Always On: The Hidden Cost for the Man Who Never Stops

By Christopher Piercecchi, MD — Physician and Wellness Manager, Founder, The Men’s Clinic for Wellness & Vitality

SITREP is an evidence-review briefing for patients and colleagues of The Men’s Clinic for Wellness & Vitality. It is educational and does not constitute individualized medical advice.

Most patients I see in clinic are the high-performing type. These guys are always on the go, making moves, and seem to do it all. They run companies, sit on several boards, travel constantly, and their phones never stop. They are making decisions from the moment they wake up until late in the evening. They have families, investments, projects, meetings, dinners, workouts, and more that consume their time. And here’s the interesting part: they love it.

Ask them whether they are stressed, and they’ll usually tell you they’re fine. “I like what I do.” They may tell you they sleep pretty well, train four, five, maybe six days a week, and eat a pretty clean diet. They may be lean and fit, their blood pressure may look good, and they might have a resting heart rate most men their age would love to have.

So when you suggest that they may be pushing too hard and doing too much, their response is understandable: “What’s the problem? I feel great.” Maybe there isn’t a problem. But high-performing men should understand an important physiological concept: your perception of stress and the total physiological load on your body aren’t necessarily the same.

You can enjoy being busy, thrive on responsibility, love competition, and perform exceptionally well under pressure, but your body still has to respond to everything you’re asking it to do. If there is never enough recovery between those demands, there can eventually be a physiological cost, and researchers call this concept allostatic load.[1,2]

Stress Is Supposed to Exist

Stress itself isn’t inherently bad. In fact, much of what makes us healthier is technically a stressor. Exercise stresses your cardiovascular system and skeletal muscle, and your body responds, recovers, and adapts by becoming fitter and stronger. A difficult business presentation, an important negotiation, a deadline, competition, travel, physical training, lack of food, heat, cold, and illness can all require the body to temporarily change its physiology: your sympathetic nervous system activates, epinephrine and norepinephrine increase, heart rate and cardiac output can rise, and your hypothalamic-pituitary-adrenal, or HPA, axis can increase cortisol production so that energy substrates are mobilized and your brain and muscles have access to the fuel they may need.[1,11] That is exactly what those systems are designed to do.

The scientific term allostasis describes the way the body maintains internal stability by continually adjusting its physiology in response to changing demands, challenges, or stressors. The problem develops when those adaptive systems are activated repeatedly without adequate recovery, and the cumulative physiologic burden is what we mean by allostatic load.[1,2] This is important: allostatic load isn’t just another way of saying that your cortisol is high. A major 2023 individual-participant meta-analysis examined 67,126 people from 13 cohorts and 40 biomarkers across 12 different physiological systems, including the HPA axis, sympathetic and parasympathetic nervous systems, inflammation, cardiovascular function, glucose metabolism, lipids, kidney function, liver function, respiratory function, and oxidative stress.[2] In other words, this is potentially a whole-body phenomenon.

“But I Don’t Feel Stressed”

That’s good. I would much rather have a guy who enjoys his work than someone who spends 60 hours every week doing something he hates. How we perceive stress matters, and so do control, meaning, and personality. A successful entrepreneur enthusiastically building his company is not necessarily experiencing the same psychological stress as someone working the same number of hours in a job he despises.

But subjective stress still isn’t a perfect measurement of physiologic load. A guy can genuinely tell me that his stress is “moderate” while also working 60 hours a week, traveling, sleeping six hours, training five days a week, answering emails until bedtime, waking up to his phone, and having essentially no period during the week when he is truly off. He may have adapted so well to that routine that it simply feels normal. That doesn’t automatically mean something is wrong, but it does mean that feeling fine cannot tell you whether your body is fully recovering from everything you are asking it to do. You can feel capable, productive, and completely in control while still accumulating a physiological load that your body eventually has to pay for.

What About Cortisol?

