Decreased insulin action in skeletal muscle (insulin resistance) is a key feature of non-insulin-dependent diabetes mellitus (NIDDM) and obesity. The mechanisms underlying the development of insulin resistance are not clearly defined but recent interest has focused on tumour necrosis factor-alpha (TNFa). Adipose tissue TNFa expression is increased in human obesity [1], and is closely correlated with circulating insulin levels which serve as an index of insulin resistance [1]. TNFa has also been shown to be expressed in skeletal muscle, and again this is increased in muscle from insulin resistant subjects [2]. More recently it was reported that obese mice homozygous for a targeted null mutation in the TNFa gene were significantly less insulin resistant than normal obese mice [3]. These observations strongly suggest that TNFa impairs insulin action, and the mechanism seems to Diabetologia (1998) Summary Insulin resistance is a feature of non-diabetic relatives of non-insulin-dependent diabetic (NIDDM) families. Tumour necrosis factor-alpha (TNFa) expression is linked with insulin resistance, and is under strong genetic control. We examined the relationship between insulin resistance and two polymorphisms of the TNFa promoter region (positions ±238 and ±-308). Non-diabetic relatives (n = 123) of NIDDM families and control subjects (n = 126) with no family history of diabetes were studied. Insulin resistance was determined by homeostasis model assessment (HOMA) and short insulin tolerance test (ITT), and genotyping was by restriction digest. The ±238 polymorphism (TNFA-A allele) was carried by 14 relatives and 11 control subjects, and all were heterozygotes. To examine the relationship between the ±238 polymorphism and insulin resistance independent of potentially confounding factors, the relatives with the TNFA-A allele were individually pair-matched for age, sex, waist-hip ratio, body mass index, and glucose tolerance with relatives homozygous for the wild-type allele. Relatives with the TNFA-A allele had decreased insulin resistance (HOMA index: 2.0, 3.6 ± 2.1 [means ± SD of differences], p = 0.03), and this was true for comparable pair-matched control subjects (HOMA index: 1.1, 1.9 ± 0.8, p = 0.01). Combining relative (n = 7) and control (n = 4) pairs that had undergone an ITT, subjects with the TNFA-A allele had an increased K ITT (3.8, 3.0 ± 1.0 %/min, p = 0.04) similarly indicating decreased insulin resistance. There was no significant relationship between the ±308 polymorphism and insulin resistance. We conclude that the TNFA-A allele is associated with decreased insulin resistance as assessed by two independent methods, and may protect against the future development of NIDDM in susceptible individuals. [Diabetologia (1998) 41: 430±434]