# Validation of REFRESH: a dietary screener for Rapid Evaluation FoR Environmentally Sustainable and Healthy diets

Ujué Fresán, Anna Boronat, Itziar Zazpe, Maira Bes-Rastrollo, Joren Buekers, Rafael de la Torre, Guillaume Chevance

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## To cite this version:

Ujué Fresán, Anna Boronat, Itziar Zazpe, Maira Bes-Rastrollo, Joren Buekers, et al.. Validation of REFRESH: a dietary screener for Rapid Evaluation FoR Environmentally Sustainable and Healthy diets. Journal of Nutrition, 2025, 155 (7), pp.2122-2131. 10.1016/j.tjnut.2025.05.029. hal-05092347

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Nutritional Epidemiology

# Validation of REFRESH: A Dietary Screener for Rapid Evaluation FoR Environmentally Sustainable and Healthy Diets

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Ujué Fresán<fnref n="1" />,*, Anna Boronat², Itziar Zazpe³,<fnref n="4" />,⁵, Maira Bes-Rastrollo<fnref n="4" />,⁵,⁶, Joren Buekers<fnref n="1" />,⁷,⁸, Rafael de la Torre²,⁵,<fnref n="9" />, Guillaume Chevance¹⁰,<fnref n="1" />,**

## ABSTRACT

**Background:** The urgency of promoting sustainable diets, coupled with limited knowledge of dietary sustainability among health professionals, highlights the need for simple tools to assist in advocating for such diets in clinical settings.

**Objectives:** We aimed to design a dietary screener to assess dietary healthiness and environmental sustainability, and validate it.

**Methods:** Rapid Evaluation FoR Environmentally Sustainable and Healthy diets (REFRESH) is a dichotomous tool targeting 10 key food groups for healthy diets with low environmental impacts. Each food group is scored as either 0 or 1 point, resulting in a total score ranging from 0 to 10—where 0 indicates the lowest and 10 the highest adherence to an environmentally sustainable and healthy diet. Internal consistency was assessed using the Kuder Richardson-20 (KR-20) coefficient. REFRESH's relative validity was compared against food diaries, evaluating item agreement, and using Bland-Altman analysis for the total REFRESH score. Cross-classification was tested in low, medium, and high adherence to sustainable healthy diets, along with weighted kappa index. Construct validity was evaluated through Pearson correlation between REFRESH-derived scores and health-promoting and detrimental food groups and nutrients, and environmental impact indicators, as derived from food diaries.

**Results:** REFRESH had a KR-20 coefficient of 0.70, indicating good internal consistency. It showed high agreement with food diaries (60%–88% item agreement), and Bland-Altman analysis indicated that mean REFRESH scores were 1.1 points higher than food diaries. Cross-classification showed 59% agreement between methods, with only 1% of participants misclassified in the opposite category. REFRESH-derived scores positively correlated with health-promoting food groups and nutrients, and negatively with detrimental ones. Higher scores were linked to reduced environmental impacts.

**Conclusions:** REFRESH has demonstrated good validity for assessing dietary healthiness and environmental sustainability, helping identify individuals with suboptimal diets. REFRESH can be downloaded from https://osf.io/avby9/.

**Keywords:** dietary assessment, sustainability, sustainable diets, dietary screener, validity, life cycle assessment

## Introduction

Until recently, health professionals have predominantly focused on the relationship between food and health outcomes, with dietary recommendations primarily emphasizing the

healthiness of foods and diets. Current dietary patterns are a leading cause of morbidity and mortality worldwide [1], highlighting the ongoing necessity of promoting healthy diets. However, considering only the healthfulness of a diet is insufficient. The diet should not only be healthy but also

<footnote n="1">¹ ISGlobal, Barcelona, Spain; ² Integrative Pharmacology and Systems Neurosciences Research Group, Neurosciences Research Program, Hospital del Mar Research Institute, Barcelona, Spain; ³ Department of Nutrition and Food Sciences and Physiology, University of Navarra, Pamplona, Spain;</footnote>

<footnote n="4">⁴ Navarra Institute for Health Research (IdiSNA), Pamplona, Spain; ⁵ CIBER de Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Madrid, Spain; ⁶ Department of Preventive Medicine and Public Health, University of Navarra, Pamplona, Spain; ⁷ Universitat Pompeu Fabra, Barcelona, Spain; ⁸ CIBER Epidemiología y Salud Pública (CIBERESP), C. de Melchor Fernández Almagro, Madrid, Spain;</footnote>

<footnote n="9">⁹ Universitat Pompeu Fabra, MELIS Department (Medicine and Life Sciences), Barcelona, Spain; ¹⁰ University Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail) - UMR_S, Rennes, France</footnote>

<footnote>*Abbreviations:* 95% CI, 95% confidence interval; ICC, Intraclass correlation coefficient; KR-20, Kuder Richardson Formula 20; LCA, life cycle assessment; LCI, life cycle inventory; r, Pearson correlation coefficient; REFRESH, Rapid Evaluation FoR Environmentally Sustainable and Healthy diets.</footnote>

<footnote>* Corresponding author.</footnote>

<footnote>** Corresponding author. E-mail addresses: ujuefresan@gmail.com (U. Fresán), guillaume.chevance@ehesp.fr (G. Chevance).</footnote>
environmentally sustainable, as the current food system is a major driver of resources overuse, ecosystems degradation, and biodiversity loss [2]. Indeed, although improving agricultural techniques and reducing food loss and waste are crucial for mitigating the food system's environmental impacts, the widespread adoption of low-environmental impact diets is essential to enhance ecosystem resilience and achieve sustainable management of natural resources [3].