This is where we need to be careful, because the wellness industry has turned cortisol into a catch-all explanation for everything from fatigue and weight gain to poor sleep and “burnout,” often without much regard for the actual physiology. And yes, hypercortisolism can be part of chronic stress, but it is only part of the problem. By hypercortisolism here, I mean periods of excessive or prolonged cortisol exposure caused by repeated HPA-axis activation. I am not saying that the busy executive has Cushing syndrome, and I am not saying that his serum cortisol is necessarily elevated every minute of the day. The point is that cortisol is one component of a much broader stress-response system, and when that system is activated repeatedly without adequate recovery, the cumulative physiological effects can eventually become harmful.

Cortisol is supposed to increase when the body perceives a demand, helping us respond by making energy available and adjusting other physiological systems to meet that challenge. It belongs to a class of steroid hormones called glucocorticoids, which influence glucose metabolism, immune activity, blood pressure, and other processes involved in the stress response. Among other things, glucocorticoids increase hepatic glucose production and can oppose insulin-mediated glucose uptake in skeletal muscle and adipose tissue, and when that exposure becomes excessive or prolonged, those effects can contribute to insulin resistance.[11,12] Chronic or recurrent psychosocial stress can also dysregulate both the sympathoadrenal system and the HPA axis, affecting insulin sensitivity, inflammation, blood pressure, and lipid metabolism.[13] In other words, the concern is not that cortisol itself is inherently harmful; the concern is what happens when a normal stress-response system is being called upon too frequently and does not get enough opportunity to return to baseline.

So when I talk about hypercortisolism in the high-performing guy, I am talking about the possibility that he spends too much time activating a system that is designed to turn on when needed and then settle back down once the demand has passed. If the next demand arrives before that recovery process is complete, and that pattern repeats day after day, the issue becomes less about any single cortisol spike and more about the cumulative physiological burden created by repeated activation. And to be clear, this is not “adrenal fatigue.” Adrenal fatigue is not a recognized medical diagnosis, and there is no good evidence that chronic stress causes the adrenal glands to become “tired” or unable to produce cortisol. That concept is largely promoted in alternative and naturopathic medicine and should not be confused with the very real physiology of chronic stress, HPA-axis dysregulation, and excessive glucocorticoid exposure.

One Place This Can Show Up Is Insulin Resistance

This is one of the more interesting metabolic consequences of chronic physiologic stress, because the usual markers can still look completely normal. Imagine a lean, active guy whose fasting glucose is 90 mg/dL and whose HbA1c is 5.3 or 5.4%, both of which would generally be considered normal, who has little visceral fat and exercises regularly. On paper, he looks metabolically healthy.

But now look at his fasting insulin. If his pancreas has to produce an insulin level of 15, 17, or 20 μU/mL just to keep that fasting glucose at 90, that tells a different story. Insulin is the hormone that helps move glucose out of the bloodstream and into cells, so if the body requires a relatively large amount of insulin to maintain a normal glucose level, it can be a sign that those tissues are becoming less responsive to insulin. The glucose may still look normal because the pancreas is working harder to keep it there.

With chronic stress, the HPA axis and sympathetic nervous system are called upon repeatedly to make more fuel available to meet the body’s demands. Cortisol increases glucose production by the liver, while glucocorticoid and sympathetic signaling can reduce insulin sensitivity in muscle and fat, so the pancreas has to release more insulin to keep blood glucose under control. That response is useful during short periods of stress, but when it is repeated day after day, the metabolic cost can be a progressively higher insulin requirement even while fasting glucose and HbA1c still look reassuringly normal.

Sleep restriction gives us a particularly useful example of this physiology because inadequate sleep is itself a physiologic stressor, and unlike many forms of real-world stress, researchers can study it under controlled conditions. In one inpatient study, 20 healthy young men were limited to five hours in bed per night for seven nights while their diet and activity were controlled. By the end of the week, their insulin sensitivity had fallen significantly, showing that even short-term sleep restriction can impair the body’s ability to handle glucose.[3] These were not unhealthy people with preexisting metabolic disease; they were healthy men whose sleep was deliberately restricted.

