Context: The increasing prevalence of overweight in youth has been well chronicled, but less is known about the unique patterns and risks that may exist in rural and urban environments. A better understanding of possible rural-urban differences in physical activity profiles may facilitate the development of more targeted physical activity interventions. Methods: Participants (1,687 boys; 1,729 girls) were recruited from fourth, fifth, and sixth grade classes in schools from urban areas, small cities, and rural areas. Multilevel modeling analysis was used to examine rural-urban differences in physical activity and prevalence of overweight. Physical activity was assessed by self-report and body mass index was calculated from measured height and weight. Findings: Prevalence of overweight was higher among rural children (25%; P less than 0.001) than children from urban areas (19%) and small cities (17%). Urban children were the least active overall (Cohens' d = -0.4), particularly around lunchtime while at school (d = -0.9 to -1.1). Children from small cities reported the highest levels of physical activity. Conclusions: The results of this study suggest there are rural-urban differences in children's prevalence of overweight and physical activity even within a fairly homogenous Midwestern state.