Health professionals acknowledge the importance of promoting dietary transitions that benefit both human and planet health, and most are committed to supporting these shifts [4,5]. However, they often report having limited knowledge about sustainable healthy diets or insufficient time to incorporate dietary counseling into routine healthcare practice [4–6]. Practical tools for briefly assessing dietary adequacy from both perspectives are therefore essential. Although various dietary indices have been developed to evaluate adherence to healthy, low–environmental–impact diets [7], their reliance on detailed food consumption data renders them impractical for time-constrained clinical settings. Conversely, dietary screeners have been developed to enhance the efficiency of dietary counseling by enabling health professionals to identify individuals with suboptimal diets and provide targeted dietary recommendations [6]. However, existing screeners are primarily designed to promote healthier diets without necessarily considering environmental sustainability [6]. Bridging this gap necessitates the development and validation of brief dietary screeners that incorporate both human health and environmental dimensions through simplified scoring systems. Such tools would offer a cost-effective and practical solution, allowing health professionals to assess and guide patients toward sustainable, health-promoting dietary patterns while minimizing the burden on both patients and practitioners [8].

In response to this need, our research group has developed REFRESH—Rapid Evaluation FoR Environmentally Sustainable and Healthy diets. This screener comprises a concise dietary questionnaire and a scoring system that are designed to efficiently and succinctly evaluate environmentally sustainable and healthy dietary patterns in Spain, but easily adaptable to the realities of other countries. The objective of this study was to introduce REFRESH, assess its internal consistency, and evaluate its relative and construct validity against food diaries, with a particular focus on its potential to characterize dietary patterns in terms of healthiness, nutritional quality, and environmental sustainability.

## Methods

### Study design

We conducted an observational study between May and July 2023 in Spain. The duration of the study for each participant was 8 d. On the first day, participants completed REFRESH as part of an online baseline assessment using the EU Survey platform, containing also inquiries regarding sociodemographic, lifestyle and health dimensions. Starting on Monday, participants maintained an app-based food diary for 7 consecutive d using a smartphone application called m-Path, which is compliant with the General Data Protection Regulation (GDPR) [9]. This diary served as the reference method for dietary assessment in our study. Each evening, the app sent a notification asking if that day's diet was typical, and if not, participants were asked to explain any deviations from their habitual diet.

## Sample size estimation and study population

The sample size calculation was based on the expected intraclass correlation coefficient (ICC) between REFRESH scores and those derived from the reference method (food diaries). Given a minimum acceptable ICC of 0.50, an expected ICC of 0.71 based on previous literature [10], an α error of 0.05, a statistical power of 0.80, and 2 sets of observations, the required number of participants was 70 [11].

To select participants, we disseminated the study through social media accounts and a database of former participants from nutrition studies. Interested individuals were provided with further study details and, if agreed, were asked to complete an online selection survey, including questions regarding inclusion/exclusion criteria. Respondents were eligible to participate in the study if they self-reported meeting the following inclusion criteria: 1) adults, from 18 y old; 2) Spanish speaking and writing fluently; 3) having a mobile phone supporting the installation of smartphones' apps; 4) no active illness that could compromise eating behaviors (for example, anorexia nervosa, bulimia nervosa, binge eating, and cancer), and 5) no cognition or memory problems.

A total of 249 people initially requested to be part of the study, all of whom met inclusion criteria. Among them, 155 were invited to participate in the study. The objective of this selection was to obtain a diverse sample in terms of sex, age, and residency (across Spain), to enhance the external validity. Finally, 108 individuals gave informed consent and were initially included in the study. Two individuals were excluded due to their lack of adherence to the protocol, and an additional 13 were excluded from the analysis for failing to meet the dietary assessment criteria of ≥2 typical weekdays and 1 weekend day [12]. In totality, comprehensive data were obtained from 93 participants (refers to flow chart in Supplemental Figure 1), encompassing a total of 505 daily food diaries that documented typical eating patterns.

Participants did not receive any financial incentives but were provided with a personalized report with an analysis of their diet's healthiness and environmental sustainability, as well as tailored dietary advices.

## Rapid Evaluation FoR Environmentally Sustainable and Healthy diets (REFRESH)

REFRESH is a 10-item dietary screener intended to evaluate the habitual consumption of key food groups that are crucial for dietary healthiness and environmental sustainability. REFRESH targets the following food groups: 1) meat (any type), fish, and eggs; 2) red and processed meat; 3) dairy products; 4) legumes and legume-based products; 5) fruits and vegetables; 6) nuts and seeds; 7) sugary, salty, and ultraprocessed foods; 8) beverages such as sodas, juices, and energy drinks; 9) whole grains; and 10) main added fats/oils. Each item provides details about the targeted food group to help participants identify it more clearly (Supplemental Table 1).

REFRESH entails a dichotomous inquiry, wherein responses are rated as either 0 or 1 points. The scoring criteria adheres to guidelines for healthy diets with minimal environmental impacts as outlined by nutrition authorities, such as the EAT Lancet Commission, the FAO, and the WHO [13–16], and is backed by the most recent scientific evidence [13,14,17–33]. The total REFRESH score is the sum of the scores from the 10 individual items, resulting in an index ranging from 0 to 10 points. A score of 0 indicates minimal adherence to an environmentally
sustainable healthy diet, whereas a score of 10 represents the highest (best) level of adherence. Supplemental Table 1 provides detailed information about targeted food groups, possible answers, and the scoring rationale.

Before the validation study, a pilot test for understandability and face validity was conducted to ensure that REFRESH was comprehensible to the general population in a different sample of individuals. Ten individuals without nutrition expertise reviewed the questions and possible answers, and the necessary adjustments were made based on their feedback, mainly adding some clarifications.

## Dietary assessment

Seven-day food diaries were used as the reference method to assess the relative and construct validity of REFRESH. For 7 consecutive days, participants were instructed to maintain an app-based food diary. They were asked to provide details of consumed products, estimate quantities, and include any other relevant information immediately after consumption. The digital food diary interface provided clear instructions and illustrative examples to guide participants.

A nutritionist converted household measures as reported in the diaries into grams, to ensure a precise assessment of dietary intake. All mixed dishes were systematically deconstructed into individual ingredients using household standard recipes. These data were then used to assess the number of servings from each food group consumed, as well as nutrient intake, dietary environmental impacts and EAT-Lancet indices scores (see following sections).

