinically in the population. Most of the
"polio iceberg" is submerged - for every individual presenting with paralysis, there are at

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least 99 others who are infected and capable of spreading the disease but who show no signs
of paralysis

 Recovery, Disability or death

The final stage in the natural history of disease concerns the outcome: recovery, disability or
death. For any given disease or condition, how this stage is manifested is influenced by a
number of factors.

Myocardial infarction, for example, can result in recovery, recovery associated with
significant activity restrictions, or death. Factors such as time between infarct and medical
attention, presence of other conditions, availability of treatment, methods of treatment, and
severity of the event all influence the final outcome.

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FACTORS OF DISEASE CAUSATION

 Predisposing Factors ;

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 Factors which create a state of susceptibility, making the host vulnearable to the agent.
These are age, sex, and previous illnesses.

 Enabling Factors;

Enabling factors are those which assist in the development of the [Link] ,housing
conditions and socioeconomic status.

 Precipitating Factors;
Precipitating factors are those which are associated with immediate exposure to
the disease agent or onset of the disease. E.g., drinking contaminated water, close
contact with a case of pulmonary TB.
 Reinforcing Factors;
These are those which aggravate an already existing [Link], malnutrition,
repeated exposure.
 Risk Factors ;
Risk factors are conditions, quality or attributes, the presence of which increases
the chances of an individual to have, develop, or adversely affected by a disease
process. The risk factors need not necessarily cause the disease but does increase the
probability that the person exposed to the factor may get the disease easily.

PSYCHODYNAMIC CAUSATION OF DISEASE

It is study of the interrelationship of various parts of the mind, personality as

they related to mental, emotional motivational forces especially at the unconscious level.
The interrelationship of various conscious and unconscious mental as they influence
personality behaviour and attitude.

Psychosomatic Model of Health and Disease

The causation of lifestyle diseases could not be explained convincingly based on the
biomedical model. In an attempt to explain the causes of diseases from different
psychosomatic relationships, the psychosomatic model was developed in 1930 by Dunbar and
associates. According to this model, disease develops as a result of continuous interplay of

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physical and mental factors (Tamm, 1993). All somatic diseases have social and emotional
precedents. Similarly, all psychic diseases present with somatic symptoms. Healing of
diseases can be promoted by developing positive attitude and stress reduction strategies
which helps in striking a balance between body and mind. According to the psychosomatic
model, health cannot be administered to any individual rather that person should take
responsibility to attain health. Since the psychosomatic theory encompasses too broad
concepts it is not well accepted.

Psychodynamic theory

Psychodynamic theory is systematized study and theory of the psychological forces that
underlie human behaviour, emphasizing the interplay between conscious and
unconscious motivation. It is processes and behaviour. The original concepts of
psychodynamics was developed by Sigmund Freud, it includes;
1. ID
2. Ego
3. Super- ego
ID
The id is the source of all [Link] present at birth. It operate according to the pleasure
principle, that is, seeking pleasure and avoiding pain, regardless of societal beliefs or
restraints. This means actions generated predominantly by id are likely to be
unsuppressed or unrestricted. The behaviour of young children often shows control of
id.
EGO
The ego begins its development during the 4th or 5th month of life. In Freud‘s approach to
the personality, the is the problem solving part of the personality ,which operates
according to the reality principle. The ego seeks pleasure and avoids pain in rational
ways that the society approves. The ego, thus seems to take the demands of id and
determines how to satisfy them in an acceptable manner.
SUPEREGO
The superego is the necessary part of socializing that develops during 3-6 years of age.
According to Freud, the superego reminds the person of what would be ideal behaviours
and what behaviours are totally unacceptable. The conscience found in the superego

