Background Validation of the EAT-Lancet reference (ELR) diet, recently proposed by the EAT-Lancet Commission, within the context of real-life studies is necessary to elucidate its feasibility, nutritional value, sustainability, and health effects. Objective To develop a dietary index (DI score) to measure adherence to the ELR-diet. To study the association between the DI score and a) nutritional characteristics, b) indicators of ecological sustainability, and c) anthropometric and biomarkers for cardio-metabolic health. Methods A DI score was constructed by comparing the categories defined by the ELR-diet to the dietary data of 2–5 sets of three-day weighed dietary records from DONALD study participants (n = 298; ≥ 15 years of age). Prospective associations between the DI score and risk markers (anthropometric and cardio-metabolic) in young adulthood (≥18 years) were investigated using multivariate linear regression. Results Adherence to the DI score components was considerable (majority > 50%), but varied within the population (2%–100%). The highest tertile of the DI score was inversely associated with the intake of protein (13.5 vs. 14.5 energy%), added sugars (10.5 vs. 12.4 energy%), and cholesterol (100 vs. 116 mg/1000 kcal), but positively associated with fiber intake (10.0 vs. 8.82 g/1000 kcal) (all P < 0.05). The DI score was inversely associated with greenhouse-gas emissions (6.48 vs. 5.85 kgCO2eq/2500 kcal; P < 0.001), and land use (8.24 vs. 7.16 m2 × year/2500 kcal; P < 0.001). Inverse associations between the DI score and anthropometric markers during young adulthood were observed with BMI (22.9 vs. 21.9 kg/m2; P = 0.03) (all P < 0.05). No associations between the DI score and cardio-metabolic risk markers were found (all P ≥ 0.05). Conclusions Adherence to the ELR-diet was associated with favorable nutritional characteristics and reduced environmental impact. Adherence to the DI score in adolescence was also beneficial with respect to anthropometric markers in early adulthood, though not for further cardio-metabolic risk markers.

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