Background: Atherosclerosis as a complication of diabetes, is considered to be a chronic inflammatory disease, developing over years and proceeding through many steps. Adiposity fatty acid–binding protein (A-FABP) is highly expressed in mature adipocytes and plays a central regulatory role in energy metabolism and inflammation. A-FABP mRNA expression in adipose tissues predicted coronary artery disease in homozygous subjects. A-FABP may also play a role in the development of atherosclerotic diseases in humans. Objective: To detect the relationship between serum A-FABP level and carotid intima-media thickness (IMT) as indicator of atherosclerosis in patients with type 2 diabetes mellitus. Patients and methods: 124 patients with type 2 diabetes (T2D), were divided into two groups: Group 1: 62 patients with T2D ≤ 5 years duration, and Group 2: 62 patients with T2D > 5 years duration. They were subjected to full history taking, clinical examination, and laboratory investigations in the form of CBC, LFT, KFT, HBA1c, fasting and postprandial blood sugar, A-FABP serum level, and carotid Doppler. Results: Serum level A-FABP and carotid IMT was significantly higher in long standing diabetes group compared to short standing diabetes group.A-FABP cutoff was proven to have a high sensitivity 94.4%, specificity 100.0%, positive predictive value of 100.0%, negative predictive value of 97.7% and overall accuracy of 98.3% regarding the prediction of atherosclerosis. Conclusions: A-FABP serum level have a high sensitivity, specificity, predictive value and overall accuracy regarding atherosclerosis, and should be recommended as a part of routine surveillance for atherosclerosis in patients with type 2 diabetes.