"You have to have curves, but only certain types of curves."

A conversation with Nicaraguan size-inclusive doctor Mónica Peralta

The Internet can feel like a dumpster fire these days! But — it is also worth remembering that it can connect people around the world. I feel very, very lucky to have a growing group of physician friends who are passionate about making health care more welcoming to people of all body sizes.

And that includes the badass Dr. Mónica Peralta, a size-inclusive doctor in practice in Managua, Nicaragua, whom I’ve gotten to know over the past few months though, yep, you got it — the Internet.

By day, Dr. Peralta provides size-inclusive medical care in her private practice, and by night she posts hilarious videos and takes down trolls on Instagram. (We spoke in English for this interview, but she says, “I’m much funnier in Spanish.”)

It has been such a pleasure to learn about how Dr. Peralta’s activism is connected to our work in the United States. There’s a growing network of body justice advocates all over the world.

Here, we spoke about size-inclusive medicine, beauty standards in the United States and Latin America, and why we can’t talk about weight stigma without talking about colonialism. Thanks for being here.

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Mara: What got you interested in being a size-inclusive doctor?

Mónica: Like many people, I did everything I could to lose weight. I believed it was the key to health. I live in a fat body. I have lived in a fat body my whole life. But instead of feeling better when I dieted, my health took a hit. The more I restricted and pushed my body, the worse I felt. Which is exactly the opposite of what healthcare is supposed to promote. Meanwhile, I saw my patients go through the same cycle of dieting, weight regain, and self-blame. Diets are the only product where failure is blamed on the consumer and not the product itself.

Mara: How did you change the way you started thinking about your own body? And how did it affect the way you treated your patients?

Mónica: When the Covid pandemic hit, it exposed so many cracks in the health care system, particularly in how fat people were treated. We were failing people, particularly here in Latin America. There was a newspaper that on the front page said: “If you're fat, you do not deserve oxygen” [if you’re sick with Covid]. And that, for me, was so personal. Then I read the comments. [Editor’s note: Don’t read the comments! Except on Substack, where people are remarkably thoughtful and civil.] That's where I lost faith in humanity for a little bit, because all the comments were agreeing with what the newspaper was saying: “Oh my God, you're so right. If they don't take care of themselves, why are we going to waste a hospital bed with one of those fat people?” And I looked at the commenter’s profiles, and so many of them were fat people themselves. I was thinking, “Why are you talking like that?”

Mara: There’s a real failure of political solidarity amongst people who live in bigger bodies. So many fat people think of themselves as a thin person waiting to emerge.

Mónica: When you go on a diet, it’s because you want to be accepted. It’s because you don’t want to be oppressed. You don’t want to be treated badly. Sometimes it’s almost a survival instinct to get onto the side of the oppressor, the ones who are doing the harm. And if I attempt to become thin by going on a diet, people will say, “She’s actively trying to become a thin person. She’s actively pursuing health. She’s not one of them. She looks like one of them, but she’s trying not to be.”

Mara: I’ve heard that described in some fat activist circles as “being a good fatty.” Can you help people understand that term?

Mónica: I heard it first from writer and activist Aubrey Gordon [Editor’s note: No relation, but she’s pretty fabulous.] It’s a fat person who is actively trying to fit standards that are not built for us. We're always doing what we think is going to get us on the popular side with the cool kids. And so we do everything. We go on a diet, we buy all these miracle products, and we're always, constantly talking about all our efforts. Our life revolves around those efforts.

Mara: Let’s talk about size-inclusive medicine. We’re both primary care doctors. You’re in private practice in Managua, Nicaragua. You focus on a weight-neutral approach, particularly for people with diabetes.

Mónica: Early in my career, I became interested in how health care systems function. If I find a problem, I need to understand the root of it. I studied Health Care Systems Administration, and it gave me a broader perspective on why medical care is structured the way it is, and how systemic changes are necessary to make it more inclusive. When we talk about fatphobia, we center the problem around the fat person or the fat patient. But the problem is systemic.

These days, my whole practice is online. I specialize in nutrition and diabetes. Diabetes is a disease with so much weight stigma. The whole consultation around diabetes is based on weight stigma. And then I said, of course, “I need to understand nutrition!” Physicians don’t learn about nutrition; we don’t spend even a whole semester on nutrition, and then you see physicians giving nutrition advice.

Now, my practice is focused on providing weight-inclusive, evidence-based care. My priority is my patient’s well-being over weight loss. I’m not against weight loss, but weight loss does not equal health. I work with people who have experienced a lot of medical trauma.

Mara: What is medical trauma? How does it manifest in your patients?

Mónica: Here’s a personal example. I accompanied a friend to see her doctor. My friend lives in a thin body, she’s able-bodied, she’s White, she’s cisgender. We went to the consultation, and they doctor didn’t even say hi, or “Who is Monica? Who is Laura?” He didn’t even ask. He just assumed I was the patient and he said, “Okay, so you’re diabetic. You have high cholesterol. You have high blood pressure. You have diabetes. You have let yourself go.” Because I was the fat one in the room, he assumed I was the patient. He opened up some folders, gave me a diet, an exercise regimen, and some pills. He said, “If you don’t lose weight, you’re going to die, and you’re going to leave your family alone.” Because in Latin America it is always about family, and I was a woman, so I must be taking care of my family.

