Although some in vitro studies indicate that insulin stimulates bone formation(17) and bone resorption,(18) clinical studies across a wide range of hyperinsulinemic states such as polycystic ovarian syndrome, impaired glucose tolerance, and type 2 diabetes feature the consistent finding of high BMD.(19, 20, 21) Thus, the higher prevalence of type 2 diabetes in patients with NAFLD in comparison to control subjects and tendency toward higher prevalence in patients with NASH than in those with steatosis in our study could have potentially impacted/mitigated differences in BMD between the groups. Here, INS is linked to metabolic dysfunction-associated steatohepatitis.