We investigated the attitudinal and perceptual components of body image and its link with body mass index (BMI) in a sample of urban Gambians. We also looked at cross-cultural differences in body image and views on attractiveness between Gambians and Americans. METHODS: Four groups of 50 subjects were assessed: men 14–25y (YM); women 14–25y (YW); men 35–50y (OM); women 35–50y (OW). Socio-economic status, education, healthy lifestyle and western influences were investigated. Height and weight were measured. Body dissatisfaction was assessed with the body dissatisfaction scale of the Eating Disorder Inventory. Perceptions of body image and attractiveness were assessed using the Body Image Assessment for Obesity (BIA-O) and Figure Rating Scale (FRS). RESULTS: Different generations of Gambians had very different perceptions and attitudes towards obesity. Current body size was realistically perceived and largely well tolerated. Older women had a higher body discrepancy (current minus ideal body size) than other groups (p<0.001). Regression analysis showed they were not worried about their body size until they were overweight (BMI=27.8 kg/m2), whilst OM, YM and YW started to be concerned at a BMI respectively of 22.9, 19.8 and 21.5 kg/m2. A cross-cultural comparison using published data on FRS showed that Gambians were more obesity tolerant than black and white Americans. DISCUSSION: The Gambia is a country in the early stage of demographic transitions but in urban areas there is an increase in obesity prevalence. Inherent tensions between the preservation of cultural values and traditional habits, and raising awareness of the risks of obesity, may limit health interventions to prevent weight gain.