All of this is traumatizing for a patient. Imagine all their life, they have been told that their body is to blame for everything. People are not going to be eager to go to the doctor.

Mara: I’m so sorry that happened. There are so many levels of problematic bias in that example. And it makes me think about the ways that fatphobia can harm thin people, too. Your friend didn’t get the care she needed.

Mónica: Weight stigma deeply impacts health care. It's going to lead to misdiagnosis, delay care, and cause harm for everyone. Doctors will overlook diagnoses in both fat and thin people. And doctors assume that weight loss is always good, when it can be a sign of serious disease.

Mara: You’re a certified Body Trust provider. What does that mean?

Mónica: Body Trust is a radically compassionate, weight-inclusive framework. It has made a huge impact on me, both professionally and personally. It helped me to unlearn internalized fatphobia. It has helped me give my patients the tools to navigate the world with a more compassionate lens. It helps people develop a framework for dealing with harmful fatphobic interactions. Sometimes a patient is like, “You know what? I don’t have the strength to answer back to my mom, to my auntie.” Body Trust gives them building blocks: “Okay, you can take a step back, breathe, and remember all the work that we have done.”

Here’s an example of what that looks like: I have one patient who takes her iPhone and she says, if a family member makes a fatphobic comment, “Oh you know what? I’m just going to write that down. That’s really good advice. I’m going to put it in my notes.”

Mara: I heard great advice from a psychologist. If somebody’s making comments about dieting or body size at a meal, you say, “It tastes so much better when everyone feels really guilty about it!” It’s using humor to deflect a bit.

Mónica: Here is a very Spanish saying that’s similar: “Tu envida hace que mi plato sepa aún más delicioso.” In English, it means, “Your envy is making my plate more tasty.”

Mara: How does fatphobia in health care differ in Nicaragua from the United States?

Mónica: Fatphobia is universal. But in Latin America, it's deeply tied to cultural beauty standards. Then you have economic disparities, and then you have limited access to health care. In the public health settings where I did my training, patients don’t have private rooms. You have the patient with 20 other patients, if you're lucky, so you're giving this person a lecture about weight loss, and you're humiliating them in front of 20 more patients and their families, and you're blaming everything on their body size.

And the assumption that fat equals unhealthy was so pervasive that it often overrode scientific evidence. And it can be hard to combat those assumptions with science, because there are so many barriers to accessing science that’s being done around the world: language barriers, paywalls. There are so many scientific journals that I didn’t know existed until I graduated, and I had access to other educational opportunities around the world.

Mara: The Internet can be a powerful tool to learn about new ways of thinking. And you’re really taking this to heart: You have a thriving online presence that really helps normalize body acceptance. How does your online advocacy work fit into your medical practice?

Mónica: My work on social media began with my attempts at weight loss. I started posting online to document my “weight loss journey.” I wanted to show people that it could be done. That was a dark moment.

Mara: Thank you for sharing that.

Mónica: Everyone just was like, “Oh my gosh, she's so disciplined, she's a doctor, and she has all this knowledge, and she's losing weight.” And I actually did lose weight. Then I regained it. And I lost it, and I regained it. For so many years.

The pandemic showed me all of these cracks in our health care system. So I put a stop to it. I was like, “I’m feeding this monster of false information.” So then I started using my social media to share my transition to weight-inclusive care. And I’ve connected with other size-inclusive activists all over the world: North American, European, Mexico, Chile, Argentina. The beauty of size-inclusive activism and advocacy is that it's going to transcend borders, because it's a global issue. Everywhere around the world, there’s a woman actively trying to fight these beauty standards.

Here in Nicaragua, as of right now, I’m the only one talking about fatphobia and weight stigma. We live in a culture here in Nicaragua that revolves around a type of curvy body – a curvy body, not a fat body. You can be fat, but only up to a certain point. You can have an ass, but not a big ass. You have to have curves, but only certain types of curves. For us, in Latin America, it's about a European beauty standard. It’s about colonialism and how we are supposed to let go of our indigenous roots to fit into this European look. There's no fatphobia without racism, without colonialism.

Mara: How do you deal with trolls?

Mónica: It depends on the day. Sometimes I’ll take the higher road and just block the person. But sometimes I’m ready to rumble, you know? I often use humor. You can sense when someone is truly interested in learning, and they just don’t know how to ask.

Mara: What are you most optimistic about?

Mónica: Despite all these challenges, I do see a shift happening. I see more health care providers are questioning weight-centric approaches. More people are resisting the culture. So much more research is emerging that supports size-inclusive care. I'm also deeply inspired by younger generations, who are growing up with more awareness of weight stigma, and they are actively demanding better from their healthcare providers.

My generation grew up with mothers commenting on your weight, on your body type. So my peers actively don’t want to replicate that with our children. Our children are growing up in a more safe environment. They are actively demanding better.

In Latin America, we’re taught not to talk back to our parents and our elders. This younger generation, they don’t care. They’re not afraid of the chancla. A chancla is a sandal: Your mom or your grandma, if you talk back to them, they’re going to throw a sandal at you. This younger generation, they’re not afraid.