BACKGROUND: A Mediterranean-type diet could play a role in decreasing serum uric acid concentrations due to its antioxidant and anti-inflammatory properties. The aim of this study was to evaluate whether better adherence to the Mediterranean diet (MeDiet) reduced or prevented the development of hyperuricemia. METHODS: Cross-sectional and prospective analysis in 4,449 elderly participants at high cardiovascular risk from the PREvención con DIeta MEDiterránea trial randomized to two MeDiet interventions (supplemented with either olive oil or nuts) or a control diet. A validated 14-item questionnaire was used to assess adherence to the MeDiet. Hyperuricemia was considered to be present when serum uric acid was higher than 7mg/dL in men or higher than 6mg/dL in women. RESULTS: After a median follow-up of 5 years, 756 individuals of the 3,037 (24.9%) who did not have hyperuricemia at baseline developed hyperuricemia, whereas 422 of the 964 hyperuricemic individuals at baseline (43.8%) reverted this condition. In cross-sectional analyses, an inverse association was observed between increasing levels of adherence to the 14-item MeDiet score and decreasing hyperuricemia (p trend < .001). Baseline consumption of red meat, fish and seafood, and wine were associated with a higher prevalence of hyperuricemia. Reversion of hyperuricemia was significantly higher (multivariable-adjusted odds ratio = 1.73; 95% confidence interval: 1.04-2.89) in the highest category of baseline adherence to the MeDiet as compared with the lowest. No association was found between baseline adherence to MeDiet and the incidence of hyperuricemia. The three intervention diets had similar effects in the reduction of hyperuricemia. CONCLUSIONS: Higher baseline adherence to the MeDiet is associated with lower risk of hyperuricemia.