nutrients

Article
Second Version of a Mini-Survey to Evaluate Food
Intake Quality (Mini-ECCA v.2): Reproducibility and
Ability to Identify Dietary Patterns in
University Students
María Fernanda Bernal-Orozco 1,2,3,4 , Patricia Belen Salmeron-Curiel 1 ,
Ruth Jackelyne Prado-Arriaga 1 , Jaime Fernando Orozco-Gutiérrez 1 , Nayeli Badillo-Camacho 1,2 ,
Fabiola Márquez-Sandoval 1,2,3,4 , Martha Betzaida Altamirano-Martínez 1,3 ,
Montserrat González-Gómez 1 , Porfirio Gutiérrez-González 2,5 , Barbara Vizmanos 1,2,3,4 and
Gabriela Macedo-Ojeda 1,2,4,6, *
1 Bachelor of Nutrition, Centro Universitario de Ciencias de la Salud (CUCS), Universidad de
Guadalajara (UdeG), Sierra Mojada 950, Building “N”, Colonia Independencia, Guadalajara,
Jalisco, ZC 44340, Mexico; [email protected] (M.F.B.-O.); [email protected] (P.B.S.-C.);
[email protected] (R.J.P.-A.); [email protected] (J.F.O.-G.); [email protected] (N.B.-C.);
[email protected] (F.M.-S.); [email protected] (M.B.A.-M.);
[email protected] (M.G.-G.); [email protected] (B.V.)
2 Doctorate in Traslational Nutritional Sciences, CUCS, UdeG, Juan Díaz Covarrubias and Salvador Quevedo
y Zubieta, Building “C”, Colonia Independencia, Guadalajara, Jalisco, ZC 44340, Mexico;
[email protected]
3 Department of Human Reproduction, Growth and Child Development, CUCS, UdeG, Hospital 320, Colonia
El Retiro, Guadalajara, Jalisco, ZC 44100, Mexico
4 Translational Nutrigenetics and Nutrigenomics Institute, CUCS, UdeG, Sierra Mojada 950, Building Q, first
floor, Colonia Independencia, Guadalajara, Jalisco, ZC 44340, Mexico
5 Mathematics Department, Centro Universitario de Ciencias Exactas e Ingenierías, UdeG, Blvd. Marcelino
García Barragán 1421, Guadalajara, Jalisco, ZC 44430, Mexico
6 Department of Public Health, CUCS, UdeG, Sierra Mojada 950, Building “N”, Colonia Independencia,
Guadalajara, Jalisco, ZC 44340, Mexico
* Correspondence: [email protected]; Tel.: +52-331-058-5200 (ext. 33900)




Received: 27 February 2020; Accepted: 17 March 2020; Published: 19 March 2020


Abstract: Evaluation of food intake quality using validated tools makes it possible to give individuals
or populations recommendations for improving their diet. This study’s objective was to evaluate the
reproducibility and ability to identify dietary patterns of the second version of the Mini Food Intake
Quality Survey (Mini-ECCA v.2). The survey was administered using a remote voting system on two
occasions with four-week intervals between administrations to 276 health science students (average
age = 20.1 ± 3.1 years; 68% women). We then performed a per-question weighted kappa calculation,
a cluster analysis, an ANOVA test by questionnaire item and between identified clusters, and a
discriminant analysis. Moderate to excellent agreement was observed (weighted κ = 0.422–0.662).
The cluster analysis identified three groups, and the discriminant analysis obtained three classification
functions (85.9% of cases were correctly classified): group 1 (19.9%) was characterized by higher
intake of water, vegetables, fruit, fats, oilseeds/avocado, meat and legumes (healthy food intake);
group 2 (47.1%) frequently consumed both fish and unhealthy fats (habits in need of improvement);
group 3 (33%) frequently consumed sweetened beverages, foods not prepared at home, processed
foods, refined cereals and alcohol (unhealthy food intake). In conclusion, the Mini-ECCA v.2 has
moderate to excellent agreement, and it is able to identify dietary patterns in university students.

Nutrients 2020, 12, 809; doi:10.3390/nu12030809 www.mdpi.com/journal/nutrients

Nutrients 2020, 12, 809 2 of 18

Keywords: diet patterns; food intake quality; reproducibility; eating behavior; food assessment; diet;
undergraduate health students

1. Introduction
Diet plays a determinant role in either the maintenance or deterioration of health. More specifically,
the intake of certain foods, food groups or nutrients has been proven to have an influential effect on
the prevention, development and treatment of a number of chronic non-communicable diseases [1,2].
In light of this reality, dietary quality evaluations have become fundamentally important in today’s
clinical and epidemiological research [3].
The term dietary quality is often used to identify the components of a healthy, balanced and
nutritious diet and adapt them to the needs of specific populations with the aim of optimizing health [4].
One way of determining dietary quality is through the use of indices that make it possible to categorize
an individual’s diet after comparing that person’s actual and recommended intake levels [5,6]. Some of
the most internationally recognized indices are the Healthy Eating Index (HEI) [7–12], the Alternative
Healthy Eating Index (AHEI), the Diet Quality Index (DQI) [13,14] (this one has been adapted in
different countries and age groups), the Diet Diversity Score (DDS) [15] and the Healthy Diet Indicator
(HDI) [16], among others. In Mexico, the Mexican Diet Quality Index (ICDMx) has gained significant
recognition [17].
The administration, analysis and data interpretation of these tools are time-consuming, as they
entail the use of mechanisms such as food surveys, 24-h reminders, food records or semiquantitative
food frequency questionnaires in order to study dietary factors such as adequacy, balance, variety,
safety, and so on [5,18]. With 24-h recalls and semiquantitative food frequency questionnaires, cognitive
functions such as conceptualization (the ability to make a mental construction of a particular amount
of food not present) and memory (the ability to remember the amount ingested) may lead to confusion
in the subject and contribute to potential sources of error in estimating quantities, which do not allow
the accuracy of the tool used to be assessed with a risk of under-reporting bias to be present [19].
The need of surpassing these application difficulties inherent in the evaluation of the diet led
us to seek to build an easy and quick tool to apply with visual support, to be able to make both
group and individual diagnosis of eating habits and decisions of intervention for the improvement of
quality consumption.
Taking this into consideration, we identified other indices that have been developed which
evaluate only food intake quality, as opposed to diet quality. In particular, they analyze the extent to
which adherence to food intake recommendations, the intake of specific food groups or a mixture of
both has either a positive or negative effect on health [20]. These tools have few question items, are
precise and easy to answer and require short administration and interpretation times [21]. Examples of
such indices are those that measure adherence to the Mediterranean diet [22–25].
In Mexico, a tool called the Mini Food Intake Quality Survey (Mini-ECCA), whose structure was
similar to that of indices which measured adherence to the Mediterranean diet and included photographs
as a visual reference to estimate quantity, as they present lower food quantity estimation error than
other visual support tools [19], provided a rapid assessment of food intake quality as indicated by
adherence to intake recommendations. This survey produced good levels of reproducibility (ρ = 0.713,
p < 0.001; ICC = 0.844, 95% CI, 0.793–0.883) and moderate levels of agreement in terms of food intake
quality classification (κ = 0.545, 95% CI, 0.484 to 0.606, p < 0.001), and thus proved to be suitable for
dietary evaluation and guidance purposes [26]. This is, as far as we know, the only short survey
assessing food quality or adherence to national (Mexican) [17,27,28] and international guidelines (at
that time) [1,29–36] in Latin America.
Nutrients 2020, 12, 809 3 of 18