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GLOBAL BURDEN OF DISEASE

Everyone, all over the world, deserves to live a long life in full health. In order to achieve
this goal, we need a comprehensive picture of what disables and kills people across
countries, time, age, and sex. The Global Burden of Disease (GBD) provides a tool to
quantify health loss from hundreds of diseases, injuries, and risk factors, so that health
systems can be improved and disparities can be eliminated.
In order to align health systems with the populations they serve, policymakers first need to
understand the true nature of their country’s health challenges – and how those challenges
are shifting over time. That means more than just estimating disease prevalence, such as
the number of people with depression or diabetes in a population. GBD research
incorporates both the prevalence of a given disease or risk factor and the relative harm it
causes. The tools allow decision-makers to compare the effects of different diseases, such
as malaria versus cancer, and then use that information at home
The Lancet medical journal released a study on April 3, 2019 titled “ Health effects of
dietary risks in 195 countries, 1990–2017: a systematic analysis for the Global Burden of
Disease Study 2017” or the Global Burden of Disease study. This study aims to evaluate
the consumption of major foods and nutrients across 195 countries and hence, quantify the
impact of a suboptimal dietary intake, an important preventable risk factor for non-
communicable diseases (NCDs), on mortality and morbidity.
The study has collected geographically representative dietary data and estimated the
effects of dietary factors on NCD-related mortality as well as the overall impact of poor
dietary practices. Using comparative risk assessment, the study estimates the proportion of
disease-specific burden, attributable to each dietary risk factor amongst adults aged 25
years and above. The main inputs of analysis included the intake of each dietary factor, the
effect size of the dietary factor on disease endpoint and the level of intake associated with
the lowest risk of mortality. The study then calculated the number of deaths and disability-
adjusted life-years or DALYs attributable to diet for each disease outcome.
The study analysed 15 dietary elements i.e. diets low in vegetables, fruits, legumes, nuts
and seeds, whole grains, milk, fibre, calcium, seafood, omega-3 fatty acids,
polyunsaturated fats as well as diets high in red meat, processed meat, sugar-sweetened
beverages, trans fatty acids, and sodium. According to the study, 11 million deaths and
255 million DALYs were attributable to dietary risk factors in 2011. Globally, the leading

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 dietary risk factors for deaths and DALYs were high intake of sodium, intake of whole
grains and low intake of fruits.
Poor dietary habits can lead to a wide range of chronic diseases and this study provides a
comprehensive picture of the potential impact of suboptimal diets on NCD-related
morbidity and mortality. It highlights the urgent need for qualitatively improving diets
across countries and aims to inform the implementation of evidence-based dietary
interventions, while providing a platform for the evaluation of their impacts on human
health on an annual basis. Given, the complexity of dietary behaviours and wide range of
influences on diets globally, the improvement of diets worldwide demands an active
collaboration between multiple stakeholders across the global food system with specific
policies targeting particular sectors.

PREVENTION OF DISEASE CAUSATION

Successful prevention depends upon the knowledge of causation, dynamics of

transmission, identification of risk factors and risk group, availability of prophylactic and
early detection & treatment measures ,an organisation for applying these measures to
appropriate persons or groups, and continuous evaluation and development of procedures
applied.
Levels of prevention;
1. Primordial prevention
2. Primary prevention
3. Secondary prevention
4. Tertiary prevention

1. PRIMORDIAL PREVENTION;
It focuses on prevention of the emergence and development of risk factors in
the countries for the population groups in they have not yet appeared. For example, many
adult health problems (e.g. obesity, hypertension) have their early origins in childhood,
because this the time when the lifestyles are formed. In this level of prevention, efforts are
directed towards discouraging children from adopting harmful lifestyles. The main
intervention in primordial prevention is through individual and mass education.
2. PRIMARY PREVENTION;

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 Primary Prevention can be defined as “action taken prior to the onset of
disease, which removes the possibility that a disease will ever occur”. It signifies
intervention in the pre pathogenesis phase of a disease or health problem (e.g., low birth
weight) or other departure from health. Primary prevention may be accomplished by
measures designed to promote general health and well-being, and quality of life of people
or by Specific protective measures. These are discussed in detail elsewhere under “Mode
of Intervention”.

Primary prevention is far more than averting the occurrence of a disease and prolonging
life. It includes the concept of “positive health”, a concept that encourages achievement
and maintenance of “an acceptable level of health that will enable every individual to lead
a socially and economically productive life”. It concerns an individual’s attitude towards
life and health and the initiative he .takes about positive and responsible measures for
himself, his family and his community. The concept of primary prevention is now being
applied to the prevention of chronic diseases such as coronary heart disease, hypertension
and cancer based on elimination or modification of “risk factors” of disease. The WHO
has recommended the following approaches for the primary prevention of chronic diseases
where the risk factors are established.
a). population(mass) strategy
b). high-risk strategy
a. Population (mass) strategy:
Another preventive approach is “population strategy” which is directed at the
whole population irrespective of individual risk levels. For example, studies have shown
that even a small reduction in the average blood pressure or serum cholesterol of a
population would produce a large reduction in the incidence of cardiovascular disease. The
population approach is directed towards socio-economic, behavioural and lifestyle
changes.

