West Virginia's prevalence of obesity is among the highest in the nation, contributing to an excess mortality rate from heart disease. Individuals who are overweight and obese have a greater risk for coronary artery disease. To gain insight into the impact of obesity on other modifiable cardiovascular disease (CVD) risk factors among children, 5,887 students from 27 rural West Virginia counties participated in the school-based Coronary Artery Risk Detection in Appalachian Communities (CARDIAC) Project during the 1999-2002 school years. Results confirmed a very high prevalence of overweight and obese children in this rural, pre-adolescent population. Almost 43 percent of the children screened were considered to be overweight (BMI > or = 85th percentile), and over one-fourth of them were obese (BMI > or = 95th percentile). This high rate of obesity among schoolchildren in West Virginia is associated with increased prevalence of other CVD risk factors such as hypertension, dyslipidemia, and insulin resistance. Interventions for prevention of excess weight and obesity should be implemented through schools and community-based programs.