Because REFRESH assesses habitual dietary patterns, only daily food consumption from diary entries identified as representative of participants' typical eating habits was considered for data analysis. Each day's inclusion was subjected to scrutiny by the research team, who reviewed the justifications provided by the participants for considering a day as atypical. Ultimately, the habitual daily intake of each food group, nutrients, and dietary environmental impacts for every participant was determined by averaging values across all identified typical days.

### Food groups estimation from food diaries

Individual foods reported in the food diaries were converted into servings of the respective food groups assessed by REFRESH. Standard adult serving sizes were obtained from a Spanish Clinical Nutrition Manual [34].

### Nutrient intake estimation from food diaries

The Nutritics Research Edition v6.01 was employed to estimate energy and nutrient intake [35], not considering supplement intake. Specifically, we assessed total intake of energy, macronutrients (including protein; total, monounsaturated, polyunsaturated—both omega(ω)-3 and ω-6, saturated, and trans fats; carbohydrates; fiber; and free sugars), minerals (such as sodium, calcium, iron, zinc, and potassium), and vitamins (including A, riboflavin, folate, B12, C, D, and E).

### Dietary environmental impacts estimation from food diaries

The dietary environmental impacts were estimated using the life cycle assessment (LCA) methodology, following the ISO 14040/44:2006 norm [36]. LCA is a method that

quantifies the environmental impacts throughout the course of the entire life cycle of a product, material, organization, or any human activity. All data were processed using SimaPro v9.6.0.1 [37].

The functional unit (quantity of a product for which the environmental impacts of the LCA study are calculated) utilized in this analysis was the daily diet. The system boundaries (unit processes of the food system included in the study) were defined from cradle to fork, including pre- and on-farm activities, processing, packaging, transportation from farm to retail, and storage at the wholesale market, retail and home, and cooking. Food loss and waste within the system boundaries were accounted for. Agribalyse v3.1.1 was the main life cycle inventories (LCI) library used in this study (see [38] for details of this library). Each food product reported in the diaries was matched with its corresponding LCI from Agribalyse, which was then adjusted to meet our specific needs. Those inventory modifications mainly referred to food packaging and cooking methods. Subsequently, LCI characterization was performed through ReCiPe 2016 v1.1 method. We opted for the hierarchist perspective, which aligns with common policy principles regarding timeframes and other considerations [39]. There are 2 mainstream ways to derive characterization factors within this method, that is, at midpoint and at endpoint levels. Midpoint indicators focus on single environmental problems, whereas endpoint indicators show the environmental impacts on 3 higher aggregation levels, being the effect on human health, biodiversity and resources scarcity. Converting midpoints to endpoints simplifies the interpretation of the results. Thus, we primarily focused on the 3 endpoint indicators, and secondarily on 18 midpoint indicators (that is, global warming, stratospheric ozone depletion, ionizing radiation, ozone formation-human health, fine particulate matter formation, ozone formation-terrestrial ecosystems, terrestrial acidification, freshwater eutrophication, marine eutrophication, terrestrial ecotoxicity, freshwater ecotoxicity, marine ecotoxicity, human carcinogenic toxicity, human noncarcinogenic toxicity, land use, mineral resource scarcity, fossil resource scarcity, and water consumption).

### EAT-Lancet indices scores estimation from food diaries

To further evaluate the construct validity, we also examined the relationship between REFRESH-derived scores and indices that measure adherence to EAT-Lancet recommendations. Among the various EAT-Lancet indices available, we selected the 2 versions proven to perform better in assessing healthiness and environmental outcomes [7]. The food groups included and their respective scoring criteria in each version are detailed in the original publications [40,41]. Data from food diaries were used to calculate the EAT-Lancet scores. The only adaptations made were converting grams of dairy products to milk equivalents and applying the raw-to-cooked conversion rate for grains and legumes, as outlined in the original manuscripts [40,41].

## Statistical analysis

### Study population

Descriptive statistics (frequency and percentage for categorical variables, and mean, minimum, and maximum for continuous variables) were used to characterize the sample's sociodemographic, health-related, and lifestyle-related factors.
## Internal consistency

To assess the internal consistency of REFRESH, we employed Kuder Richardson Formula 20 (KR-20) [42]. KR-20 coefficient between 0.70 and 0.95 is generally regarded as acceptable [43]. In order to ensure that every item contributes positively to REFRESH, we evaluated the impact of removing each individual item on the internal consistency of the overall scale.

## Relative validity

We assessed the relative validity of REFRESH by applying its scoring criteria to food group consumption derived from food diaries. Agreement percentages for each REFRESH item were calculated, along with underestimation and overestimation rates compared with food diaries. In relation to the total REFRESH score, Spearman correlation analysis was conducted to examine the association between the total scores derived from both methods (REFRESH and food diaries). Correlation coefficients with absolute values of 0.70 or higher were deemed as exhibiting a high correlation [44]. Additionally, ICC between methods was also assessed to determine REFRESH's reliability, based on the ICC (C,1) formula from McGraw and Wong [45]. Values <0.50, between 0.50 and 0.75, between 0.75 and 0.90, and >0.90 are indicative of poor, moderate, good, and excellent reliability, respectively [46]. Recognizing that correlation does not imply agreement, a Bland-Altman analysis was employed to evaluate the absolute differences between the 2 measurements [47]. To further assess the absolute agreement between both methods, we evaluated cross-classification within 3 pre-established categories: 1) score 0-4 points: indicates a less healthy and environmentally sustainable diet; 2) score 5-7 points: indicates a moderately healthy and environmentally sustainable diet; 3) score 8-10 points: indicates a healthy and environmentally sustainable diet. Having 50% of the subjects classified in the same category by both instruments and <10% of subjects misclassified in the opposite category (for example, an individual classified in category 1 according to the REFRESH questionnaire and in category 3 using data from food diaries, or vice versa) are desirable [48]. The weighted kappa index was also evaluated to account for and rule out the possibility of agreement occurring by chance. Values of weighted kappa above 0.4 are recommended in nutritional epidemiological studies [48].