However, several areas of opportunity were identified to improve the tool. Specifically, due to the
low number of items, a one-point variation between test and retest scores could have an impact on
the food intake quality classification, so it was suggested changing the Mini-ECCA’s response option
format from a dichotomous one to the type found on a Likert scale, and changing the way this survey is
scored. Furthermore, our tool did not include alcohol intake, a topic that also must be evaluated in food
intake quality. Another limitation of the first version of the tool was that some questions needed to be
reworded so people unfamiliar with nutritional terminology could easily understand them like fats and
sweetened beverages, and no other analyses besides reproducibility were considered [26]. In addition,
given the benefits associated with reviewing, updating, improving and validating existing tools in
ways that will give health professionals and authorities more accurate data for decision-making [4], a
second version of the Mini-ECCA was developed.
On the other hand, in this second version of the Mini-ECCA, the reproducibility analysis is
complemented by the evaluation of the tool’s ability to identify dietary patterns. This perspective
provides additional elements to examine the overall diet and not the consumption of specific nutrients
or food groups, as it is suggested that dietary patterns could have a more real relationship with positive
or adverse health effects [37]. The objective of this study was to assess the levels of reproducibility of
the Mini-ECCA v.2 and its ability to identify dietary patterns in university students. The reason for
choosing university students is because identifying the quality of their food consumption must allow
us to contribute to favor an environment of healthy options, so that they could improve their dietary
intake and, therefore, their health.

2. Materials and Methods

2.1. Modification of the Mini-ECCA Questionnaire

A group of experts who participated in the instrument’s original design, all of whom are health
professionals with clinical and nutritional research experience (M.F.B-O.; F.M.-S.; M.B.A.-M.; M.G.-G.;
B.V.; G.M.-O.), with a group of young nutritionists (R.J.P.-A.; N.B.-C. and J.F.O.-G.) analyzed, discussed
and approved changes to the tool based on the areas of opportunity above mentioned.
As a result of this process (Table 1), changes were made to recommended intake amounts of some
foods and food groups, such as fish and sweetened beverages. Several questions were reformulated to
make them clearer and more specific (like in sweetened beverages, fish, sweets and desserts, fats and
legumes), and with more emphasis on food intake frequency (daily or per week); Questions that were
not in the original instrument were also added, specifically on the intake of avocados, oilseeds and
alcoholic beverages. In addition, a Likert scale replaced the dichotomous (yes/no) response options
found in the previous version. This change was designed to make the options more indicative actual
food intake behaviors, which tend not to be strictly dichotomous in nature.
The Mini-ECCA v.2 thus consists of 14 questions focused on assessing food and beverage (alcoholic
and non-alcoholic) intake. The questions are based on a review of relevant literature on the subject,
including Mexican [38,39] and international nutritional recommendations [1,35,36,40–57] (Table 1).
For each question, three or four answer choices are given, generally on a Likert scale (see Table S1:
Mini-ECCA v.2 survey). The questionnaire uses photographs as a visual reference to estimate quantity;
thus, images are shown simultaneously with questions during the administration of the Mini-ECCA
v.2 (see Presentation S1: Mini-ECCA’s visual aid for food quantity estimation).
Nutrients 2020, 12, 809 4 of 18

Table 1. Recommendations on which the changes to each question in the Mini-ECCA v.2 were based.

