Despite major advances in understanding monogenic causes of morbid obesity, the complex genetic and environmental etiology of idiopathic metabolic syndrome remains poorly understood. One hypothesis suggests that similarities between the metabolic disease of plasma glucocorticoid excess (Cushing's syndrome) and idiopathic metabolic syndrome results from increased glucocorticoid reamplification within adipose tissue by 11-hydroxysteroid dehydrogenase type 1 (11-HSD-1). Indeed, 11-HSD-1 is now a major therapeutic target. Because much supporting evidence for a role of adipose 11-HSD-1 comes from transgenic or obese rodents with single-gene mutations, we investigated whether the predicted traits of metabolic syndrome and glucocorticoid metabolism were coassociated in a unique polygenic model of obesity developed by long-term selection for divergent fat mass (Fat and Lean mice with 23 vs. 4% fat as body weight, respectively). Fat mice exhibited an insulin-resistant metabolic syndrome including fatty liver and hypertension. Unexpectedly, Fat mice had a marked intra-adipose (11-HSD-1) and plasma glucocorticoid deficiency but higher liver glucocorticoid action. Furthermore, metabolic disease was exacerbated only in Fat mice when challenged with exogenous glucocorticoids or a high-fat diet. Our data suggest that idiopathic metabolic syndrome might associate with such a novel pattern of glucocorticoid action and sensitivity in humans, with implications for tissue-specific therapeutic targeting of 11-HSD-1. Diabetes 54:3371-3378, 2005 I diopathic obesity is highly prevalent and strongly associated with other comorbid conditions such as insulin resistance, type 2 diabetes, dyslipidemia, and hypertension (the metabolic syndrome) (1). Despite major advances in understanding rare monogenic causes of obesity in humans and their striking recapitulation in transgenic or mutant rodent models (2), there is no consensus on a unified underlying biological mechanism accounting for the broader incidence of the metabolic syndrome because of its complex (3) polygenic origins.Close phenotypic parallels exist between idiopathic metabolic syndrome and plasma cortisol excess (e.g., Cushing's syndrome) (4), suggesting a common underlying role for glucocorticoid action in these disease processes. Indeed, rodent obesity and metabolic disease are ameliorated by adrenalectomy (5) and reinstated by exogenous glucocorticoids. Mechanistically, glucocorticoids mediate exaggerated adipocyte formation and hypertrophy (6,7), elevate liver glucose (8) and lipid production (9), exacerbate muscle insulin resistance (10), and inhibit central energy expenditure systems (11). However, in idiopathic human obesity, circulating glucocorticoid levels are usually unaltered, or even low (12). A potential explanation for this paradox is increased amplification of active glucocorticoid levels by the intracellular enzyme 11-hydroxysteroid dehydrogenase type 1 (11-HSD-1). 11-HSD-1 is elevated in the subcutaneous adipose tissue of obese humans (13-15) and in vis...