## Construct validity

We assessed the relationship between the REFRESH score and food diary-derived variables, including the average daily consumption of food groups, nutrient intake, environmental impacts, and EAT-Lancet indices scores of participants' diets. Pearson correlation coefficients ($r$) were calculated to quantify the strength and direction of the associations, whereas $p$ values assess statistical significance. The strength of the correlations was interpreted as follows: values ≥0.50 were considered good correlation, values between 0.20 and 0.49 were considered acceptable, and values lower than 0.20 as poor or no correlation [49]. Statistical significance was set at $P < 0.05$.

## Ethics

This study has been approved by the Comité de Ética de la Investigación con Medicamentos del Parc de Salut Mar (Observational study number 2023/10861) on Barcelona, 10 May, 2023. All participants were informed about the study protocol

and provided written informed consent before participating in the study.

## Results

### Study population

Table 1 outlines the sociodemographic characteristics, lifestyle factors, and health-related data of the study population ($n = 93$). The sample was evenly distributed among age groups (mean age: 41.3 y; range: 19-77), gender (53% females, 47% males), and educational attainment (approximately one-third each with secondary education, university degrees, and postgraduate degrees). The vast majority of the participants (99%) were born in Spain, and resided in various Autonomous Communities at the time of the survey. Most respondents reported a relatively healthy lifestyle, with a high percentage of participants being nonsmokers (92%), either non or occasionally alcohol drinkers (65%), and reporting medium to high levels of physical activity (89%). The majority of the study population was free of chronic diseases (88%) and food allergies or intolerances (92%).

## Internal consistency

The internal consistency assessment yielded a KR-20 coefficient of 0.70. This coefficient demonstrated stability, as evidenced by its consistency when individual items were removed (ranging from 0.63 to 0.71) (Supplemental Table 2).

### Relative validity

According to Table 2, both methods showed agreement percentages for individual items ranging from 60% to 88%; the lowest absolute agreement was observed in the category “sugary, salty, and ultraprocessed foods.” Compared with food diaries, more than a quarter of the sample underestimated their consumption of those products, and overestimated their consumption of fruits and vegetables and whole grains when replying REFRESH.

Focusing on the total REFRESH score, Spearman correlation analysis showed a coefficient of 0.74 [95% confidence interval (CI): 0.63, 0.82] between scores derived from REFRESH and those from food diaries. The ICC for the total scores between the 2 methods was 0.71 (95% CI: 0.59, 0.80). Bland-Altman analysis (Figure 1) showed that scores obtained from the REFRESH questionnaire were on average 1.1 points higher (95% CI: 0.7, 1.4) than those obtained from the food diaries, of a possible total score of 10 points. Participants scored an average of 7.0 points (range: 1-10) using REFRESH, and 5.9 points (range: 1-10) using food diaries. REFRESH showed a high absolute agreement with food diaries when categorizing participants into the 3 pre-defined groups [that is, low (0-4 points), medium (5-7 points), and high (8-10 points) adherence to an environmentally sustainable healthy diet]. Notably, 99% of participants were classified into the same (59%) or contiguous (40%) categories, with 1% being misclassified into the opposite category. Weighted kappa index resulted in 0.53 (95% CI: 0.41, 0.65).

### Construct validity

Table 3 outlines the association between REFRESH-derived scores and food diaries-derived data. Absolute values of food group consumption, nutrient intake, environmental impacts, and
<table><caption>**TABLE 1**

Characteristics of participants involved in the REFRESH validation study.</caption><thead><tr><th></th><th>Study population (n = 93)</th></tr></thead><tbody><tr><td>Sociodemographic characteristics</td><td></td></tr><tr><td>Age [mean (min-max)]</td><td>41.3 (19-77) y</td></tr><tr><td>Gender</td><td></td></tr><tr><td>Female</td><td>49 (53)</td></tr><tr><td>Male</td><td>44 (47)</td></tr><tr><td>Other</td><td>0 (0)</td></tr><tr><td>Educational level</td><td></td></tr><tr><td>No studies</td><td>0 (0)</td></tr><tr><td>Primary</td><td>1 (1)</td></tr><tr><td>Secondary</td><td>29 (31)</td></tr><tr><td>Graduate</td><td>32 (34)</td></tr><tr><td>Master</td><td>23 (25)</td></tr><tr><td>PhD</td><td>8 (9)</td></tr><tr><td>Family income (per month after taxes)</td><td></td></tr><tr><td>&lt;500€</td><td>2 (2)</td></tr><tr><td>500-999€</td><td>5 (5)</td></tr><tr><td>1000-1499€</td><td>6 (6)</td></tr><tr><td>1500-1999€</td><td>12 (13)</td></tr><tr><td>2000-2999€</td><td>25 (27)</td></tr><tr><td>3000-3999€</td><td>21 (23)</td></tr><tr><td>4000€ or more</td><td>22 (24)</td></tr><tr><td>Civil status</td><td></td></tr><tr><td>Single</td><td>30 (32)</td></tr><tr><td>Married or stable relationship</td><td>60 (65)</td></tr><tr><td>Divorced</td><td>2 (2)</td></tr><tr><td>Widow</td><td>0 (0)</td></tr><tr><td>Other</td><td>1 (1)</td></tr><tr><td>Country of origin</td><td></td></tr><tr><td>Spain</td><td>92 (99)</td></tr><tr><td>Other European country</td><td>1 (1)</td></tr><tr><td>Autonomous Community in Spain</td><td></td></tr><tr><td>Andalucía</td><td>8 (9)</td></tr><tr><td>Balears</td><td>3 (3)</td></tr><tr><td>Canarias</td><td>4 (4)</td></tr><tr><td>Cantabria</td><td>2 (2)</td></tr><tr><td>Castilla La Mancha</td><td>2 (2)</td></tr><tr><td>Castilla León</td><td>6 (6)</td></tr><tr><td>Cataluña</td><td>36 (39)</td></tr><tr><td>Ceuta</td><td>1 (1)</td></tr><tr><td>Euskadi</td><td>6 (6)</td></tr><tr><td>Extremadura</td><td>2 (2)</td></tr><tr><td>Galicia</td><td>6 (6)</td></tr><tr><td>Madrid</td><td>7 (8)</td></tr><tr><td>Navarra</td><td>2 (2)</td></tr><tr><td>Comunidad Valenciana</td><td>7 (8)</td></tr><tr><td>Lifestyle and health</td><td></td></tr><tr><td>Smoking</td><td></td></tr><tr><td>Never</td><td>64 (69)</td></tr><tr><td>Given up &gt;6 mo ago</td><td>21 (23)</td></tr><tr><td>Occasionally</td><td>6 (6)</td></tr><tr><td>Daily</td><td>2 (2)</td></tr><tr><td>Alcohol consumption</td><td></td></tr><tr><td>Never</td><td>30 (32)</td></tr><tr><td>Occasionally (&lt;1 serving/wk)</td><td>31 (33)</td></tr><tr><td>1 or 2 drinks along the week</td><td>17 (18)</td></tr><tr><td>1 serving daily or almost daily</td><td>3 (3)</td></tr><tr><td>2 or more servings daily or almost daily</td><td>2 (2)</td></tr><tr><td>No daily, but &gt;3 servings when drinking</td><td>10 (11)</td></tr><tr><td>Physical activity level</td><td></td></tr><tr><td>Low</td><td>10 (11)</td></tr><tr><td>Medium</td><td>46 (49)</td></tr><tr><td>High</td><td>37 (40)</td></tr><tr><td>Chronic disease</td><td></td></tr><tr><td>None</td><td>82 (88)</td></tr></tbody></table>

