This was characterized by high insulin resistance in 8 participants, which was reflected by high insulin levels (eg, insulin of 1076 pmol/L [reference range 12–96 pmol/L] in P3), acanthosis nigricans in the axillary and inguinal regions, as well as in other areas in P3, P8, P9, and P10 (Figure 4A) and hepatic steatosis in P3–6, P8–12. Here, INS is linked to Insulin resistance.