INS and obesity due to melanocortin 4 receptor deficiency: The likely pathways for down-regulation of kisspeptin signalling include negative feedback by estrogen, which is markedly elevated in obesity (Schneider et al., 1979), resistance to leptin, also seen in human obesity (Finn et al., 1998), insulin resistance and hyperglycaemia (Castellano et al., 2006, 2009), and inflammation, which is up-regulated in hypogonadal men with diabetes (Dandona et al., 2008) and is associated with decreased kisspeptin expression in rats (Iwasa et al., 2008).