Production of Vegetables and Artichokes Is Associated with Lower Cardiovascular Mortality: An Ecological Study

Mortality due to cardiovascular disease (CVD), including cerebrovascular disease (CED) and ischaemic heart disease (IHD), was considerably different in eight municipalities of the province of Castellón, Community of Valencia (Spain) during the period of 1991-2011. In addition, these villages showed differences in agricultural practices and production. Since high vegetable consumption has been linked to decreased all-cause, CVD, and CED mortalities, we hypothesized that the diversity in vegetable and artichoke production, used as proxies for their consumption, could be associated with the diversity of mortality rates. In order to test our hypothesis, we estimated the smoothed standardized mortality ratios (SMRs) of CVD, CED, and IHD mortalities and a directed, age-adjusted mortality rate (AMR). We used a multilevel linear regression analysis to account for the ecological nature of our study. After adjustment, the CVD and CED SMRs were inversely associated with vegetable and artichoke production, with a reduction in SMRs for CVD: -0.19 (95% Confidence Interval [CI] -0.31 to -0.07) and -0.42 (95% CI -0.70 to -0.15) per hectare/10³ inhabitants, respectively. The SMRs for CED also decreased: -0.68 (95% CI -1.61 to -0.19) and -1.47 (95% CI -2.57 to -0.36) per hectare/10³ inhabitants, respectively. The SMRs for IHD were not associated with vegetal and artichoke production. When the directed AMR was used, CED mortality was consistent with the previous results, whereas the CVD mortality association was lost. Our results indicate that vegetable and artichoke production may act as protective factors of CED and CVD mortalities.