OBJECTIVE: The goal of this study was to examine weight misperception among overweight adolescents in recent years and compare the demographic characteristics and weight-related behaviors of overweight adolescents who accurately and inaccurately perceive their weight status. METHODS: We used data from the nationally representative Youth Risk Behavior Surveillance System, collected every 2 years from 1999 through 2007. On the basis of self-reported height and weight, BMI percentile for age and sex was calculated. Overweight and obese respondents (BMI ≥ 85th percentile) were classified into 2 groups: (1) misperceivers (weight perception "about right" or "underweight") or (2) accurate perceivers (weight perception "overweight"). We examined the proportion of misperceivers at each time point. Using the 2007 data, we compared demographic characteristics and weight-related behaviors of accurate perceivers and misperceivers with bivariate and multivariate analyses. RESULTS: Among overweight adolescents, the overall proportion of misperceivers ranged between 29% and 33% from 1999 through 2007. In 2007, 23% of overweight girls and 40% of overweight boys were misperceivers (P < .001). Both male and female accurate perceivers were significantly more likely than misperceivers to report trying to maintain or lose weight, exercising for weight control, and eating less for weight control. Adjusting for age, race/ethnicity, and BMI percentile, no significant differences in unhealthy weight-related behaviors were found between accurate perceivers and misperceivers in boys or girls. Male accurate perceivers were significantly less likely to report achieving recommended levels of fruit and vegetable intake and physical activity. CONCLUSIONS: Nearly 3 in 10 overweight adolescents do not consider themselves overweight. Those with an accurate weight perception reported some healthy weight-related behaviors but not higher levels of unhealthy weight-related behaviors. With the substantial prevalence of weight misperception, clinicians should consider their patients' perceived weight status when pursuing patient-centered counseling of overweight adolescents.