Higher-level evidence points in the same direction. A 2022 systematic review looked at 35 randomized sleep-manipulation studies, including 26 sleep-restriction experiments, and found that restricting sleep consistently worsened the body’s ability to respond to insulin.[4] An earlier meta-analysis of 41 randomized controlled trials found the same general pattern and also showed that people ate about 253 more calories per day when their sleep was restricted.[5]

And this is the larger point: a nonstop, always-on lifestyle can create real physiologic stress even when you enjoy it, feel good, and believe you are handling it well. If that pattern continues without enough recovery, one of the places the effects can eventually show up is in worsening insulin sensitivity.

The Always-On Schedule Can Affect Sleep Even When You “Sleep Well”

This is another distinction that matters. When I ask somebody whether he sleeps well, he may say yes because he falls asleep quickly, stays asleep, and wakes feeling rested. That may be completely true, and some people genuinely function well on six hours of sleep. Sleep need varies from person to person, so the number alone does not tell me whether somebody is getting enough.

The question is whether the amount of sleep he is getting is actually sufficient for him, and whether his schedule allows that sleep to remain consistent. A guy who naturally does well on six hours is very different from someone who needs seven or eight but repeatedly cuts himself down to five and a half or six because work, travel, training, and late-night obligations keep crowding sleep out.

Now put that sleep pattern into the context of an “always-on” schedule: an early flight, a late business dinner, a 5:00 AM workout because that’s the only place it fits, emails at 10:30 PM, changing time zones, or a breakfast meeting at 6:30 AM. Even when the total amount of sleep seems adequate, that kind of schedule can interfere with the normal timing and architecture of sleep. We cycle through different stages of sleep throughout the night, with more deep sleep occurring earlier and more REM sleep occurring later, so repeatedly staying up late, waking early, or shifting the timing of sleep can change which portions of that normal sleep pattern we are getting. Irregular schedules and travel can also push sleep out of alignment with the body’s circadian clock.

The issue, then, is not that everyone needs eight hours or that six hours is automatically too little. It is whether you are consistently getting the amount and pattern of sleep your body actually needs, at a reasonably consistent biological time, rather than repeatedly forcing sleep to fit into whatever space is left in the schedule.

Then There Is the Cardiovascular System

The cardiovascular system is another place where a chronically high-demand lifestyle can take a toll. When work demands remain high day after day and there is little opportunity for genuine recovery, the repeated stress response is not biologically neutral. One of the best-studied examples is what researchers call job strain, generally defined as the combination of high work demands and relatively little control over those demands. In a large individual-participant meta-analysis that pooled 197,473 workers from 13 European cohorts, people reporting job strain had a significantly higher risk of developing coronary heart disease than those without job strain.[6]

That association becomes even more important when you consider what chronic stress is asking the cardiovascular system to do. Repeated activation of the sympathetic nervous system increases heart rate, vascular tone, and blood pressure and is accompanied by changes in inflammatory, metabolic, and neuroendocrine signaling. These responses are useful when they are temporary, but an “always-on” lifestyle can repeatedly call upon those same systems throughout the day, whether the trigger is a difficult meeting, another flight, a late-night call, an early workout, inadequate sleep, or simply never having a meaningful period when the body is allowed to disengage and recover.

Another analysis involving 102,128 workers found the same pattern: job strain was associated with a significantly higher risk of developing coronary heart disease.[7] Lifestyle clearly influenced the magnitude of that risk. Among people experiencing job strain, the 10-year incidence of coronary disease was 14.7 per 1,000 in those with a healthy lifestyle compared with 31.2 per 1,000 in those with an unhealthy lifestyle.[7] That does not make the occupational stress irrelevant. It shows that the cardiovascular consequences of chronic stress exist alongside the other factors that determine cardiovascular health and can compound an already unfavorable risk profile.

And that brings us back to the high-performing guy who tells me he feels great. He may love his work, enjoy the pressure, exercise regularly, and genuinely believe that being constantly on the move is simply how he is wired. But his cardiovascular system does not get to opt out of the physiological response just because he enjoys the life producing it. When high demands become chronic, and recovery is repeatedly pushed aside, that lifestyle can become another contributor to the cardiovascular burden accumulating over time.

What About Working Long Hours?

