INS and metabolic syndrome: The first hypothesis involves metabolic syndrome and insulin resistance leading to increased circulating free fatty acid in the blood, liver uptake of free fatty acid, and lipogenesis in the liver.[11,29] The second explanation is that malnutrition and EPI due to pancreatectomy result in malabsorption of amino acids, decreased insulin secretion, decreased carnitine and choline levels, and upregulated levels of peroxisome proliferator-activated receptors.