BACKGROUND Few studies have examined the prevalence of overweight status and physical inactivity among children and adolescents living in rural America. OBJECTIVE We examined urban and rural differences in the prevalence of overweight status and physical inactivity among US children. METHODS Data were drawn from the 2003 National Survey of Children's Health, restricted to children aged 10-17 (unweighted N = 47,757). Overweight status was defined as the gender- and age-specific body mass index (BMI) values at or above the 95th percentile. Physical inactivity was defined using parentally reported moderate-to-vigorous intensity leisure-time physical activity lasting for at least 20 minutes/d on less than three days in the past week. The 2003 Urban Influence Codes were used to define rurality. Multiple logistic regression models were used to examine urban/rural differences in overweight status and physical inactivity after adjusting for potential confounders. RESULTS Overweight status was more prevalent among rural (16.5%) than urban children (14.3%). After adjusting for covariates including physical activity, rural children had higher odds of being overweight than urban children (OR: 1.13; 95% CI: 1.01-1.25). Minorities, children from families with lower socioeconomic status, and children living in the South experienced higher odds of being overweight. More urban children (29.1%) were physically inactive than rural children (25.2%) and this pattern remained after adjusting for covariates (OR: 0.79; 95% CI: 0.73-0.86). CONCLUSIONS The higher prevalence of overweight among rural children, despite modestly higher physical activity levels, calls for further research into effective intervention programs specifically tailored for rural children.