Mini-ECCA v.1 Mini-ECCA v.2 Changes Made from

Food/Food Group Evidence
Question Question the First Version
The intake of at least 6 glasses
(1500 mL) per day is
recommended [38] to meet daily The wording was
Do you drink at least
fluid needs and achieve an Do you drink at least changed to emphasize
1.5 liters of water every
Water optimal state of hydration to 1.5 liters of water per that intake days should
day (Monday to
help maintain metabolism and day? be from Monday to
Sunday)?
normal physiological functions Sunday.
such as thermoregulation,
excretion, transport, etc. [39].
It is recommended to consume
at least five whole pieces or
portions equivalent to 400 g per Do you consume at
Do you consume at
day [1], because of this group’s least 200 g of fruit
least 200 g of fruit per
significant fiber, micronutrient every day (Monday to The wording was
day?
and phytochemical content Sunday)? changed to emphasize
Fruits and vegetables which contributes to health that intake days should
Do you consume at
maintenance [51,52]. However, Do you consume at be from Monday to
least 200 g of cooked or
since the recommendation is for least 200 g of Sunday.
raw vegetables per
two food groups considered vegetables every day
day?
collectively, the total amount (Monday to Sunday)?
was divided evenly (200 g for
fruits and 200 g for vegetables).
It is recommended to consume
fish at least twice per week (or
two portions per week) because
of its long-chain
Do you eat fresh or Do you consume at
polyunsaturated fatty acid
frozen fish (100 g) at least 200 g of fresh or The previous intake
Fish content, which is associated
least one day per frozen (not canned) amount was 100 g.
with reduced cardiovascular
week? fish per week?
risk [53,54]. With a serving
defined as 100 g (3.5 ounces), the
recommendation calls for an
intake of 200 g per week [55].
The intake of sweetened
beverages should be occasional
and in small portions, as they
are associated with increased
energy intake, higher body
weight, increased risk of type 2 In the previous version,
How many times per
diabetes mellitus, and because an intake of 4 or more
Do you consume four week do you consume
they have little or no nutritional drinks per week was
Sweetened beverages or more sweetened one or more cans (or
value [38]. It was calculated that mentioned with no
beverages per week? glasses) of sweetened
the maximum tolerable limit reference to intake
beverages?
would be one glass (250 mL) or volume.
less per day, an amount which
would not exceed the
recommended maximum of 10%
of total calories from added
sugars [35].
A total fat intake comprising
15%–35% of daily energy is
recommended (less than 7%
from saturated fatty acids, up to
10% from polyunsaturated fatty
acids and up to 20% from What oil or fat-based
What type of fat do This question was
monounsaturated fatty ingredient do you use
you most frequently divided into two
Oils and fats acids) [56] in order to deliver a most often on a weekly
consume during the categories: oils/fats
supply of essential fatty acids basis to prepare your
week? and oilseeds/avocado.
and fat-soluble vitamins that meals?
meets the needs of most
individuals, as well as to ensure
optimal health and prevent the
development of cardiovascular
diseases [40,57].
Nutrients 2020, 12, 809 5 of 18

Table 1. Cont.

Mini-ECCA v.1 Mini-ECCA v.2 Changes Made from

Food/Food Group Evidence
Question Question the First Version
It is recommended to consume
20–30 g of nuts, seeds and
olives [41] due to the decrease in
cardiovascular risk factors
associated with their daily
intake, and particularly in light This question did not
of the antioxidant properties of Do you consume at appear in the previous
this food group which may least 30 g of oilseeds or version.
Oilseeds and
inhibit or delay atherogenic — one-half of an avocado Oilseeds had been
avocado
processes [42,43,58]. No precise every day (Monday to included in the
avocado intake Sunday)? question on oils and
recommendations have been fats.
established, but a minimum
intake of half of an avocado per
day has been found to be
effective in reducing
cardiovascular risk [44,45].
Red meat intake should be
limited to less than twice per
week because of its association In the new version,
What type of meat do
with an increased incidence of What type of meat do intake was specified as
you consume most
Meat cardiovascular disease and you consume most weekly in order to
often on a weekly
cancer [46]. The intake of often? make the question
basis?
skinless poultry and fish is more precise.
recommended as an
alternative [41,47].
Processed foods are
characterized by their high
Do you consume
sodium content. It is The wording was
processed foods (fried
recommended for adults to Do you eat processed changed. In the
foods, sausages,
Processed foods maintain daily sodium intake foods two or more previous version,
packaged meals ready
below 2 g (5 g of salt) [36]. In days per week? intake was measured
to heat and serve) 2 or
addition, the intake of processed in days per week.
more times per week?
foods should be limited because
of their link to cancer [46,48].
Eating out more frequently has
been associated with increased
weight gain due to the higher
The wording was
energy content of the food Do you eat foods not Do you consume food
changed. In the
Meals consumed consumed and the larger prepared at home three not prepared at home 3
previous version,
away from home portions served [49]. It is or more days per or more times per
intake was measured
recommended to limit meals week? week?
in days per week.
consumed away from home to
less than three times per
week [50].
It is recommended for free
sugars not to exceed 10% of total
Do you eat dessert Only commercially
daily energy intake, although it
foods (cookies, creme produced desserts or
has been suggested that
Do you consume caramel (flan), rice sweets were
additional benefits may result
sweets or commercial pudding, cakes) or mentioned in the
Sweets and desserts from reducing total energy
desserts two or more sweets (hard candy, previous version.
intake from sugars to 5% or
days per week? popsicles, chocolates) 2 Examples of desserts
less [35]. Consequently, the
or more times per and sweets were
intake of sweets and desserts
week? added.
should be limited due to their
high sugar content.
It is recommended to consume
two to four portions of legumes
per week, as they are an
affordable source of fiber,
protein and other nutrients
associated with the prevention
An intake frequency of
of various diseases [59,60]. Do you eat legumes at Do you consume at
3 times per week was
Legumes Considering that a portion is least three days per least 300 g of legumes
used in the previous
equivalent to 150–200 g of week (300 g per week)? per week?
version.
cooked legumes,
recommendations range from
300–800 g per week [41]. Due to
variability in quantity, a
minimum recommended
quantity was established (300 g).
Nutrients 2020, 12, 809 6 of 18

Table 1. Cont.

Mini-ECCA v.1 Mini-ECCA v.2 Changes Made from

Food/Food Group Evidence
Question Question the First Version
It is recommended for more
than 50% of daily cereal intake
to be whole grain. Because of its
high content of fiber and other
nutrients, this food has been
shown to protect against various
chronic non-communicable What kind of cereals
diseases, contribute to What cereals do you do you consume most Intake frequency was
Cereals
gastrointestinal health consume most often? often on a weekly stated as weekly.
maintenance and help control basis?
body weight [34,61]. It is
therefore advisable to consume
three or more servings of whole
grains per day and to reduce the
intake of refined and processed
cereals [34,62].
While avoiding alcohol intake
has been recommended [63,64],
a recent review of 83 prospective If you are a man, do
studies concluded that 100 g of you consume more
alcohol per week is the intake than 2 alcoholic
This question did not
threshold associated with the beverages per day?
Alcoholic beverages — appear in the previous
lowest risk of mortality [63]. If you are a woman, do
version.
Based on national and you consume more
international guidelines, a limit than 1 alcoholic
of one drink per day was beverage per day?
established for women and two
for men [34,38,65].

