Background and aims: Benefits of Mediterranean diet on MetS risk have been suggested, but overall prospective evidence in the general population is limited. For the first time, the prospective association of adherence to Mediterranean diet with the 6-y risk of MetS and its components was evaluated in a large cohort in Europe. Methods and results: Subjects included were participants from the Supplementation en Vitamines et Mineraux AntioXydants (SU.VI.MAX) study. Adherence to Mediterranean diet was assessed using traditional Mediterranean diet score (MDS), an updated Mediterranean score (MED) and Mediterranean style-dietary pattern score (MSDPS) calculated from at least three 24-h records. In 3232 subjects, the association between Mediterranean diet scores and 6-y risk of MetS was evaluated. The association between Mediterranean scores and MetS components was also estimated. A lower risk of MetS was observed with increasing MED score (P-trend = 0.001) and MDS (P-trend = 0.03) in multivariate models. The adjusted odds ratios (95% Confidence Interval) for MetS risk were 0.47 (0.32-0.69) and 0.50 (0.32-0.77) in subjects in the highest versus lowest tertile of MED score and MDS, respectively. The MED score was inversely associated with waist circumference, systolic blood pressure and triglycerides, and directly associated with HDL-cholesterol. The MDS was negatively associated with waist circumference and triglycerides, and MSDPS was positively associated with HDL-cholesterol. Conclusions: All Mediterranean diet scores were associated in a potentially beneficial direction with components of MetS or MetS incidence. Our findings support that individuals should be encouraged to follow a Mediterranean dietary pattern for reduction of MetS risk. Trial Registration: clinicaltrials.gov Identifier: NCT00272428. (C) 2012 Elsevier B.V. All rights reserved.