<table><caption>**TABLE 1 (continued)**</caption><thead><tr><th></th><th>Study population (n = 93)</th></tr></thead><tbody><tr><td>Food allergy or intolerance</td><td></td></tr><tr><td>None</td><td>86 (92)</td></tr><tr><td>Intake of supplements</td><td></td></tr><tr><td>None</td><td>62 (67)</td></tr></tbody></table>

Data shown as *n* (%).

Abbreviation: REFRESH, Rapid Evaluation FoR Environmentally Sustainable and Healthy diets.

<table><caption>**TABLE 2**

Item agreement between REFRESH and food diaries¹.</caption><thead><tr><th></th><th>Agreement (%)</th><th>Underestimation (%)</th><th>Overestimation (%)</th></tr></thead><tbody><tr><td>Meat, fish, and egg</td><td>78</td><td>10</td><td>12</td></tr><tr><td>Red and processed meat</td><td>80</td><td>17</td><td>3</td></tr><tr><td>Dairy products</td><td>74</td><td>10</td><td>16</td></tr><tr><td>Legumes</td><td>73</td><td>17</td><td>10</td></tr><tr><td>Fruit and vegetable</td><td>71</td><td>2</td><td>27</td></tr><tr><td>Nuts and seeds</td><td>84</td><td>5</td><td>11</td></tr><tr><td>Sugary, salty, ultraprocessed foods</td><td>60</td><td>33</td><td>6</td></tr><tr><td>Sodas, juices, energy drinks</td><td>83</td><td>15</td><td>2</td></tr><tr><td>Whole grains</td><td>66</td><td>4</td><td>30</td></tr><tr><td>Added fats</td><td>88</td><td>0</td><td>12</td></tr></tbody></table>

Abbreviation: REFRESH, Rapid Evaluation FoR Environmentally Sustainable and Healthy diets.

¹ Agreement indicates that the intake of food groups as reported in REFRESH aligns with the quantities reported in the food diaries. Underestimation indicates that the intake of the food group was reported as lower when using REFRESH compared with the quantities reported in the food diaries. Overestimation indicates that intake was reported as higher with REFRESH than in the food diaries.

EAT-Lancet scores by REFRESH within the 3 categories are shown in Supplemental Table 3.

Statistically significant associations were observed between the REFRESH-derived scores and the assessed food groups derived from food diaries, with results aligning in the expected directions: positive associations with whole plant-based foods and negative associations with animal-based and unhealthy food groups. Despite the expected direction of the association, the *P* value did not reach statistical significance for dairy products (Table 3).

Significant positive associations were observed between the REFRESH-derived score and health-promoting macronutrients (for example, PUFA, both ω-3 and ω-6, and dietary fiber) in addition to various micronutrients (for example, iron, zinc, potassium, and several vitamins) derived from the reference method. Conversely, significant negative associations were found with detrimental nutrients such as saturated and trans fatty acids, free sugars, and sodium. Notably, no significant associations were observed between REFRESH scores and intake of energy, protein, total fats, MUFA, and calcium. Vitamin B12 demonstrated a negative and statistically significant association with the REFRESH score (Table 3).

For measures of environmental impacts, statistically significant negative correlations were observed between REFRESH-derived scores and the 3 endpoint indicators (human health,
<figure><img src="image_5.png" /><figcaption>FIGURE 1. Bland–Altman plot illustrating absolute differences between REFRESH and food diaries (n = 93 individuals). n, number of observations; REFRESH, Rapid Evaluation FoR Environmentally Sustainable and Healthy diets.</figcaption></figure>

ecosystem quality, and resource availability). Specifically, sig-
nificant negative associations were found with 9 out of 18
midpoint indicators, with no associations observed for the
remaining ones (Table 3).

The REFRESH-derived score showed a statistically significant
positive association with both EAT-Lancet indices (Table 3).

