The Fat Doctor Podcast

Rice, Beans, and Resistance with Dra. Mónica Peralta

• Dr Asher Larmie • Season 5 • Episode 8

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In this explosive episode, Dr. Asher Larmie speaks with Dra. Mónica Peralta, a physician from Nicaragua specializing in diabetes, intuitive eating, and Body Trust. Together they explore weight stigma in healthcare across cultures, focusing on the unique challenges faced in Latin America. Dra. Monica shares her journey from promoting weight loss to becoming a weight-inclusive practitioner, offering a candid critique of how diabetes care is too often reduced to weight management. Their conversation tackles the harmful impacts of GLP-1 medications being repurposed for weight loss, the deeply problematic concept of World Ob*sity Day, and the hope found in the organization AWSIM (Association for Weight and Size Inclusive Medicine). 

Key Moments:

0:00 Introduction
11:02Diabetes and Weight Stigma - A Double Burden 18:40 
19:12 Weight Cycling and Its Impact on Diabetes Management 
27:12 GLP-1 Medications: From Diabetes Treatment to Weight Loss Industry 
38:42 World Ob*sity Day - "A Day to Eradicate a Type of Human Being" 
50:12 AWSIM: The Association for Weight and Size Inclusive Medicine 
57:42 Connecting with Dra. Mónica Peralta and Final Thoughts 

Dra Mónica Peralta is a nutritionist and diabetologist who practices in Nicaragua and sees clients worldwide. She is certified in intuitive eating, eating disorders, psychonutrition, and body image. You can learn all about her and the services she offers on her website, and follow her inspiring content on Instagram. 

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The Fat Doctor Podcast - Episode 8, Season 5


Host: Dr. Asher Larmie


Guest: Dra. Mónica Peralta

Asher Larmie: Hi everyone and welcome to episode 8 of Season 5 of the Fat Doctor Podcast. I am your host, Dr. Asher Larmie. With me today is Dr. Mónica Peralta, who I am very excited to have as a guest. We currently work together in a roundabout kind of way, as we're both board members of an incredible organization called AWESOME - the Association of Weight and Size Inclusive Medicine, and we will be talking about that a little bit later on. But before we do, I'm going to hand over to Mónica, who, by the way, is fluent in not one, but 2 languages, maybe even more. My biggest dream is to be able to speak Spanish as well as you speak English. Without further ado, I would love to get to know you a little bit more and introduce you, or let you introduce yourself to my audience.

Dra. Mónica Peralta: Hi! Hello! It's a pleasure and an honor to be here. My name is Mónica Peralta. I'm a physician. I'm from Nicaragua and currently living here in Nicaragua. I specialize in diabetes, intuitive eating and Body Trust. I'm a Body Trust certified provider, and as Asher said, we work together at AWESOME. I am the communication committee chair. So I just like to talk and communicate stuff through every channel that's open to me. And Asher was so kindly to bring me to his podcast so I'm happy we can do this.

Asher Larmie: Mónica, by the way, just in her spare time, has an amazing Instagram page. If you go into her Instagram account, you're like, how are you able to do all of these things and work, and does a lot for communications as Communications chair for AWESOME as well. You're just amazing. I'm somewhat jealous of the people who live near you, who have a doctor who specializes in diabetes, who is weight inclusive and is a Body Trust certified professional. That's crazy. I'm jealous of them. But speaking of them, we often center the US, the UK, Canada, places like that when we're talking about weight inclusive care, and most of my guests live in one of those countries. I would really like to decenter us for a moment and talk about what life is like in the rest of the world. What does it feel like in Nicaragua for people who are fat, who perhaps are fat and disabled, perhaps are fat and have chronic health conditions and are experiencing weight stigma at the doctor? What's the vibe in your part of the world?

Dra. Mónica Peralta: Well, there's definitely a vibe, because weight stigma is rooted in so many different things. But when you live in Latin America, besides racism that we know is one of the roots of weight stigma, then you have colonialism, and then you have economic disparities that we live here in Latin America. And sometimes when you are sick or you get an illness, and you go to the public health setting, you're not gonna be in a private bed. You're gonna be with more than 20-15 patients and doctors. We are doing rounds, and we are blaming you and your body for your disease in front of all of these people, and all of these people have families with them. So you don't only have the patient.

And then, because of the cultural surrounding that I was talking about, Latin American people, we don't speak quietly. So we're not only talking to you like "oh, hey, well, you know, because of your body." No, it's "because you are always eating," and we're loud. We're kind of loud. So imagine just the shame that comes with it. Not only are you getting a diagnosis that can affect your life forever, then you have all this shame, not only surrounding that diagnosis, but surrounding the way that diagnosis is given. And so that's cultural.

