The Cortisol Paradox
An Essay on Why Stressed People Gain Belly Fat While Starving
Clinically depressed patients admitted to psychiatric wards—people who aren’t eating, who derive no pleasure from food, who are losing weight—show increasing visceral fat on imaging while their subcutaneous fat decreases.
Robert Lustig, pediatric endocrinologist and professor at UCSF, describes scanning these patients. They’re anhedonic. They’re losing total body mass. Weight loss is so characteristic of major depressive disorder that it’s a standard question on the Beck Depression Inventory. Yet the scans reveal something that should be impossible under the calorie model: the most metabolically dangerous fat depot in their bodies is growing.
If visceral fat accumulation were driven by food intake, this wouldn’t happen. These patients are in caloric deficit. They’re wasting away visibly. But the fat wrapping their organs is expanding.
The mechanism is cortisol. And the implications extend far beyond psychiatric wards.
Support Independent Research
This work remains free because paid subscribers make it possible. If you find value here, consider joining them.
What paid subscribers get: Access to the Deep Dive Audio Library — 180+ in-depth discussions (30-50 min each) exploring the books behind these essays. New discussions added weekly. That’s 100+ hours of content for less than the price of a single audiobook.
[Upgrade to Paid – $5/month or $50/year]
Get in touch Essay ideas, stories, or expertise to share: unbekoming@outlook.com
The Biology of a Different Fat
Visceral fat operates under different rules than the subcutaneous fat people can pinch on their arms and thighs. Subcutaneous fat expands and contracts primarily in response to caloric balance. You can accumulate roughly 10 kilograms of it before the inflammatory cytokines it releases reach concentrations high enough to cause systemic problems.
Visceral fat responds to cortisol. This is observable in Cushing’s syndrome, the clinical condition of chronic hypercortisolism: patients develop enormous bellies while their arms and legs waste away. The cortisol directs energy specifically to visceral fat, independent of what or how much they eat.
The danger isn’t just the location. It’s the plumbing.
Subcutaneous fat releases inflammatory cytokines into the general systemic circulation—a volume of distribution of approximately six liters. Visceral fat drains through the portal vein directly into the liver, a volume of distribution of roughly 250 cubic centimeters. The math is straightforward: cytokines from visceral fat hit the liver and brain at 24 times the concentration of those from subcutaneous fat.
This means a small amount of visceral fat produces the same inflammatory load as a much larger amount of subcutaneous fat. Lustig estimates that 22 pounds of subcutaneous fat equals about 4 pounds of visceral fat in terms of metabolic damage. The belly is not just aesthetically concerning—it’s a fundamentally more dangerous place to store energy.
Photographing the Fat
Sean O’Mara, who has spent 13 years specializing in visceral fat reduction and imaging, can photograph these changes directly with MRI. His data reveals how quickly visceral fat responds to inputs.
When clients added rice to their diet on Friday evening, eating it through the weekend and returning Monday morning for rescanning, the imaging showed measurable visceral fat accumulation over those three days. The sensitivity cuts both ways: reductions in visceral fat also appear within days to weeks when the right interventions are applied.
O’Mara’s clinical experience across thousands of patients produced one consistent finding. Every patient presenting with chronic disease had elevated visceral fat, heart fat, or fat infiltration in muscle. Every patient arriving with acute trauma but no chronic disease had normal levels. During COVID, he observed that every ICU patient had elevated dangerous fat stores. The correlation held without exception across his practice.
The implication is that visceral fat isn’t merely associated with chronic disease—it may be its first structural expression, appearing before symptoms manifest and persisting as long as the inflammatory burden continues.
The Paradox of Trying Harder
Consider what this means for the person who has done everything right.
They’ve cut calories. They’ve exercised more. They’ve displayed tremendous willpower, white-knuckling through hunger, skipping meals, pushing through the discomfort of energy restriction. The scale may even be moving in the right direction.
But calorie restriction is itself a physiological stressor. The body doesn’t distinguish between voluntary famine and involuntary famine. It registers the energy deficit as a threat and mounts a stress response accordingly. If that response elevates cortisol sufficiently, the person may be losing subcutaneous fat while accumulating visceral fat—exactly the pattern observed in the psychiatric patients Lustig describes.
The more desperately someone diets, the more stress they experience around food. The more stress they experience, the more cortisol they produce. The more cortisol they produce, the more energy gets directed to the visceral compartment regardless of their caloric intake.
