SPECIAL COMMUNICATION Actual Causes of Death in the United States, 2000

IN A SEMINAL 1993 ARTICLE,McGinnis and Foege1 described themajor external (nongenetic) modi-fiable factors that contributed to death in the United States and labeled them the “actual causes of death. ” Dur-ing the 1990s, substantial lifestyle pat-tern changes may have led to variations in actual causes of death. Mortality rates from heart disease, stroke, and cancer have declined.2 At the same time, behav-ioral changes have led to an increased prevalence of obesity and diabetes.3 Most diseases and injuries have mul-tiple potential causes and several fac-tors and conditions may contribute to a single death. Therefore, it is a chal-lenge to estimate the contribution o