There is also a surprisingly large literature examining working hours themselves. WHO and International Labour Organization investigators conducted systematic reviews comparing people working 55 hours or more per week with those working 35 to 40 hours. Across the pooled studies, working at least 55 hours per week was associated with a higher risk of death from ischemic heart disease and a higher incidence of stroke.[8,9]

These are observational data, so they cannot prove that working long hours directly causes a heart attack or stroke in any individual person, and researchers have raised legitimate questions about the causal interpretation of some of this evidence.[10] But taken together with the broader literature on occupational stress, the message is difficult to ignore: repeatedly spending very long hours working, while leaving less time for sleep, recovery, exercise, relationships, and genuine downtime, is not physiologically neutral simply because you enjoy the work or feel capable of sustaining the pace.

Exercise Can Become Another Stressor

This is where high-performing guys sometimes get themselves into trouble. Exercise is one of the most powerful interventions we have for human health, but training itself is a physiological stressor, and the benefit occurs because the body is stressed, given adequate time to recover, and then adapts by becoming fitter and stronger.

Consider the guy who wakes up early because it’s the only time he can exercise. He does a hard interval workout, rushes home, showers, gets on a conference call, heads to the office, sits through meetings all day, eats lunch while answering emails, deals with problems, goes to a business dinner, answers emails afterward, sleeps six hours, and then does it again. The workout is healthy. But the body doesn’t maintain a separate accounting ledger that treats 5:30 to 6:30 AM as healthy stress and everything from 7:00 AM onward as unrelated stress. It receives the total physiological load.

When training demands exceed recovery capacity for prolonged periods, performance and health can eventually suffer. Sleep loss itself is considered a physiologic stressor that contributes to allostatic load.[14] This doesn’t mean the guy should exercise less. It means the hardest workout isn’t necessarily the smartest workout on the hardest day of the week. Sometimes Zone 2 is enough. Sometimes recovery is the training.

What Might You Actually Notice?

Often, nothing at first. High-performing people are generally very good at operating under load. That’s part of how they became high-performing people in the first place. But over time I may start seeing subtle changes:

• the resting heart rate creeps upward

• blood pressure becomes a little less favorable

• sleep duration slowly contracts

• training performance plateaus

• heart-rate recovery isn’t quite what it used to be

• fasting insulin increases even though glucose remains normal

• triglycerides become less favorable

• libido changes

• recovery from workouts slows down

• small injuries start accumulating

• testosterone becomes less favorable

Testosterone deserves a little more context because the male reproductive axis can be quite sensitive to periods when physiologic demands substantially exceed recovery. When heavy physical demands, insufficient energy intake, psychological stress, and inadequate recovery occur together for prolonged periods, testosterone can fall substantially. Military training gives us some of the clearest examples. During an eight-week U.S. Army Ranger course involving severe physical demands and a persistent energy deficit, testosterone fell significantly while cortisol increased, and during a 20-day military field exercise, total and free testosterone fell by roughly 27% during the most severe period of physiologic stress.[15,16]

An even more striking example comes from Norwegian Special Forces selection, where soldiers underwent a week of rigorous activity with extremely limited opportunity for recovery. By the end of that week, testosterone had fallen by about 70%, while cortisol had increased dramatically; with rest and adequate nutrition, the hormonal changes began returning toward baseline.[17] These conditions are obviously far more extreme than the life of the typical high-performing executive, but they demonstrate an important physiological principle: when the demands placed on the body repeatedly exceed its ability to recover, the male reproductive system is one of the systems that can be downregulated. Being busy does not automatically lower testosterone, but a lifestyle characterized by persistent physical and psychological demands, inadequate fueling, disrupted recovery, and too little genuine downtime can create the kind of cumulative physiologic load in which testosterone becomes another place those effects can show up.