This is the cruel arithmetic of the anxious dieter: effort can be inversely correlated with outcome.
Morgan Nolte, a doctor of physical therapy specializing in metabolic health, documents the stress response with continuous glucose monitors. One of her clients wore a CGM during a public speaking course. On the morning of her first speech, without eating anything, her blood glucose spiked from the 90s to 170—the kind of elevation typically associated with a bowl of ice cream. Pure psychological stress, no food involved, producing the same metabolic signature as a carbohydrate binge.
That glucose spike requires an insulin response to clear it. The insulin promotes storage. If this pattern repeats daily—and for many people living with chronic anxiety, financial stress, or work pressure, it does—the metabolic consequences accumulate independent of dietary choices.
The Stress Beneath the Diet
Cortisol doesn’t just direct fat storage. It shapes eating behavior through downstream effects on neuropeptide Y, a compound that specifically increases cravings for carbohydrates and sweets. This is why stressed people reach for chips, crackers, candy, and ice cream rather than chicken breast. It’s why sleep-deprived people preferentially want sugar. The craving isn’t weakness—it’s neurochemistry responding to hormonal signals.
Sleep deprivation itself raises baseline cortisol levels. The cascade becomes self-reinforcing: stress disrupts sleep, poor sleep elevates cortisol, elevated cortisol increases carbohydrate cravings, the cravings lead to eating patterns that further disrupt sleep. Each element feeds the others.
The person trapped in this cycle can apply tremendous dietary discipline and still fail. They’re addressing the downstream symptom—food choice—while the upstream driver—chronic stress and its cortisol output—continues operating. All the dietary intervention in the world won’t overcome persistently elevated cortisol. The body will find ways to accumulate visceral fat regardless of caloric restriction.
This reframes why so many motivated, disciplined, health-conscious people remain stuck. They’re not failing for lack of effort or knowledge about nutrition. They’re failing because the variable that most determines their visceral fat accumulation isn’t on their plate. It’s in their nervous system.
Where This Leads
The standard advice to the overweight person is to eat less and move more. This advice assumes the calorie model tells the complete story. It doesn’t account for the psychiatric patients gaining visceral fat while starving. It doesn’t account for the stress-cortisol-visceral fat pathway that operates independent of energy balance. It doesn’t account for the 24x concentration difference that makes belly fat so much more dangerous than fat elsewhere.
The person working 60-hour weeks at a high-pressure job, chronically undersleeping, skipping meals to get more done, anxious about finances or relationships or the state of the world—this person may be doing more metabolic damage through their stress than they could possibly offset through dietary restriction. Every skipped meal is both a caloric deficit and a stress signal. The body responds to the stress signal.
O’Mara can photograph the difference in two months. A CEO came to him with substantial visceral fat. After intervention, the reduction wasn’t just in quantity but in quality—the remaining fat became less inflammatory. The visible change in the man’s face between scans made him look like a different person. He later took up modeling.
The fat responds. But it responds to the right inputs, which may not be the inputs people have been told to focus on.
This suggests the path to metabolic health may need to run through stress reduction before diet modification. Sleep before macros. Nervous system regulation before calorie counting. Addressing the cortisol first, and only then expecting dietary changes to produce their intended effects.
The metabolic crisis and the mental health crisis may be the same crisis, expressed in different tissues. The gig economy, the attention economy, the erosion of financial security, the fragmentation of social connection, the chronic sleep debt of modern life—these aren’t just psychological burdens. They’re metabolic burdens, writing themselves into visceral fat stores regardless of what people eat.
The psychiatric patients Lustig scans aren’t an anomaly. They’re an extreme expression of a mechanism operating more subtly in millions of people who can’t understand why trying so hard produces so little result.
References
Dr. Robert Lustig – “The REAL Cause of Insulin Resistance & How to FIX IT” (The Jesse Chappus Show). Pediatric endocrinologist, UCSF Professor Emeritus. Source for psychiatric ward observations, cortisol-visceral fat mechanism, volume of distribution calculations (6L systemic vs 250cc portal = 24x concentration), Cushing’s syndrome pathology, and fat depot hierarchy.
