Objective According to the concept of adipose tissue expandability, the vascular complications of obesity are related less to the amount of stored fat than to the low-grade inflammation that excess fat storage may elicit. We tested this concept in 7-year-old children by assessing whether carotid intima-media thickness (cIMT) is related to obesity measures or to circulating highly sensitive C-reactive protein (hsCRP), as a marker of low-grade inflammation. Study design The study group comprised 135 asymptomatic Caucasian children (72 girls and 63 boys; mean age, 7.1 ± 1.1 years) with normal height and weight distributions. Relationships were assessed among cIMT, hsCRP, obesity measures (ie, body mass index BMI, total fat by bioelectric impedance, and visceral fat by ultrasound), insulin resistance (by the homeostasis model assessment for insulin resistance), and fasting serum lipid levels. Results cIMT was correlated with hsCRP, but not with BMI or body fat; the regression coefficients between cIMT and hsCRP (adjusted for age, sex, BMI, body fat, and serum lipid levels) were fairly similar across all BMI categories (β = 0.370-0.411; all P < .001 to < .0001). Serum hsCRP increased with increasing BMI, total fat, and visceral fat (all P < .001). Conclusion At age 7 years, cIMT is already associated with low-grade inflammation, as measured by hsCRP, but not with BMI or body fat. These findings imply that public health strategies aimed at early prevention of cardiovascular disease may need to target low-grade inflammation rather than only BMI or adiposity.