INS and acanthosis nigricans: For these cases, the evaluation of plasma insulin, acanthosis nigricans, and fatty liver was unavailable, but serum triglycerides were increased (4.6, 6.2, and 5.5 mmol/L (reference <1.3 (20)) and HDL levels were low (0.9, 1.1, and 1.1 mmol/L, reference >1.2 (20), personal communication, Dr Shalev).