Dr. Sean O’Mara – “This Fat Is the Root of Chronic Disease (Doctors Aren’t Measuring It)” (The Jesse Chappus Show). Health optimization physician with 13 years specializing in visceral fat imaging and reduction. Source for MRI documentation of rapid visceral fat changes (Friday-Monday accumulation), chronic disease correlation across thousands of patients, COVID ICU observations, and before/after imaging data.
Dr. Morgan Nolte – “How to ELIMINATE Insulin Resistance Once and for All (COMMON Early Signs)” (The Jesse Chappus Show). Doctor of Physical Therapy specializing in metabolic health. Source for CGM documentation of stress-induced glucose spikes (90s to 170 from public speaking anxiety), cortisol-NPY-carbohydrate craving pathway, and sleep deprivation effects on cortisol and hunger hormones.
Dr. William Davis – “1/2 Cup per Day to Fix Insulin Resistance & Shrink Belly Fat” (The Jesse Chappus Show). Cardiologist and author. Source for calorie restriction effects on basal metabolic rate, muscle loss during weight loss interventions, and long-term weight regain patterns.
Dr. Ben Bikman – “If You DO THIS Your Insulin Resistance Will Be Normal FAST” (The Jesse Chappus Show). Metabolic scientist, Brigham Young University. Source for visceral fat immune cell population, fructose-visceral fat relationship, and ethnic differences in metabolic threshold.
Dr. Jason Fung – “Get Rid of Diabetes Once and for All” (The Jesse Chappus Show). Nephrologist and fasting researcher. Source for fasting versus calorie restriction effects on basal metabolic rate and the distinction between stored energy and available energy.
Medicalized Motherhood: From First Pill to Permanent Patient
Available as a free download. 123 interventions documented across six phases—from pre-conception capture through postpartum surveillance. Includes practical tools: birth plan template, provider interview questions, quick reference card, and a new chapter on interrupting the cascade. Download it, share it with someone facing their first prenatal appointment, their induction date, their cesarean recommendation. The cascade works because women don’t see it coming. This book makes it visible.
Support Independent Research
This work remains free because paid subscribers make it possible. If you find value here, consider joining them.
What paid subscribers get: Access to the Deep Dive Audio Library — 180+ in-depth discussions (30-50 min each) exploring the books behind these essays. New discussions added weekly. That’s 100+ hours of content for less than the price of a single audiobook.
[Upgrade to Paid – $5/month or $50/year]
Get in touch Essay ideas, stories, or expertise to share: unbekoming@outlook.com
Bitcoin: 3Q6BK8x8zjoPaXykQggzvoJxg5FiEbkb3U
Ethereum: 0x4CB0d39d8466a34609318FC1B003B745893788b3
New Biology Clinic
For those of you looking for practitioners who actually understand terrain medicine and the principles we explore here, I want to share something valuable. Dr. Tom Cowan—whose books and podcasts have shaped much of my own thinking about health—has created the New Biology Clinic, a virtual practice staffed by wellness specialists who operate from the same foundational understanding. This isn’t about symptom suppression or the conventional model. It’s about personalized guidance rooted in how living systems actually work. The clinic offers individual and family memberships that include not just private consults, but group sessions covering movement, nutrition, breathwork, biofield tuning, and more. Everything is virtual, making it accessible wherever you are. If you’ve been searching for practitioners who won’t look at you blankly when you mention structured water or the importance of the extracellular matrix, this is worth exploring. Use discount code “Unbekoming” to get $100 off the member activation fee. You can learn more and sign up at newbiologyclinic.com
Makes perfect sense. I remain in deep grief after the death of my wife just over a year ago, and it feels like no matter how much I limit the empty calories of sugar and carbs that the ten pounds of belly fat I've gained stay stubbornly attached. I of course intuitively know that the daily stress of grief impacts me physiologically in profound ways. My daily hikes, eating right and getting plenty of sleep I know are all very important routines for me - but now I know I'm up against a stress response that doesn't really differentiate my grief stress from the daily high level stress of some much younger extended family members immersed in the high pressure 24/7 world of modern professional working lives. People in mid-40's who because of intense chronic work stress that literally never shuts off - can only focus on diet to control belly fat accumulation, because finding time to "hike" and getting enough "sleep" are absolutely impossible options for them. Their work-life is by definition - daily chronic stress with no clear path out of it for them. It is very helpful to have this information as I try to maintain my basic health in the midst of the stress of deep grief. It explains a lot also about our "obesity epidemic."
Carnivore diet helped me. BMI 18.5 🙌