INS and acanthosis nigricans: 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.