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insulin resistance can alter estrogen metabolism, inviting unwanted growth or tissue changes

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Furthermore, IL-6initiated inflammatory cascade activates additional cytokines, such as TNF and IL-1, through NF-B, forkhead box O4 (FOXO4), and related signaling networks, further exacerbating muscle atrophy [48, 63]

The activation of Ral leads to the phosphorylation of FOXO4 at specific sites