Discussion

REFRESH was developed as a short-form, low-burden, dietary
screening tool intended to identify individuals based on both
dietary healthiness and environmental sustainability, with a
focus on user accessibility. It demonstrated good internal con-
sistency and showed strong agreement with the reference
method, namely food diaries. Regarding construct validity,
higher REFRESH-derived scores were positively associated with
whole plant-based diets and health-promoting nutrients, and
negatively associated with detrimental nutrients, and both
endpoint and midpoint environmental impact indicators.

REFRESH design

The application of published EAT-Lancet indices typically
requires detailed dietary consumption data [7,50], rendering
them impractical for rapid evaluation in clinical practice or
comparable real-world settings. This limitation hindered the
development of a simple questionnaire for utilizing such indices.
Therefore, the creation of a new dietary screener with a corre-
sponding scoring system was warranted.

Similar to EAT-Lancet indices, REFRESH targets key food
groups associated with healthy and low environmental impact
diets, but does so in a more straightforward manner (for example,
by grouping all types of vegetables into a single item). It over-
comes the energy-dependent scoring criteria by focusing on the
quality rather than the quantity of food groups that are major
sources of energy, such as cereals and added fats. Additionally,
the EAT-Lancet indices combine food groups with dietary com-
ponents (for example, added sugars), but REFRESH is entirely

food-based [6]. While reporting precise sugar intake can be
challenging for the general population [51], REFRESH stream-
lines the procedure by prompting respondents to recognize
readily identifiable sugary products such as pastries, sodas, and
juices. Furthermore, REFRESH includes foods not explicitly
considered in the EAT-Lancet diet indices, such as energy drinks
and ultraprocessed foods, which scientific evidence suggests
should ideally be minimized in an optimal diet [14,25]. Other
dietary screeners have similarly emphasized the importance of
including such unhealthy products to discourage their con-
sumption [52]. We acknowledge, however, that the interpreta-
tion of "ultraprocessed food" is currently under debate, but the
inclusion of specific food examples in REFRESH ensured a clear
understanding of the term during content validation (that is,
highly processed industrial foods with poor nutritional quality).
Despite all these differences, REFRESH-derived scores demon-
strated a strong correlation with EAT-Lancet indices.

A further distinctive feature of REFRESH is its dichotomous
scoring structure, which mirrors the design employed in long-
standing dietary screeners [53,54]. This enhances the
low-burden and time-efficient nature of REFRESH. The binary
scoring system, however, measures only full adherence to rec-
ommendations, making REFRESH less suitable for assessing
precise behavioral changes over time. Nonetheless, REFRESH
was not designed for this purpose but rather as a tool to help
health professionals identify suboptimal diets.

Internal consistency

The items encompassed in REFRESH displayed a commend-
able internal consistency, besides integrating 2 dimensions (that
is, healthiness and environmental sustainability). Notably, the
greatest reduction in the KR-20 coefficient occurred when the
item “red and processed meat” was removed, which is consistent
with the overall design of REFRESH. As our screener addresses
both dimensions, some recommendations prioritize healthiness
(for example, increasing whole grains intake), whereas others
emphasize environmental sustainability (for example, limiting
<caption>TABLE 3</caption>

Correlation between REFRESH-derived score and food groups, nutrient intake, relative risk of health outcomes, environmental impacts, and EAT-lancet indices scores as derived from the reference method (food diaries)¹.