2.2. Study Population and Design

A study was carried out between October 2017 and May 2018 to determine the reproducibility
and the ability to identify dietary patterns of the Mini-ECCA v.2 in university students enrolled in the
Nutrition (NUT), Medicine (MED) and Dentistry (OD) programs at the University of Guadalajara’s
Health Sciences Center. Subjects were students of both sexes of varying ages who were enrolled in
different university grade levels. In the case of NUT students, we randomly selected a group from
each semester, from first to sixth, and invited them to participate (October-December 2017). In the case
of MED and OD students, we invited to participate all groups attending the subject called “Healthy
lifestyles promotion” (March-May 2018). Those groups whose teachers allowed us to invite students
were selected. Finally, we included volunteers who agreed to participate and gave their informed
consent. Excluded were pregnant or lactating women, as were individuals diagnosed with any illness
requiring a diet different from that of healthy people, due to the significant differences in nutritional
needs associated with such conditions. In addition, subjects on vegetarian diets were excluded since
the instrument considers a healthy omnivorous diet as its benchmark. Additionally, participants who
did not take part in the questionnaire’s second administration were excluded.
A minimum sample of 140 participants was determined based on criteria in scientific literature
suggesting the inclusion of 10 subjects for each question on the instrument, which will be analyzed in
reproducibility studies [66].
The study adhered to Mexican and international ethical principles for research involving human
subjects which are designed to safeguard the dignity, autonomy, rights, privacy and confidentiality
of research participants [67]. Additionally, the study’s protocol was approved by the Research and
Research Ethics Committees of the University’s Health Sciences Center (registration number: CI-01519).

2.3. Data collection Procedures and Strategies

After obtaining the required university authorizations, the administration schedule for the
Mini-ECCA v.2 was planned based on the times when the selected group’s teacher and fieldwork
researchers would be available. The procedure followed for each administration is described below.
Nutrients 2020, 12, 809 7 of 18

Administration 1: The researchers arrived to the selected group’s classroom on the day and at
the time agreed with their teacher. The objective, implications and importance of participation in the
study were explained to the volunteer subjects verbally, and a document with detailed information
on the project was provided. After explanations, volunteers signed an informed consent form and
filled out a self-reported medical history in which they gave contact, socioeconomic, anthropometric
(weight and height that allowed us to calculate Body Mass Index classified according to WHO criteria),
and pathological (personal and family) data. They also completed the International Physical Activity
Questionnaire (Short Form IPAQ-SF) [68] as part of the self-reported medical history procedure. The
Mini-ECCA v.2 was then administered using the SunVote® system (software v.3.1.0.20, M52 Plus
response clicker). Researchers trained in the use of this remote voting system explained the procedure
for using it to participants. The students answered each of the questions in the Mini-ECCA v.2 using
remote control units following the projection of questions, answer options and visual support for
estimating food quantities (see Presentation S1: Mini-ECCA’s visual aid for food quantity estimation).
First administration’s duration was 30 min in total (15 min only for Mini-ECCA, the other 15 min were
used for answering the other personal information).
Administration 2: One month after the first administration, the second administration of the
questionnaire was carried out on the same group of students. Second administration’s duration was
15 min and was performed the same as the first administration. Finally, personal results (from both the
first and second administrations) together with a thank you message were e-mailed to each participant
a few days following the second administration.

2.4. Statistical Analysis

The data obtained were statistically analyzed using SPSS® software (version 25.0, SPSS Inc.,
Chicago, IL). Qualitative variables are expressed as frequency (percentage) and quantitative variables
as averages (standard deviations).
The reproducibility of the Mini-ECCA was determined using the agreement between the answers
of each question in the Mini-ECCA v.2 based on Cohen’s weighted kappa—which ranges from 1 (perfect
disagreement) to 1 (perfect agreement)—and categorized according to Landis and Koch criteria [69].
McNemar test was used to determine whether changes in categorical responses between test and retest
were significant.
The determination of the instrument’s ability to identify dietary patterns was carried out by the
following analyses. First, a cluster analysis was performed using Ward’s method for non-standardized
variables. Cluster analysis is a multivariate method that, in this case, aggregates individuals in relatively
homogeneous subgroups according to the frequency of the food groups consumed [37]. Subsequently,
an analysis of simple variance (ANOVA) was performed for each item in the questionnaire to compare
the groups identified in the cluster analysis. Finally, a discriminant analysis was performed. These
analyses aimed to verify that the groups identified in the cluster analysis had significant differences in
food intake quality or dietary patterns. A value of p < 0.05 was considered significant.

3. Results

3.1. Description of the Population

Mini-ECCA v.2 was initially administered to 397 students (all the students agreed to participate).
From this group, the following were excluded: 8 who reported following a vegetarian diet; 3 who
reported being pregnant or lactating; 4 who were psychology students (for not being a representative
sample of their major); and 7 who did not complete the test. Of the 375 remaining students, 96 did not
take the retest and another 3 did not complete the second test (26.4% attrition rate). Thus, this study
analyzed a final total of 276 participants who completed both survey administrations.
The average age of the population was 20.1 ± 3.1 years (n = 270, 6 did not respond). Of the
total number of participants, 68% were women and 56% were medical students. In addition, 80% did
Nutrients 2020, 12, 809 8 of 18

not work and almost all of them (98%) had no financial dependents. Approximately 37% reported
moderate physical activity, and their average number of hours spent sitting per day was 8.3 ± 3.9
(n = 223). According to self-reported data on disease history, 30.4% of participants reported being
overweight/obese, while 2.5% reported having some form of heart disease, 2.2% reported having
asthma and 1.1% reported having other diseases such as hypothyroidism or polycystic ovary syndrome
(data not shown).
Other self-reported data included an average weight of 64.4 ± 13.7 kg (n = 268), an average height
of 166.7 ± 9.3 cm (n = 267) and an average BMI of 23.1 ± 3.8 kg/cm2 (n = 267). The majority of the
sample (65.2%) had normal weight. For more details on the characteristics of the population, see
Table 2.