Allostatic Load and Long-Term Outcomes

This is where the concept becomes more than theoretical. As a reminder, allostatic load is the cumulative physiological burden that builds when the body’s stress-response systems are repeatedly called upon to adapt to ongoing demands without enough opportunity to fully recover. A 2022 systematic review and meta-analysis examined 17 studies evaluating allostatic load and mortality and found that higher allostatic load was associated with increased all-cause mortality and cardiovascular mortality.[18] There is an important caveat, however, because heterogeneity across the studies was very high, generally greater than 90%, and investigators have used different biomarkers and definitions to calculate allostatic load.[18]

So I wouldn’t tell somebody that his “allostatic load score” predicts exactly how long he will live, because that isn’t what the concept is useful for. What it does remind us is that these systems do not operate independently: blood pressure, glucose regulation, insulin, lipids, inflammation, autonomic function, sleep, and fitness all interact with one another, and looking at that broader physiological picture can reveal a pattern of accumulating stress that may not be obvious when each laboratory value or measurement is considered in isolation.

So What Do You Do If You’re That Guy?

I’m not going to tell you to sell your company, resign from your boards, or spend two hours every morning meditating, and I’m certainly not going to tell an ambitious guy who loves what he does that ambition is unhealthy. Most of these guys don’t want to slow down, and that’s fine. The objective is not necessarily to do less; it is to make recovery deliberate.

And if you are the guy who says, “I don’t want to slow down. I hate sitting still. My mind is always going,” I understand that too. Recovery does not mean you have to sit still for an hour or force yourself into some form of downtime that feels unnatural to you. What matters is whether there are periods when you are no longer responding to work, solving problems, checking messages, making decisions, or trying to accomplish something. For some people that may be an easy walk, time with family, cooking, reading, working on a hobby, or doing something physical that is genuinely easy rather than another performance goal. The activity itself matters less than whether it allows you to disengage from the demands that have been driving you all day.

And if being unoccupied makes you immediately restless and you feel compelled to fill every available minute with another task, I would not automatically take that as evidence that you simply don’t need recovery. It may be that you have become so accustomed to constant stimulation and productivity that being off feels abnormal. The goal is not to turn a driven person into an inactive one; it is to make sure that being driven does not mean remaining physiologically and psychologically engaged with demands from the moment you wake up until the moment you fall asleep.

That starts with taking an honest look at whether your schedule is actually giving your body enough opportunity to recover. Are you getting the amount of sleep you personally need, and is that sleep reasonably consistent, or are work, travel, late dinners, early workouts, and changing time zones constantly pushing it around? If business emails continue until the moment you go to bed and your phone is the first thing you reach for when you wake up, it is worth asking whether there is ever a meaningful period when you are actually off.

Training deserves the same scrutiny. Exercise is obviously beneficial, but it is still a physiological stressor, and there is a difference between training that your body is adapting to and training that has simply become another obligation forced into an already overloaded calendar. If performance has plateaued, recovery is getting slower, or small injuries are accumulating, more training may not be the answer.

There is also value in looking beyond how you feel and following some objective measures over time. Blood pressure, resting heart rate, cardiovascular fitness, body composition, glucose regulation, insulin, lipids, sleep, and changes in training performance can all provide clues about how well your body is handling the total load being placed on it. The goal is to use those measurements, along with how you actually feel and perform, to recognize when your current workload and recovery are getting out of balance.

Here’s the Point

Ambition, success, and working hard are not inherently unhealthy, and loving what you do is a very different psychological experience from spending your life trapped in something you hate. But none of that gives you unlimited recovery capacity.

You can love the pace and still accumulate physiological load, feel completely fine while insulin sensitivity begins to deteriorate, sleep well but not get enough sleep for your own needs, or exercise consistently while still becoming under-recovered. Enjoying what you are doing does not prevent your sympathetic nervous system, HPA axis, and other stress-response systems from responding to the demands you continue to place on them.

The high-performing guy usually understands this perfectly when it comes to his company: equipment needs maintenance, high-performing employees need recovery, and systems that run at maximum capacity indefinitely eventually become less reliable. Yet somehow, many men assume the one system that should be capable of running at maximum output every day for decades is their own body. It isn’t.

You don’t necessarily have to slow down. But if you want to keep operating at that level for another 20 or 30 years, recovery has to become part of the performance strategy.

Know a guy who is always on? Send this to him.

Refer a friend

References

1. McEwen BS. Allostasis and allostatic load: implications for neuropsychopharmacology. Neuropsychopharmacology. 2000;22(2):108-124. doi:10.1016/S0893-133X(99)00129-3.