<table><caption>TABLE 3 (continued)</caption><thead><tr><th>Category</th><th>Variable</th><th>r</th><th>p value</th></tr></thead><tbody><tr><td rowspan="10">Food groups</td><td>Meat, fish and eggs (serv/d)</td><td>-0.54</td><td>&lt;0.001</td></tr><tr><td>Red and processed meat (serv/d)</td><td>-0.54</td><td>&lt;0.001</td></tr><tr><td>Dairy products (serv/d)</td><td>-0.17</td><td>0.100</td></tr><tr><td>Legumes (serv/d)</td><td>0.56</td><td>&lt;0.001</td></tr><tr><td>Fruits and vegetables (serv/d)</td><td>0.52</td><td>&lt;0.001</td></tr><tr><td>Nuts and seeds (serv/d)</td><td>0.48</td><td>&lt;0.001</td></tr><tr><td>Sugary, salty, ultraprocessed foods (serv/d)</td><td>-0.42</td><td>&lt;0.001</td></tr><tr><td>Sodas, juices, energy drinks (serv/d)</td><td>-0.37</td><td>&lt;0.001</td></tr><tr><td>Whole grains (% total grains)</td><td>0.47</td><td>&lt;0.001</td></tr><tr><td>Added fats (% total added fats)</td><td>0.28</td><td>0.006</td></tr><tr><td rowspan="20">Nutrients</td><td>Total energy intake (Kcal)</td><td>0.12</td><td>0.257</td></tr><tr><td>Protein (g)</td><td>-0.12</td><td>0.251</td></tr><tr><td>Total fats (g)</td><td>0.11</td><td>0.279</td></tr><tr><td>MUFA (g)</td><td>0.12</td><td>0.254</td></tr><tr><td>PUFA (g)</td><td>0.44</td><td>&lt;0.001</td></tr><tr><td>Omega3 (g)</td><td>0.31</td><td>0.003</td></tr><tr><td>Omega6 (g)</td><td>0.37</td><td>&lt;0.001</td></tr><tr><td>SFA (g)</td><td>-0.31</td><td>0.002</td></tr><tr><td>Trans fatty acids (g)</td><td>-0.26</td><td>0.010</td></tr><tr><td>Carbohydrates (g)</td><td>0.29</td><td>0.005</td></tr><tr><td>Fiber (g)</td><td>0.65</td><td>&lt;0.001</td></tr><tr><td>Free sugars (g)</td><td>-0.32</td><td>0.002</td></tr><tr><td>Sodium (mg)</td><td>-0.22</td><td>0.038</td></tr><tr><td>Calcium (mg)</td><td>0.19</td><td>0.070</td></tr><tr><td>Iron (mg)</td><td>0.56</td><td>&lt;0.001</td></tr><tr><td>Zinc (mg)</td><td>0.25</td><td>0.016</td></tr><tr><td>Potassium (mg)</td><td>0.38</td><td>&lt;0.001</td></tr><tr><td>Vitamin A (retinol equivalents)</td><td>0.29</td><td>0.004</td></tr><tr><td>Riboflavin (mg)</td><td>0.03</td><td>0.756</td></tr><tr><td>Folate (mg)</td><td>0.39</td><td>&lt;0.001</td></tr><tr><td>Vitamin B12 (mg)</td><td>-0.37</td><td>&lt;0.001</td></tr><tr><td>Vitamin C (mg)</td><td>0.36</td><td>&lt;0.001</td></tr><tr><td>Vitamin D (mg)</td><td>0.04</td><td>0.702</td></tr><tr><td>Vitamin E (mg)</td><td>0.39</td><td>&lt;0.001</td></tr><tr><td rowspan="20">Environmental impact indicators</td><td>Human health (DALY)</td><td>-0.31</td><td>0.003</td></tr><tr><td>Ecosystems (species.yr)</td><td>-0.3</td><td>0.003</td></tr><tr><td>Resources (USD2013)</td><td>-0.24</td><td>0.021</td></tr><tr><td>Global warming (kg CO<sub>2</sub> equivalents)</td><td>-0.39</td><td>&lt;0.001</td></tr><tr><td>Stratospheric ozone depletion (kg CFC11 equivalents)</td><td>-0.34</td><td>0.001</td></tr><tr><td>Ionizing radiation (kBq Co-60 equivalents)</td><td>-0.39</td><td>&lt;0.001</td></tr><tr><td>Ozone formation, human health (kg NOx equivalents)</td><td>-0.24</td><td>0.021</td></tr><tr><td>Fine particulate matter formation (kg PM<sub>2.5</sub> equivalents)</td><td>-0.37</td><td>&lt;0.001</td></tr><tr><td>Ozone formation, terrestrial ecosystems (kg NOx equivalents)</td><td>-0.24</td><td>0.020</td></tr><tr><td>Terrestrial acidification (kg SO<sub>2</sub> equivalents)</td><td>-0.46</td><td>&lt;0.001</td></tr><tr><td>Freshwater eutrophication (kg P equivalents)</td><td>-0.09</td><td>0.398</td></tr><tr><td>Marine eutrophication (kg N equivalents)</td><td>-0.08</td><td>0.698</td></tr><tr><td>Terrestrial ecotoxicity (kg 1,4-DCB)</td><td>0.11</td><td>0.460</td></tr><tr><td>Freshwater ecotoxicity (kg 1,4-DCB)</td><td>0.04</td><td>0.734</td></tr><tr><td>Marine ecotoxicity (kg 1,4-DCB)</td><td>0</td><td>0.982</td></tr><tr><td>Human carcinogenic toxicity (kg 1,4-DCB)</td><td>-0.14</td><td>0.173</td></tr><tr><td>Human noncarcinogenic toxicity (kg 1,4-DCB)</td><td>0.03</td><td>0.788</td></tr><tr><td>Land use (m<sup>2</sup>a crop equivalents)</td><td>-0.26</td><td>0.013</td></tr></tbody></table>

<table><thead><tr><th>Category</th><th>Variable</th><th>r</th><th>p value</th></tr></thead><tbody><tr><td rowspan="3">EAT-Lancet Scores</td><td>Mineral resource scarcity (kg Cu equivalents)</td><td>-0.02</td><td>0.879</td></tr><tr><td>Fossil resource scarcity (kg oil equivalents)</td><td>-0.23</td><td>0.026</td></tr><tr><td>Water consumption (m<sup>3</sup>)</td><td>0.19</td><td>0.061</td></tr><tr><td></td><td>Stubbendorff et al. 2022 (points) [40]</td><td>0.74</td><td>&lt;0.001</td></tr><tr><td></td><td>Colizzi et al. 2023 (points) [41]</td><td>0.48</td><td>&lt;0.001</td></tr></tbody></table>

Abbreviations: serv/d, servings per day; Kcal, kilocalories; g, grams; mg, milligrams; %, percentage; DALY, disability-adjusted life years; species.yr, potential species loss per year; USD2013, U.S. dollars (2013 value); kg CO₂ equivalents, kilograms of carbon dioxide equivalents; kg CFC11 equivalents, kilograms of trichlorofluoromethane equivalents; kBq Co-60 equivalents, kilobecquerels of cobalt-60 equivalents; kg NOx equivalents, kilograms of nitrogen oxides equivalents; kg PM₂.₅ equivalents, kilograms of fine particulate matter (PM₂.₅) equivalents; kg SO₂ equivalents, kilograms of sulfur dioxide equivalents; kg P equivalents, kilograms of phosphorus equivalents; kg N equivalents, kilograms of nitrogen equivalents; kg 1,4-DCB, kilograms of 1,4-dichlorobenzene equivalents; m²a crop equivalents, square meter-years of crop-equivalent land use; kg Cu equivalents, kilograms of copper equivalents; kg oil equivalents, kilograms of oil equivalents; m³, cubic meters; REFRESH, Rapid Evaluation FoR Environmentally Sustainable and Healthy diets.

¹ The table shows the Pearson correlation coefficient (r) and P values between the REFRESH-derived score and the food diaries-derived variables. The strength of the correlations was interpreted as follows: values ≥0.50 were considered good correlations, values between 0.20 and 0.49 were considered acceptable, and values lower than 0.20 as poor or no correlation. P values ≤0.05 were considered statistically significant.

dairy products). However, limiting red and processed meat is necessary for both health and environmental concerns, given their substantial impact in both areas.