Table 2. General characteristics of the population (n = 276).

Variable Frequency Percentage

Sex
Male 88 31.9
Female 188 68.1
Career
Nutrition 86 31.2
Medicine 169 61.2
Odontology 21 7.6
Worked
No 221 80.1
Yes 51 18.5
No answer given 4 1.4
Had financial dependents 1
No 266 96.4
Yes 6 2.2
No answer given 4 1.4
Had financial support 2
No 149 54.8
Yes 118 43.4
No answer given 9 1.8
Physical Activity Level
Low 96 34.8
Medium 101 36.6
High 79 28.6
BMI Classification 3
Underweight 20 7.5
Normal 174 65.2
Overweight 59 22.1
Obese 14 5.2
1 Refers to people who are financially dependent on the student (e.g., children, parents, etc.); 2 Refers to whether the
student has any scholarship or other financial assistance (such as that provided by parents) to help pay for their
studies; 3 n = 267.

3.2. Reproducibility and Concordance of the Mini-ECCA v.2

The analysis of all of the Mini-ECCA v.2’s questions between the test and retest showed moderate
concordance (weighted κ = 0.422–0.585) in questions about the intake of water, vegetables, fish, fruits,
oilseeds and/or avocado, foods not prepared at home, industrialized snacks, sweets and/or desserts,
legumes, sweetened beverages and type of cereal most frequently consumed. Three questions showed
excellent agreement (weighted κ = 0.606–0.662): intake of alcoholic beverages, type of fat used most
often, and type of meat. It should be noted that a significant change between test and retest was
Nutrients 2020, 12, 809 9 of 18

detected in two questions: water intake (p = 0.041) and intake of sweets or desserts (p = 0.035). For
details, see Table 3.

Table 3. Concordance in the questions in the Mini-ECCA v.2.

Total Weighted McNemar
Test Retest
Question. Answer Options Agreement Kappa Test
n (%) 1 n (%) 1 n (%) 2 (95% CI) (p Value)
A. Never 8 (2.9) 1 (0.4) 1 (12.5)
1. Do you drink at least 1.5 liters of water B. Sometimes 64 (23.2) 55 (19.9) 37 (57.8) 0.585
0.041
per day? C. Almost always 67 (24.3) 76 (27.5) 32 (47.8) (0.572–0.598)
D. Always 137 (49.6) 144 (52.2) 115 (83.9)
A. Never 16 (5.8) 9 (3.3) 4 (25.0)
2. Do you consume at least 200 g of cooked B. Sometimes 99 (35.9) 94 (34.1) 60 (60.6) 0.478
0.220
or raw vegetables per day? C. Almost always 111 (40.2) 112 (40.6) 67 (60.4) (0.465–0.490)
D. Always 50 (18.1) 61 (22.1) 30 (60.0)
A. Never 73 (26.4) 71 (25.7) 52 (71.2)
3. Do you eat fresh or frozen fish (100 g) at B. Sometimes 122 (44.2) 130 (47.1) 87 (71.3) 0.576
0.877
least one day per week? C. Almost always 45 (16.3) 43 (15.6) 21 (46.7) (0.562–0.589)
D. Always 36 (13.0) 32 (11.6) 19 (52.8)
A. Never 37 (13.4) 46 (16.7) 27 (73.0)
4. Do you consume one or more glasses B. 1 to 3 times 126 (45.7) 139 (50.4) 94 (74.6) 0.576
0.054
(can) of sweetened beverages per week? C. 4 to 6 times 59 (21.4) 44 (15.9) 20 (33.9) (0.562–0.589)
D. Daily 54 (19.6) 47 (17.0) 26 (48.1)
A. Never 7 (2.5) 6 (2.2) 1 (14.3)
5. Do you consume at least 200 g of fruit per B. Sometimes 71 (25.7) 70 (25.4) 44 (62.0) 0.516
0.525
day? C. Almost always 92 (33.3) 103 (37.3) 53 (57.6) (0.504–0.529)
D. Always 106 (38.4) 97 (35.1) 70 (66.0)
A. Monounsaturated 60 (21.7) 59 (21.4) 46 (76.7)
6. What type of fat do you consume most B. Polyunsaturated 201 (72.8) 201 (72.8) 182 (90.5) 0.662
0.800
frequently on a weekly basis? C. Saturated 7 (2.5) 10 (3.6) 4 (57.1) (0.654–0.671)
D. Do not know 8 (2.9) 6 (2.2) 4 (50.0)
A. Never 29 (10.5) 27 (9.8) 13 (44.8)
7. Do you consume at least 30 g of oilseeds B. Sometimes 127 (46.0) 141 (51.1) 94 (74.0) 0.483
0.270
or 1/2 of an avocado per day? C. Almost always 77 (27.9) 76 (27.5) 37 (48.1) (0.470–0.496)
D. Always 43 (15.6) 32 (11.6) 17 (39.5)
A. Never 55 (19.9) 37 (13.4) 28 (50.9)
8. Do you eat foods not prepared at home B. Sometimes 123 (44.6) 139 (50.4) 89 (72.4) 0.579
0.061
three or more days per week? C. Almost always 55 (19.9) 59 (21.4) 24 (43.6) (0.566–0.592)
D. Always 43 (15.6) 41 (14.9) 30 (69.8)
A. Red meat 116 (42.0) 109 (39.5) 87 (75.0)
9. What type of meat do you consume most 0.606
B. Chicken 148 (53.6) 154 (55.8) 123 (83.1) 0.539
often? (0.594–0.618)
C. Fish 12 (4.3) 13 (4.7) 7 (58.3)
A. Never 46 (16.7) 44 (15.9) 23 (50.0)
10. Do you eat processed foods two or more B. Sometimes 146 (52.9) 154 (55.8) 105 (71.9) 0.458
0.823
days per week? C. Almost always 57 (20.7) 52 (18.8) 22 (38.6) (0.445–0.470)
D. Always 27 (9.8) 26 (9.4) 14 (51.9)
A. Never 22 (8.0) 33 (12) 12 (54.5)
11. Do you consume sweets or commercially
B. Sometimes 119 (43.1) 131 (47.5) 78 (65.5) 0.422
produced desserts two or more days per 0.035
C. Almost always 71 (25.7) 64 (23.2) 23 (32.4) (0.409–0.436)
week?
D. Always 64 (23.2) 48 (17.4) 26 (40.6)
A. Never 18 (6.5) 17 (6.2) 10 (55.6)
12. Do you eat legumes at least three days B. Sometimes 56 (20.3) 55 (19.9) 25 (44.6) 0.495
0.946
per week (300 g per week)? C. Almost always 74 (26.8) 77 (27.9) 31 (41.9) (0.482–0.509)
D. Always 128 (46.4) 127 (46.0) 92 (71.9)
A. Whole grain 118 (42.8) 135 (48.9) 88 (74.6)
13. What type of cereals do you consume 0.427
B. Minimally processed 120 (43.5) 111 (40.2) 77 (64.2) 0.200
most often? (0.414–0.441)
C. Processed and
38 (13.8) 30 (10.9) 16 (42.1)
ultra-processed
14. If you are a man, do you consume more A. Never 169 (61.2) 165 (59.8) 148 (87.6)
than 2 alcoholic beverages per day? If you B. Sometimes 79 (28.6) 83 (30.1) 52 (65.8) 0.636
0.492
are a woman, do you consume more than 1 C. Almost always 20 (7.2) 14 (5.1) 5 (25.0) (0.625–0.647)
alcoholic beverage per day? D. Always 8 (2.9) 14 (5.1) 4 (50.0)
1Data are presented as frequency (percentage of the total); 2 It refers to frequency (percentage of test subjects who
showed agreement on the retest or answered the same in both administrations).

