I think it is very fitting to this discussion to quote from a recent letter by Urban Jonsson in the April 2014 issue of World Nutrition:
While most agencies operating in the area of nutrition have adopted the conceptual framework of the causes of malnutrition, not all have used it correctly. There are a number of misconceptions, of which the three most common and serious are the following:
-The fact that household food security (‘food’), access to basic health services (‘health’), and adequate maternal and child care (‘care’) are necessary conditions of good nutrition, but that each of them or any two together are not sufficient conditions for good nutrition, is often not understood and appreciated in planning. Sufficiency requires that each of the food, health and care conditions are satisfied at the same time.
-Some agencies tend to leave out any recognition of the basic causes. The most common reason is a deliberate avoidance of the political aspects of malnutrition. The World Bank, for example, often avoids any strong recognition of the basic causes. The Scaling Up Nutrition (SUN) initiative has gone even further by simply defining two type of causes, ‘nutrition effective causes’ for the immediate causes and ‘nutrition sensitive’ for the underlying causes, avoiding any serious discussion of the basic (structural) or ‘root causes’.
-There is confusion in the understanding of the difference between causality and correlation. Many seem to believe that for example, risk-factor epidemiology identifies ‘causes’. This is not correct. Determinants, often mixed up with causes, derived from such statistical methods, may or may not represent a cause. This mix-up had some serious consequences in the analysis of the causes of HIV infection, for example. A similar confusion has plagued the UN Food and Agriculture Organization for the last 30 years, in its insistence on using the term ‘food and nutrition planning’. This is not a correct term. The proper term should be a phrase such as ‘nutrition planning, with a particular focus on food’.
The World Nutrition Editorial’s recommendation to broaden the meaning of ‘nutrition’, to include issues like ‘clinical nutrition’, ‘public health nutrition’, and so on, is a most welcome proposal. This clearly reflects the structure and content of the conceptual framework.
In developing and then working with the conceptual framework now approaching 40 years, I have found many advantages with its use. The most important one is that in practical work, there cannot be any agreement on priority actions for solving a problem until there is a reasonable agreement on the causes of the problem. The conceptual framework helps to ‘ask the right question’. Albert _Einstein once stated: ‘In science, the most important thing is to ask the right question. The answers can be left to amateurs’.