2. Mauss D, et al. Towards a consensus definition of allostatic load: a multi-cohort, multi-system, multi-biomarker individual participant data meta-analysis. Psychoneuroendocrinology. 2023;153:106117. doi:10.1016/j.psyneuen.2023.106117.

3. Buxton OM, et al. Sleep restriction for 1 week reduces insulin sensitivity in healthy men. Diabetes. 2010;59(9):2126-2133.

4. Sondrup N, et al. Effects of sleep manipulation on markers of insulin sensitivity: a systematic review and meta-analysis of randomized controlled trials. Sleep Medicine Reviews. 2022;62:101594. doi:10.1016/j.smrv.2022.101594.

5. Zhu B, et al. Effects of sleep restriction on metabolism-related parameters in healthy adults: a comprehensive review and meta-analysis of randomized controlled trials. Sleep Medicine Reviews. 2019;45:18-30. doi:10.1016/j.smrv.2019.02.002.

6. Kivimäki M, et al. Job strain as a risk factor for coronary heart disease: a collaborative meta-analysis of individual participant data. Lancet. 2012;380(9852):1491-1497. doi:10.1016/S0140-6736(12)60994-5.

7. Kivimäki M, et al. Associations of job strain and lifestyle risk factors with risk of coronary artery disease: a meta-analysis of individual participant data. CMAJ. 2013;185(9):763-769. doi:10.1503/cmaj.121735.

8. Li J, et al. The effect of exposure to long working hours on ischaemic heart disease: a systematic review and meta-analysis from the WHO/ILO Joint Estimates. Environment International. 2020.

9. Descatha A, et al. The effect of exposure to long working hours on stroke: a systematic review and meta-analysis from the WHO/ILO Joint Estimates. Environment International. 2020.

10. Kivimäki M, et al. The WHO/ILO report on long working hours and ischaemic heart disease: conclusions are not supported by the evidence. Environment International. 2020;144:106048.

11. Kuo T, McQueen A, Chen TC, Wang JC. Regulation of glucose homeostasis by glucocorticoids. 2015.

12. Geer EB, Islam J, Buettner C. Mechanisms of glucocorticoid-induced insulin resistance: focus on adipose tissue function and lipid metabolism. Endocrinology and Metabolism Clinics of North America. 2014;43(1):75-102. doi:10.1016/j.ecl.2013.10.005.

13. Innes KE, Vincent HK, Taylor AG. Chronic stress and insulin resistance-related indices of cardiovascular disease risk, part I: neurophysiological responses and pathological sequelae. Alternative Therapies in Health and Medicine. 2007;13(4):46-52.

14. McEwen BS. Sleep deprivation as a neurobiologic and physiologic stressor: allostasis and allostatic load. Metabolism. 2006;55(10 Suppl 2):S20-S23. doi:10.1016/j.metabol.2006.07.008.

15. Nindl BC, Barnes BR, Alemany JA, Frykman PN, Shippee RL, Friedl KE. Physiological consequences of U.S. Army Ranger training. Medicine & Science in Sports & Exercise. 2007;39(8):1380-1387. doi:10.1249/MSS.0b013e318067e2f7.

16. Kyröläinen H, Karinkanta J, Santtila M, Koski H, Mäntysaari M, Pullinen T. Hormonal responses during a prolonged military field exercise with variable exercise intensity. European Journal of Applied Physiology. 2008;102(5):539-546. doi:10.1007/s00421-007-0619-0.

17. Hamarsland H, Paulsen G, Solberg PA, Slaathaug OG, Raastad T. Depressed physical performance outlasts hormonal disturbances after military training. Medicine & Science in Sports & Exercise. 2018;50(10):2076-2084. doi:10.1249/MSS.0000000000001681.

18. Parker HW, Abreu AM, Sullivan MC, Vadiveloo MK. Allostatic load and mortality: a systematic review and meta-analysis. American Journal of Preventive Medicine. 2022;63(1):131-140. doi:10.1016/j.amepre.2022.02.003.

Back to All Blogs