3.3. Ability to Identify Dietary Patterns of the Mini-ECCA v.2: Cluster and Discriminant Analysis
In the cluster analysis, three groups were identified: the first group included close to a fifth of
the participants (n = 55, 19.9%) who consumed a diet that was, based on a discriminant analysis,
subsequently classified as healthy; the habits of the second group (n = 130, 47.1%), which accounted
for almost half of the sample, were considered as in need of improvement (intake of some healthy
Nutrients 2020, 12, 809 10 of 18

and other unhealthy foods); the third group (n = 91, 33%) comprised participants with unhealthy
food choices.
After the three groups were identified, an ANOVA was performed for each item in the Mini-ECCA
v.2 questionnaire in order to verify that this grouping would be capable of identifying differences in
food intake quality. This analysis of variance produced a value of p < 0.05 in all cases (see Document
S1: Differences in the response option average for each question in the Mini-ECCA v.2 by cluster).
Table 4 shows three classification functions (one per group) obtained in the discriminant analysis,
as well as the items included in each group. The highest value for each variable was the one considered
for assignment to the group (shown in boldface). As shown in the table, group 1 was characterized
by a higher intake of water, vegetables, fruits, fats, oilseeds/water, meats and legumes (healthy food
intake). Group 2 was characterized by a healthier intake of fish combined with a higher intake of
unhealthy fats (habits in need of improvement). Group 3 was characterized by a higher intake of
sweetened beverages, foods not prepared at home, processed foods, refined cereals and alcoholic
beverages (unhealthy food intake).

Table 4. Coefficients of the classification and discriminant functions for food intake quality by group.

Discriminant
Classification Function Coefficients by Group Function
Variable
Coefficients
1 2 3
Healthy Food Habits in Need of Unhealthy Food Function 1
Intake Improvement Intake
Water intake 6.2692 5.59019 4.18735 0.403538
Vegetable intake 8.63136 7.59581 5.37525 0.50719
Fresh/frozen fish intake 1.67472 1.98176 1.50061 0.0655855
Sweet drink intake 2.24428 2.92271 3.13341 −0.15818
Fruit intake 7.30975 6.57655 4.95411 0.39329
Most consumed fats or oils 4.86969 6.71207 6.62932 −0.172202
Oilseeds or avocado intake 4.63935 3.18834 2.54328 0.333013
Intake of foods not prepared at home 1.30334 1.67774 2.47401 −0.23877
Most consumed type of meat 7.18377 5.77848 5.34274 0.198137
Intake of processed foods 1.73401 2.00778 2.42516 −0.125812
Sweets or commercially produced desserts 1.09702 2.01592 2.19824 −0.186589
Intake of legumes 4.31863 4.31195 3.02602 0.304913
Most consumed type of cereals 2.51518 3.05353 3.88732 −0.210954
Alcoholic beverages −0.460071 −0.245971 0.486413 −0.17358
CONSTANT −74.8948 −69.9333 −55.1233
Eigenvalue 2.59421
Canonical correlation 0.84957 *
Wilks’ Lambda 0.213051
Chi-squared 412.0688 **
DF 28
The coefficients that were considered for the classification of each group are shown in boldface, with the highest
value of each variable being the one considered for the group assignment. DF: degrees of freedom. ** p < 0.05.
* p value < 0.001.

By means of the discriminant analysis, two discriminant functions with a value of p < 0.05 were
also obtained. Table 4 shows only the values obtained from the first discriminant function as well as its
coefficients, as it represents a canonical correlation of 0.84957, with a relative percentage of 89.45%. The
highest values of the discriminant function indicate the characteristics that make the groups different.
In this regard, the variable that best explains the differences between groups is vegetable intake
(coefficient = 0.50719), followed by water intake (coefficient = 0.403538). The variables that explain the
differences between groups to a lesser extent are fresh or frozen fish intake (coefficient = 0.0655855)
and processed food intake (coefficient = −0.125812).
The discriminant analysis determined that the groups found were adequately classified through
application of the classification functions (Table 5), as 85.9% of the total cases were correctly grouped.
In addition, a correct classification has been identified in 96.4% of cases in the healthy food intake group
Nutrients 2020, 12, 809 11 of 18

(Group 1), 78.5% in the habits in need of improvement group (Group 2) and 90.1% in the unhealthy
food intake group (Group 3).

Table 5. Correct classification of cases according to the identified clusters.

