Furthermore, different metabolic agents (i.e. insulin, insulin-like growth factor 1,...) have the potential to induce bone formation by stimulating the proliferation of chondrocytes, fibroblasts and osteoblasts.29 Increased rates of obesity in DISH patients may indicate that certain adipokines have a role in the disorder’s development. This evidence concerns the gene INS and obesity due to melanocortin 4 receptor deficiency.