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Childhood obesity has increased markedly during the past decades; however, data on the prevalence of severe obesity in children and adolescents are limited. The present study examined the prevalence of severe obesity and its association with elevated blood pressure (BP) among children and adolescents in Shandong, China.A total of 44 630 (22 404 boys and 22 226 girls) students aged 7–18 years participated in the study. BMI cut-off points recommended by the International Obesity Task Force were used to define class I–III obesity. Relatively high BP status was defined as systolic BP and/or diastolic BP of at least 95th percentile for age and sex.The prevalence rates of class I, class II, and class III obesity were 6.67, 1.47, and 0.42% for boys and 2.88, 0.64, and 0.18% for girls, respectively; boys had a higher prevalence than girls (P<0.01). Substantial urban–rural disparities exist in childhood obesity; urban boys and girls had a higher prevalence of class I and class II obesity than their rural peers (P<0.05). Severe obesity is associated with elevated BP; the prevalence of relatively high BP increased from 39.93% (boys) and 39.53% (girls) in the class I obese group to 50.54% (boys) and 53.66% (girls) in the class III obese group (P<0.05).Although the current prevalence of severe obesity was at a relatively low level, but we should not relax our vigilance to the obesity epidemic. Our findings also emphasize the importance of the prevention of severe obesity to prevent future-related problems such as hypertension in children and adolescents.