Classification Group n (%) 1 n (%) Correctly Classified Cases 2

Group 1: Healthy food intake 55 (19.9) 53 (96.4)
Group 2: Habits in need of improvement 130 (47.1) 102 (78.5)
Group 3: Unhealthy food intake 91 (33.0) 82 (90.1)
Total 276 (100.0) 237 (85.9)
1Data are presented as frequency (percentage of the total); 2 It refers to frequency (percentage of subjects from the
middle column).

4. Discussion
The Mini-ECCA v.2 survey obtained moderate to excellent agreement [69] between the test and
the retest for each of its items. It also was able to identify dietary patterns, with 85.9% of the total cases
having been correctly classified in the three groups identified in the cluster analysis. This new version
of the questionnaire includes items covering the intake of alcohol and the most consumed types of fat.
It also provides more answer options for each question, which range from daily intake (always) to zero
intake (never), in addition to intermediate options such as almost always or sometimes, which may
reflect intake better than items with dichotomous answers [70].
The Mini-ECCA v.2 is similar in some ways to other surveys that evaluate dietary adherence
(especially to the Mediterranean diet) [21,22,29,71]: number of items, administration’s duration,
selected food groups or foods inclusion, answer options, and so on. However, it is important to notice
that these surveys were designed to examine dietary intake and association with some health outcomes
like cardiometabolic risk [21,22,29,71], which is not the aim of Mini-ECCA v.2. Our tool places special
emphasis on evaluating the quality of foods consumed, either healthy or non-healthy [72].
The Mini-ECCA v.2 used the cluster analysis and the discriminant analysis method. This procedure
complements the reproducibility analysis and helps determine if the questionnaire can identify dietary
patterns and if they present differences between them. This method is practical and does not require
parameters other than the variables found in the survey such as biochemical markers or other dietary
surveys (although these associations are also important for validation purposes and could be performed
in subsequent studies.) These analyses have been used in studies from other health areas, like in
psychology [73,74], and since food intake is an eating behavior, these analyses are suitable for our
proposed survey. Thus, this is one of the main contributions of this study.
A discriminant analysis yields the coefficients needed to generate classification functions, which
when calculated allow the quality of the food intake of an individual or a population to be determined
based on answers from the Mini-ECCA v.2. In order to obtain the classification of an individual’s food
intake quality for any one of the three groups identified in this study, the three classification functions
were applied to each subject, hence multiplying the answer options of each question of the Mini-ECCA
v.2 by the constants of the corresponding column (Table 4). After obtaining the results of the three
equations, the quality of the subject’s dietary intake was classified for the group for which the highest
figure was obtained (Document S2: Equations for the interpretation of Mini-ECCA v.2’s results). Thus
the interpretation of the first version of the Mini-ECCA went from having four possible results (very
low, low, good and excellent) to having three (healthy food intake, habits in need of improvement,
unhealthy food intake). It is important to note that subjects who fell into the “unhealthy food intake”
classification may consume some foods mentioned in the survey with a frequency that would score as
healthy, but as these behaviors occur less frequently than unhealthy ones, they were classified under
“unhealthy food intake.”
In other studies, dietary pattern analysis has led also to the identification of both healthy and
non-healthy food intake. This identification may lead to specific actions of food intake improvement in
Nutrients 2020, 12, 809 12 of 18

populations where these dietary patterns have been identified [75–77]. In the case of university health
students, dietary patterns of healthcare students and professionals was described and associated with
sociodemographic, lifestyle, anthropometric and biochemical characteristics in a previous study [75].
In this study, dietary patterns were identified through a principal component analysis of 25 food
groups of a semiquantitative food frequency questionnaire. These dietary patterns were “Traditional
Westernized”, “Healthy” and “Animal protein and alcoholic beverages”. As evidenced in that study,
healthy and non-healthy dietary patterns can be identified in this particular population.
When analyzing the answers to each of the questions in the Mini-ECCA v.2, agreement is observed
as generally being moderate to excellent (weighted κ = 0.422–0.662). However, it should be noted that
in the case of two questions (water intake and intake of sweets and desserts), intake quality showed
statistically significant improvement in the retest. This may be because, although there was a one-month
interval between administrations of the Mini-ECCA v.2, participants may have become more aware of
their food/beverage intake behavior, meaning they could have either modified their behavior or given
answers that they believed to be more acceptable [78]. In light of this possibility, it is very important
to emphasize to the survey’s subjects that their honesty is needed in order to determine what the
quality of their food intake really is and offer them appropriate guidance. It should be noted that the
degree of agreement on the first version of the Mini-ECCA was moderate (weighted κ = 0.484–0.606).
It should also be remembered that the first version consisted of dichotomous questions, and the time
interval between test–retest administrations was shorter (15 days). This shows that despite the change
of options and the increase in the time between one administration and the next, the Mini-ECCA v.2
produced a higher level of agreement.
With respect to food and drink intake habits, it is noteworthy that only 52.2% of the test sample
reported drinking at least 1.5 liters of water per day, while 45.7% of the sample reported consuming
it 1 to 3 times per week including one or more glasses of sweetened beverages. According to data
from the 2006 National Health and Nutrition Survey (ENSANUT), the average water intake of the
general population was less than 900 mL [79], a quantity similar to that reported in a study of liquid
intake in Latin America published in 2018, where the average daily intake ranged from 150 to 900 mL
per day [80]. Regarding sweetened beverage intake, it is well known that Mexico’s levels are higher
than those of any other country. This is particularly true in the case of soft drinks, for which average
intake is just over 500 mL per day [80]. Despite the fact that current recommendations advise against
consuming these drinks [35,38], their intake continues to be very common, even among health science
students. It should be noted that since most recent ENSANUT reports do not provide an analysis of
water intake in milliliters (it only asks whether or not water is consumed), subsequent surveys will
have to go back to include more precise beverage intake measurements.
Regarding the intake of vegetables, the most frequently given answers were sometimes (35.9%)
and almost always (40.2%); in the case of fruit intake, the results were similar with almost always
(33.3%) and always (38.4%) being the most answered options. Only 20%–40% of the surveyed students
comply with the recommendations for daily intake of fruits and vegetables. These results were
similar to those reported by Muñoz-Cano et al. [81], where fewer than 20% of respondents consumed
vegetables and fruits more than three times per week [81].
Regarding fresh or frozen fish intake, the most frequently given answer was sometimes (44.2%),
indicating that this population does not generally consume food from this group. This conclusion was
confirmed by the question on the type of meat consumed most often, where fish was answered by
less than 5% of the respondents. In contrast, when asked to indicate the type of meat they habitually
consume, 53.6% of respondents answered chicken, while 42.0% answered red meat. The above results
coincide with the annual intake reported by the OECD for Mexico, where chicken was the most
consumed type of meat (30 kg/per person), followed by pork (14.7 kg/per person) and beef (8.9 kg/per
person) [82]. The average fish intake per person in Mexico is estimated at 10.5 g per day [83], and Latin
America considered to be the region of the world with the lowest intake of this food category [84].
Nutrients 2020, 12, 809 13 of 18

