A vicious cycle of hepatic, muscle and adipose tissue dysfunction ensues, leading to development of a pathogenic circulating milieu of high levels of insulin, glucose, NEFA and pro-inflammatory cytokines (e.g. hsCRP, IL-6, TNF-α, and CCL-2), all of which were observed in our patients with NASH. Here, INS is linked to metabolic dysfunction-associated steatohepatitis.