This study was undertaken to determine whether perceptions about body image and size vary by body mass index (BMI) and demographic factors among American Indian children in the Southwestern United States. We surveyed 1,996 American Indian schoolchildren in the fifth grade (mean age 10.5 +/- 0.7 years) at eleven rural elementary schools. Heights and weights were measured using standard protocol. Multiple linear regression models were developed for preferred body shape, desired body shape, and body satisfaction to determine association with demographic and physical factors. Results from multiple linear regression modeling indicated that BMI and gender influence body satisfaction, with heavier children and girls being less satisfied with their bodies (P<.001 and P<.05, respectively). Geographic isolation and lack of amenities in the home did not appear to affect body satisfaction or messages from others about being too fat or thin; however, geographically isolated students were more likely to choose a larger body shape as best looking. Girls of appropriate weight were 2.2 times more likely than boys to have been told they were too fat. Sixty-one percent of all students surveyed had tried to lose weight. These findings, although similar to those for non-Hispanic Whites of the same age, are contrary to prevailing ideas that American Indians value obesity. In fact, we observed a high level of body dissatisfaction among children of appropriate weight, particularly girls, and prevalent dieting across all weight categories and both genders.