b. High risk strategy

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 The high-risk strategy aims to bring preventive care to individuals at special
risk. This requires detection of individuals at high risk by the optimum use of clinical
methods.
Primary prevention is a desirable goal. It is worthwhile to recall the fact that the
industrialized countries succeeded in eliminating a number of communicable diseases like
cholera, typhoid and dysentery and controlling several others like plague, leprosy and
tuberculosis, not by medical interventions but mainly by raising the standard of living
(primary prevention). And much of this success came even before immunization became
universal routine.
3. SECONDARY PREVENTION;
Secondary prevention can be defined as “action which halts the progress of a
disease at its incipient stage and prevents complications”. The specific interventions are
early diagnosis (e.g., screening tests, case finding programmes) and adequate treatment.
By early diagnosis and adequate treatment, secondary prevention attempts to arrest the
disease process; restore health by seeking out unrecognized disease and treating it before
irreversible pathological changes have taken place; and reverse communicability of
infectious diseases. It may also protect others in the community from acquiring the
infection and thus provide at once secondary prevention for the infected individuals and
primary prevention for their potential contacts.
4. TERTIARY PREVENTION;
When the disease process has advanced beyond its early stages, it is still
possible to accomplish prevention by what might be called “tertiary prevention” . It
signifies intervention in the late pathogenesis phase. Tertiary prevention can be defined as
“all measures available to reduce or limit impairments and disabilities, minimise suffering
caused by existing departures from good health and to promote the patient’s adjustment to
irremediable conditions”. For example, treatment, even if undertaken late in the natural
history of disease may prevent sequelae and limit disability. When defect and disability
are more or less stabilized, rehabilitation may play a preventable role. Modem
rehabilitation includes psychosocial, vocational, and medical components based on team
work from variety professions. Tertiary prevention extends the concept of prevention into
fields of rehabilitation.

MODE OF INTERVENTION;

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 Any attempt to intervene or interrupt the usual sequence in the development of
disease.
Health promotion
Specific protection
Early diagnosis and treatment
Disability limitation
Rehabilitation

1. Health Promotion
Health promotion is the process of enabling the people to increase control over, and
to improve health. It is not directed against any particular disease, but is intended to
strengthen the host through a variety of [Link] includes;
• Health education
This is the one of the most cost effective interventions. A large number of
diseases could be prevented with little or no medical intervention if people were
adequately informed about them and if they were encouraged to take necessary
precaution in time. Recognizing this truth, WHO’s constitution states that “the extension
to all people of the benefits of medical, psychological, and related knowledge is essential
to the fullest attainment of health”. The targets for essential efforts include the general
public, patients, priority groups, health providers, community leaders, and decision
makers.
• Environmental modifications
A comprehensive approach to health promotion requires environmental
modifications, such as provision of safe water, installation of sanitary latrines, control of
insects and rodents, improvement of housing etc.
• Nutritional interventions
These comprise food distribution and nutritional improvement of vulnerable
groups; child feeding programmes; food fortification; nutrition education etc.
• Life style and behavioural changes
The conventional public health measures or interventions have not been
successful in making inroads into lifestyle reforms. The action of prevention in this case,
is one of the individual and community responsibility for the health, the physician, in fact
each health workers acting as an educator than a therapist. Health education is the basic

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element of all health activity. It is of paramount importance in changing the views,
behaviour and habit of the people.

2. Specific Protection
To avoid disease altogether is the ideal but is possible only in a limited number
of cases. The following are some of the currently available interventions aimed at
specific protection.
• Immunization e.g. Vaccine preventable diseases.
• Specific nutrient e.g. Iron.
• Protection against injuries (helmet, seat belt)
• Chemoprophylaxis e.g. against Malaria.
•Control of consumer product quality and safety of foods, drugs, cosmetics. etc

3. Early diagnosis and Treatment
It is the main intervention in disease control. It is like stamping out the ‘spark’
rather than calling the fire brigade to put out the fire. It the disease is diagnosed and
treated earlier, it will prevent complications and also secondary cases in the community.
Methods employed for early diagnosis are
1) Individual and mass case finding
2) Screening and surveys
3) Periodic examination
4) Special examination of people at risk. Treatment depends on the nature of
the disease and its condition.

4. Disability Limitation
It is the intervention taken in the stage of late pathogenesis. Disability limitation
prevents complications and also prevents or postpones death. The major causes of
disability are communicable diseases, malnutrition, lack of parental care and accidents.
Disability can be prevented by:
 reducing the occurrence of impairment e.g. polio immunisation
 appropriate treatment, E.g. treatment of thrombo-angitis obliterans
(TAO) can prevent amputation
 Preventing the disability to produce handicap e.g. preventing loss of
employment in case of loss of limb.

