## 4 Discussion
However, this factor is a rather indirect one with concern to CIMT, because it affects vascular integrity by increasing the subject's susceptibility to obesity. Abdominal visceral excess adipose tissue, clinically estimated by measurement of waist circumference, is considered a marker of insulin resistance [64] and a key component of metabolic syndrome when it reaches values >90 th percentile for age and sex in children [65,66]. In the general population, CIMT values are significantly higher in men and women with a waist circumference \(\geq\)79 cm compared to values <79 cm [67]. Our study also showed a high correlation between the values of waist circumference and CIMT. In the obese group, significant correlations were detected between waist circumference and parameters like BMI, blood pressure, total cholesterol, LDL cholesterol, and triglycerides, as well (Table 6). In all three groups, the higher the mean values of waist circumference were, the stronger the correlations to CIMT and other evaluation parameters. As for blood parameters, we analyzed the correlations between CIMT values and parameters usually used for evaluating weight excess in children: lipid panel and fasting glucose levels. HDL cholesterol is considered the protective component of the lipid panel, with cytoprotective, anti-inflammatory, antithrombotic, and antioxidant functions and playing a large role in clearing away excess cholesterol from vessels and transporting it back to the liver [68]. Recent studies show that HDL-c's functionality is more important than its circulating quantity per se, and factors that affect its functionality should be avoided as much as possible: oxidative environment (acute phase response), metabolic syndrome, obesity, and consumption of saturated fats [69]. HDL-c in children is primarily affected by lack of physical activity [70]. Dietary habits that include enough polyunsaturated fats, in detriment to saturated fats, improve the anti-inflammatory function of HDL-c [71]. Children with increased CIMT and sedentary behavior are the ones with the lowest HDL-c, highest triglycerides levels, and highest risk of developing metabolic syndrome [67]. In our study, HDL cholesterol was significantly and negatively correlated to CIMT mean values (Table 8). It was also one of the most prevalent abnormal parameters detected, with 40% of the obese and normal-weight children and 7% of the overweight children presenting an HDL level of \(\leq\)40 mg/dL. LDL cholesterol plays a major role in atherosclerotic plaque progression due to its migration under the sub-endothelial space, along with excess chylomicrons, where they are regurgitated by macrophages and monocytes [72]. High LDL-c is usually associated with low HDL-c, depending on individual physical fitness. The diagnostic of dyslipidemia in an obese child should be taken into consideration as an aggravating factor for arterial long-term health [73]. Adolescents with high lipid levels present a greater risk of developing high CIMT as adults, and, should they have weight excess, the risk increases substantially compared to adults who did not have either risk during their childhood [74]. In obese children, LDL-c correlated to CIMT values (Table 8), a finding that supports international data. Furthermore, all three analysis groups showed correlations between CIMT and total cholesterol values (Figure 9), although mean values of total cholesterol were not suggestive for dyslipidemia. This may be because overall LDL-c values were not extremely high, and HDL-c levels were low (47% of cases presented \(<\)40 mg/dL values). We did note, however, that as weight excess severity increased, the lipid panel showed pathological, at-risk values. Individuals with familial hypercholesterolemia present high values for lipoproteins even in the context of less extreme weight excess, and affected children present higher CIMT than their unaffected siblings.