## 4 Discussion  
The main purpose of this study was to show to what degree CIMT can be considered a reliable evaluation parameter along with the usual ones in obese children. To achieve this goal, we analyzed whether the presence of certain genetic and epigenetic factors influence the values of CIMT and observed how CIMT correlated to certain usual clinical and blood parameters. We chose ultrasonography-measured CIMT as the focus of our analysis, which, although not the most accurate way of analyzing arterial walls, is the most appropriate for children as a screening tool. Studies have proven that MRI wall-thickness measurements may have better clinical utility because they have better prognostic value for cardiovascular risk than ultrasonography. In addition to intima-media measurement, MRI also images adventicia thickening and its vasa vasorum proliferation, the entire carotid artery, and the carotid bulb, where plaque forms early. However, its limitations make it more of a research tool than a day-to-day clinical one. It is over 10 times more expensive than ultrasonography, less accessible due to construction costs, requires longer scan times, and, because it is so sensible to motion, its common use in children is unrealistic [46; 47]. CT angiography may detect vasa vasorum neovascularization and thus be a good predictor of vascular accidents, but its limitations with regard to radiation and poor contrast between lipid and fibrotic structures makes it unfit for a screening tool, especially in children [47]. Fluorodeoxyglucose-PET can be useful in assessing plaque vulnerability, because it targets areas of inflammation that are prone to rupture. When coupled with CT or MRI, its value increases. However, it is a method that is highly unlikely to be useful in screening children at risk [48]. That said, it is obvious that for our everyday clinical risk assessment in minor patients, CIMT ultrasonography is the only imagistic tool that is useful in assessing subclinical atherosclerosis. Our patients were divided into three study groups--obese, overweight, and normal-weight--and subgroups depending on the object of study. CIMT values were correlated to BMI levels and there were significant differences between the three groups with regard to CIMT. In our study, excess adipose tissue was estimated by BMI and waist circumference measurements, but we acknowledge that the utility of peripheral adipose tissue ultrasound measurement and bioelectrical impedance analysis as a more accurate detection of subcutaneous fat tissue, which has been shown to have important roles in cytokine and growth-factor production and thus, in cardiometabolic risk [49]. Atherosclerosis is a process that starts in early childhood and has a lifelong progression, its pathological speed depending on genetic predisposition and environmental factors [7]. As a consequence, CIMT is a parameter that increases over time. In order to analyze how obesity affects children of different ages, we divided each study group into age categories: pre-pubertal (<12 years old), pubertal (12-15 years old), and post-pubertal (\(\geq\)16 years old). In the overweight group, significant differences concerning CIMT values were detected between pre-pubertal and post-pubertal patients (\(p\) = 0.024, Bonferroni corrected); see Table 1. Extremely significant differences were detected in the normal-weight group (Table 1), where CIMT values increased very clearly with age, so much so that post-pubertal normal-weight children had CIMT mean values very similar to children of the same age with weight excess. Moreover, when analyzing the <12-years-old category, we detected extremely significant differences between CIMT mean values in the obese and overweight groups (\(p\) = 0.015), and the obese and normal-weight groups (\(p\) << 0.001). Therefore, in the presence of considerable excess weight, age has a smaller impact on the endothelial wall than the pathological processes caused by excess adipose tissue.