The authors assessed associations of body size perception and weight change over 13 years in black men and women and white men and women from the Coronary Artery Risk Development in Young Adults (CARDIA) Study (1992-2005). The perceptions of self and ideal body size were measured by using the Stunkard 9-figure scale at the year 7 examination (1992-1993). Figures were classified into underweight, normal weight, overweight, and obese. Self-ideal discrepancy yielded 4 body size satisfaction categories. Body mass index (BMI) (measured at years 7, 10, 15, and 20) was the dependent variable in gender-specific adjusted multiple regression models stratified by year 7 BMI. Obese women who perceived themselves as obese lost 0.09 BMI units annually, while those who perceived themselves as normal weight gained 0.31 units annually (P = 0.0005); obese women who considered their body size much too large had less annual weight gain than did those who considered their body size a bit too large (0.21 vs. 0.38 BMI units; P = 0.009). Obese women with overweight ideal body size gained less weight annually than did those with normal weight ideal body size (0.12 vs. 0.27 BMI units; P = 0.04). Results for men showed fewer and weaker associations. When obese women perceive themselves as obese and feel that their body size is too large, they gain less weight over time.