Obese people, particularly those with abdominal or upper-body-segment obesity, share many of the metabolic, hormonal, and behavioral findings observed in Cushing syndrome. These include diabetes mellitus, hypertension, myocardial infarction, insomnia, and depression.61 Obesity is associated with increased cortisol production, as indicated by high cortisol secretion rates and levels of urinary 17-hydroxycorticosteroids, but normal or slightly diminished serum cortisol levels; these findings suggest an increased metabolic clearance rate for cortisol.62 Urinary free cortisol is increased in proportion to the waist-to-hip ratio; these individuals also exhibit increased cortisol responsiveness to ACTH stimulation and to physical and mental stress.63