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 [Link]

It is the combined and coordinated use of medical, social, educational and vocational
measures for training and retraining the individual to the highest possible level of
functional ability. The different types of rehabilitation are:
[Link] rehabilitation – It is restoration of function
[Link] rehabilitation – It is restoration of the capacity to earn livelyhood.
3. Social rehabilitation – It is the restoration of family and social relationships.
4. Psychological rehabilitation – It is restoration of personal dignity and confidence.
Examples of rehabilitation are:
1. provision of aids to the crippled
2. establishment of blind schools
3 reconstructive surgery for leprosy
4. physiotherapy and exercise in polio cases
5. change to a suitable occupation
6. reassurance and socially accepting leprosy patients
7. modification of life in general and especially in cardiac patients.

ROLE OF NURSE IN PREVENTION OF DISEASES

Nurses working in various venues have a great responsibility in preventative

care and wellness. The backbone of the nursing profession has always been recognized as
that of a caring profession and one that excels in disease prevention and health promotion.
Nurses are strong advocates for patients because they navigate the health care system.
Nurses can work formally or informally as case managers. There are formal roles for
nurses as case managers where the nurse's only role is to help patients and families
navigate through the health care system. Informally, all nurses work with patients and
families to make sure that they receive the holistic care that is needed for optimal
outcomes.
Nurses work as consultants in communities and organizations to define the
health care needs of that population, promoting activities and community development for
the citizens who live there. Nurses are most recognized as the primary caregivers of
patients in various venues. They are the ones who provide the hands-on care.
One of the most critical roles that nurses have in health promotion and disease preventions
is that of an educator. Nurses spend the most time with the patients and provide

27
anticipatory guidance about immunizations, nutrition, dietary, medications, and safety.
Nurses are consistently working to prevent illnesses such as heart disease, stroke, diabetes,
and obstructive pulmonary disease; they do this through a variation of tactics that include
education, risk factor prevention, and the monitoring of safety hazards either in the
workplace, community, or home.
Nurses are tasked with improving the health of patients through evidence-
based recommendations while encouraging individuals to receive preventative services
such as screenings, counseling and precautionary medications. Through public health
education, nurses can inspire a larger group of people to engage in healthy lifestyles and
ultimately live longer lives. Preventative health care nurses encourage:
1. Regular exercise: Nurses promote regular activity (preferably 30 minutes
of exercise at least five days a week) to combat heart conditions, high
blood pressure and other diseases such as stroke, diabetes and arthritis.
2. Weight management: Exercise also encourages weight management.
Preventative care includes maintaining and controlling weight with
exercise and healthy eating habits to prevent diseases such as obesity,
cardiovascular disease and osteoarthritis.
3. Avoidance of smoking and drug abuse: Aside from the addiction threat
associated with smoking and drug use, there is the risk of lung cancer,
emphysema and other forms of cancer.
4. Moderated alcohol use: Education about the effects of alcohol
consumption, as well as early screening for diseases such as liver disease,
stroke or high blood pressure, can significantly increase the chances of
illness prevention.
5. Control of existing diseases: Nurses involved with preventative health
care work to identify existing conditions in the early stages. Modifying an
individual’s behaviors can control or minimize the effects of a particular
ailment.

CONCLUSION

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 Health is the level of fuctional or metabolic efficiency of a living being. In
humans,it is the general condition of a person’s mind, body and spirit,usally meaning to
be free from illness, injury or pain. The disease is just the opposite of the health-ie, any
deviation from normal functioning or state of complete physical or mental well-being.
Since health and disease are mutually exclusive. In some diseases, a carrier state occurs
in which the individual remains outwardily healthy, and is able to infect others. In some
instances, same organism may cause more than one clinical manifestation. The end-point
of disease is variable- recovery, disability, or death of host. So to protect the health,we
should know the biological and psychological dynamics of causation of [Link]
includes concept of diseases, natural history of disease, factors causing diseases, and
preventive interventions. This seminar explains about these all things and also explains
what are the nurses role for the prevention of diseases and promotion of health.

BIBLIOGRAPHY
Navdeep kaur Brar, Rawat H C,” Textbook of advanced nursing practice” ,5th
edition, Jaypee publication, page no: 299-316
Park K,” park’s textbook of preventive and social medicine”, 19th edition, page
no:22-36
Potter & Perry,” Fundamentals of Nursing” , 5th edition ,Elsevier publication,
page no: 485 -500
Suresh K Sharma,” Lippincott Manual of Medical-Surgical Nursing”, 3rd edition,
Wolters Kluwer publishers , page no:4-5
Suresh K Sharma , S. Madhavi,” Brunner & Suddharth’s textbook of medical
surgical nursing”, volume 1, south Asian edition, Wolters Kluwer publishers page
no:9-11
Linton, “Introduction to Medical- Surgical Nursing”, 6th edition , Elsevier
publication ,page no:90- 92
The lancet medical journal released on April23,2019.

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