## Relative validity

The percentages of agreement we observed for each individual item between REFRESH and the reference method (ranging from 60% to 88%) align with findings from previous dietary screener validation studies [54–56]. The most substantial disagreements pertained to the items assessing intake of fruits and vegetables, whole grains, and sugary, salty, and ultraprocessed foods. We recommend that health professionals applying REFRESH place particular emphasis on assessing these food groups and encourage respondents to thoughtfully evaluate their habitual consumption. Nevertheless, it is worth noting that the tendency to overestimate healthy food consumption and underestimate unhealthy options, as observed here, is a common challenge in dietary assessment rather than a unique limitation of REFRESH [54].

## Construct validity

REFRESH aligns with the principles of healthy and nutritionally adequate diets, as evidenced by the correlation of REFRESH scores with whole plant-based dietary patterns–patterns that are well-supported by extensive scientific literature demonstrating their beneficial effects on health [57–60]–as well as with diets that have more favorable
nutritional profiles. An exception was observed for vitamin B12, which exhibited a negative association with REFRESH scores. This finding was expected, given that environmentally sustainable healthy diets are predominantly plant-based, and that animal-source foods—the principal dietary sources of vitamin B12—are reduced in such patterns. Nevertheless, individuals with the highest REFRESH scores had an average vitamin B12 intake consistent with current nutritional recommendations (Supplemental Table 3) [32,61,62]. Additionally, the indirect human health benefits associated with higher REFRESH scores should not be overlooked. Our LCA analysis demonstrated that higher REFRESH scores are linked to reduced environmental human health impacts. Although the effects of environmental degradation on human health have historically been underemphasized in nutrition research, growing scientific consensus highlights the urgency of addressing these issues. Consistent with our findings, emerging evidence suggests that healthy plant-based diets can substantially reduce the environmental burden on human health [63,64].

The alignment between the REFRESH score and dietary patterns with reduced environmental impacts should not be assumed solely based on the REFRESH score's association with healthy dietary patterns, as trade-offs between health and environmental outcomes have been documented (for example, higher adherence to a healthy diet such as the Mediterranean pattern might result in a higher environmental impact [65]). Importantly, in our analysis, higher REFRESH scores were not associated with increases in any of the environmental indicators assessed. This is a noteworthy finding, given that divergences between environmental outcomes can also occur (for example, the carbon footprint of almonds is relatively low, despite their potential contribution to water scarcity [16]). Moreover, the environmental indicators that showed no association with the REFRESH score in our study were similarly identified as unrelated to diet composition in a previous investigation employing the same LCA characterization method [63].

## Strengths, limitations, and perspective

To be societally valuable, a dietary assessment tool must be evidence-based, objective, transparent, and reliable. Furthermore, it should be easy to understand with minimal nutritional knowledge, quick to complete, and simple to score. REFRESH embodies all these attributes, and can be utilized extensively to promote environmentally sustainable healthy diets in our context. Its simplicity and straightforward results make it suitable not only for health professionals but also for self-assessment by the general population. Moreover, it could be implemented in epidemiological settings with limited resources to evaluate dietary compliance. Besides REFRESH is tailored to the Spanish context, based on food availability and traditional dietary practices, REFRESH is easily adaptable to the realities of different countries. For instance, although virgin olive oil may be the primary fat source in Spain or Italy, the tool can be adjusted in other regions to emphasize alternative options available, like canola oil in Nordic countries [66,67]. This adaptability enhances the tool's utility in promoting environmentally sustainable healthy dietary practices globally.

We validated REFRESH using a multipronged approach in a diverse cohort varying in age, sex, and educational level, including participants from different regions of Spain with

potentially diverse culinary habits. Although the study sample may not be fully representative of the overall Spanish society, these factors strengthen the robustness of the validation process and enhance its external validity [42,47]. Dietary quality was evaluated based on a comprehensive range of food groups and nutrients, and the environmental impacts assessment extended beyond global warming potential [7,49], encompassing 18 midpoint and 3 endpoint indicators in accordance with standardized LCA methodology. Nevertheless, longitudinal studies are needed to confirm the associations between REFRESH-derived scores and health outcomes. Further research is also warranted to evaluate the performance of the REFRESH scoring system when used independently of the tool itself, and to compare its effectiveness in identifying healthy diets with low environmental impact with previously published dietary indices [7].

In conclusion, based on our findings, REFRESH demonstrated good validity for assessing individuals' dietary healthiness, nutritional quality, and environmental sustainability. Its simplicity renders it useful across clinical practice, epidemiological studies, and dietary self-assessment among the general population. The widespread utilization of REFRESH has the potential to facilitate the promotion of such dietary patterns, a pressing objective in our society.

## Acknowledgments

We thank Viola di Lorenzo for her technical support.

## Author contributions

The authors' responsibilities were as follows - UF: study design, data analysis, project administration, and writing first manuscript; AB: study design and data analysis; JB: data analysis; GC: study design; and all authors: read and approved the final manuscript.

## Conflict of interest

The authors report no conflicts of interest.

## Funding

UF, JB, and GC acknowledge support from the grant CEX2023-0001290-S funded by MCIN/AEI/ 10.13039/501100011033, and support from the Generalitat de Catalunya through the CERCA Program. UF also acknowledges support from Daniel y Nina Carasso Foundation, through the Daniel Carasso postdoctoral fellowship. JB receives funding from the grant "FJC2021-046458-I" financed by MICIU/AEI /10.13039/501100011033 and by the European Union NextGenerationEU/PRTR. GC has also been awarded with the grant RYC2021-033537-I, supported by MCIN/AEI/10.13039/501100011033 and by the European Union "NextGenerationEU"/PRTR"; and from the Ministry of Research and Universities of the Government of Catalonia (2021 SGR 01563). Funders have no role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript.

## Data availability

Spanish and English versions of REFRESH, along with data described in the manuscript, code book, and analytic code will be
made publicly and freely available without restriction at https://
osf.io/avby9/.

Appendix A. Supplementary data

Supplementary data to this article can be found online at
https://doi.org/10.1016/j.tjnut.2025.05.029.

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