In addition, 52.9% of those surveyed indicated sometimes as their frequency of consuming

industrialized products, while 20.7% said they almost always consume them. Similarly, 52.9% of
participants reported sometimes consuming other products such as snacks or instant foods. Similar
results were observed in the consumption of desserts and sweets, as 43.1% indicated that they sometimes
consume them. Results from ENSANUT 2018 found that 35.4% of the population over 20 years of age
eats snacks, sweets and desserts on a daily basis [85].
All these previous studies indicate that the quality of food intake among health science students
is not very different than that of the rest of the population. This finding underscores the urgency
of making future health professionals aware of the need for them to have healthier dietary habits,
since they will be tasked with the future prevention and treatment of diseases in the population, and
congruence is an essential part of positively influencing patient behavior. To achieve this aim, it will
also be important to promote healthy habits in university campus environments by offering “healthy
menus” in student dining facilities, discouraging the on-campus sale of sweetened beverages, and
so forth.
Limitations of this study include a significant number of drop-outs in the administration of the
retest (25.8%), as is common in follow-up studies. However, these losses did not affect the minimum
number of subjects expected for validation. Another limiting factor is that the Mini-ECCA is not
suitable for administration to vegetarian or vegan subjects. The design and validation of tools for
these populations, as well as for age groups such as children and adolescents, therefore represents an
opportunity for the future. Yet another limitation is that the use of health science students as volunteers
may lead to the conclusion that this group is significantly different from the rest of the population,
or that their knowledge of health sciences may bias their responses. However, and as shown in the
analysis of each question in the Mini-ECCA v.2, food intake quality in this study is very similar to that
found in previously published data on the general population [85].
As strengths, we can highlight the method used for dietary pattern identification, which is easier
and practical than the analysis of other dietary surveys and a more practical assessment of adherence
to a healthy or to a non-healthy food intake. In addition, it allows an easier follow-up of patients and
of our academic population in order to help them to better realize food and beverages consumption for
a healthier lifestyle. The ability of identifying these three patterns, will allow us to characterize our
university population and promote changes to a better pattern consumption.

5. Conclusions
The Mini-ECCA v.2 is a tool which can be administered quickly and easily and produces moderate
to excellent levels of concordance and able to identify dietary patterns. It is useful for evaluating
the quality of food intake in university students and classifying it into healthy food intake, habits in
need of improvement and unhealthy food intake categories. This survey should also be effective for
studying the general adult population, as no major differences were identified with respect to intake
levels reported in health and nutrition surveys conducted at the national level. It may also make health
science students more aware of the effect that their own dietary habits may have on their ability to be
positive role models and thus better prepare them to care for the health of the general population. In
this regard, making university campus environments more conducive to healthy behaviors will also
be important.

Supplementary Materials: The following are available online at http://www.mdpi.com/2072-6643/12/3/809/s1,

Table S1: Mini-ECCA v.2 survey; Document S1: Differences in the response option average for each question in the
Mini-ECCA v.2 by cluster; Document S2: Equations for the interpretation of Mini-ECCA v.2’s results; Presentation
S1: Mini-ECCA’s visual aid for food quantity estimation.
Nutrients 2020, 12, 809 14 of 18

Author Contributions: Conceptualization, M.F.B.-O., G.M.-O., and B.V.; methodology, M.F.B.-O., and G.M.-O.;
validation, M.F.B.-O., P.B.S.-C., R.J.P.-A., and G.M.-O.; formal analysis, M.F.B.-O., G.M.-O., P.B.S.-C. and P.G.-G.;
investigation, all authors; resources, M.F.B.-O., and G.M.-O.; data curation, P.B.S.-C., and R.J.P.-A.; writing—original
draft preparation, M.F.B.-O., P.B.S.-C., R.J.P.-A. and J.F.O.-G.; writing, review and editing, all authors; visualization,
M.F.B.-O., and P.B.S.-C.; supervision, M.F.B.-O.; project administration, M.F.B.-O., and G.M.-O. All authors have
read and agreed to the published version of the manuscript.
Funding: This study was funded by the Program for the Improvement of Teaching Staff (Program para el
Mejoramiento del Personal Docente, PRODEP) of the Mexican Secretariat of Public Education, as part of the “Call
for Support for the Incorporation of New Full-Time Lecturers” initiative, whose project number is 233521. Ruth
Jackelyne Prado Arriaga obtained a scholarship through the Program to Support Improvement in the Production
Conditions of Members of the National System of Researchers and the National System of Art Creators (PRO-SNI)
of the University of Guadalajara in 2017, respectively. We will receive funding to cover the costs of open-access
publishing and English translation through institutional programs for the support of science and publications at
the University of Guadalajara.
Acknowledgments: We would like to thank the study participants involved in data collection and teachers that
allowed the study to be conducted during their classes. Our thanks also go to Alejandro García Souza for taking
the photographs that were used for the Mini-ECCA’s visual aids and to Robert Kimpleton for his participation as
a translator.
Conflicts of Interest: The authors declare no conflicts of interest.

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