And then, as I was saying before, we have economic disparities that prevent us from getting information about weight stigma and weight bias. I didn't know about fatphobia 5-6 years ago, because we have all these barriers. We have language barriers. We have paywalls. I didn't know about so many scientific articles. I live in Nicaragua. So how do I have access to them? Am I gonna pay $300-$400 yearly just to get access to one journal? There's not only one, there's like 5, 6.

I remember that my university used to have like one user, one code, because one of the brothers of the brother of the Dean of Medical school lived in the United States. So we had access through that. And after I graduated from medical school, I was like, there's so many things that we don't have access to.

And then, with the boom of social media, we had access to the rest of the world and to see what people were doing. The first time I opened Instagram was for me to share my weight loss journey, and to be this example of discipline. I'm a doctor and well, I've always lived in a fat body, but I do have other privileges that I live with, and I didn't even know about privileges. I was like, no, that's not a thing. People are just taking everything too deep. And because I am Latin American, I was like, people are just weak. There's people dying, and I was like, "Oh, my God! There's so much that I don't know about."

And then, of course, I grew up with moms making comments about my body, and we are not supposed to talk back to them. We are taught you don't talk back to elders. So whatever they say, you just nod, and that's it. And I'm so glad that the new generation, they are like, "I'm not afraid of you. I'm gonna talk back." Because I think that because my generation now is the aunties, the uncles, we know how we grew up and how all of those comments affected our body image and our relationship with food, that we are not willing to risk it with this new generation.

Asher Larmie: That was so amazing. And first of all, snap! I also joined Instagram to share my weight loss journey to be that doctor who was like, "Look at me! I lost weight. I am amazing." We both know how that turned out, but you speak to so many important things. You speak to the culture of weight loss, weight shaming, weight stigma within our families. And also how that has impacted how doctors treat their patients. Because at the end of the day we're humans, right? We grew up in our neighborhoods with the same uncles and aunts and parents and schools and everything. So we do what we're used to doing.

Living in a country where we have free healthcare, so private rooms are only for people who need to be separated for medical reasons, I'm used to the wards and the ward rounds and being in a big, busy ward, and it's so true. All you have, maybe, is a curtain for privacy, and doctors do not care. They say whatever they want to say in front of everybody. And that's not okay, because confidentiality is an important part of medicine. But you're right, it brings all the shame and the stigma.

So culturally, what is food and body image like? I have a Brazilian mother, so I grew up with some Latin American culture in my life. And I think perhaps it's very different to the culture in the UK. How do people feel about food and body weight, and how much access do people have to food?

Dra. Mónica Peralta: Actually, I think 2 days ago I read Latin America was one of the most expensive places for a healthy diet. But again, what do we mean with a healthy diet? Because of globalization, we don't want people to be eating carbs because carbs are the enemy and Latin America has so many cases of diabetes, and people are still eating carbs, so rice and beans are out of the question, and that's one of the main dishes for Latin American culture. And you're telling people, "Oh, my God, no rice and beans are so bad, they are so high in carbs."

So what is a healthy diet for us? Mediterranean diet? You have to have olive oil and olives and romaine lettuce, and I'm like what the fuck? It's expensive. And that's a repercussion of lazy medicine. Because why? As doctors are we not saying, "You know what? We have this food. This is our local foods. They are high in nutrients, and there's so many combinations we can do." And you know what's going to affect more the patient than rice and beans? I mean, they do not. But you know what's gonna affect more the burden, the mental space that patients spend saying, "Oh, my God! I didn't buy the quinoa! I'm not having salmon!"

Asher Larmie: Exactly, and the thing that makes me really mad is rice and beans is like one of the most nutritious... I personally live on rice and beans for a good portion of my week, because I know it's cheap, it's easy, it's tasty, and it provides all the nutrition that I need. Really add a few vegetables, and I'm done.

Dra. Mónica Peralta: And that's a perfect sample when you can see the whitewashing on nutrition, because when vegans have rice and beans, "Oh, my God, they're vegan! They're doing the Lord's work, eating rice and beans." But when we do it, that's not good.

And then you have the body image aspect of Latin America, where you can have curves, but in the right places. You have to have a meaty body, but in the right shape. So you don't get to be too thin, because that's a sign of "Oh, my God, she's not eating," and she doesn't have the curves of a Latina, because Latinas have to be curvy, but not fat. So that's a whole other topic, because you get to have this voluptuous body, but just like a centimeter, like 1 cm more, and you're like, "Ouch!"

Asher Larmie: Right? Yeah. It's a very narrow standard.

Dra. Mónica Peralta: Like, you're not fitting that beauty standard anymore.

Asher Larmie: I saw a post on this, actually on your Instagram account about how you're allowed to have curves, but not be fat. Two very different things, right?

Dra. Mónica Peralta: There's a right type of fat. We can talk about the good fatty. She's always trying to be this thin person. She's just a thin person in progress, I think we call it, and that's like, "No dude. I'm just fat." The diversity is the thing we're not supposed to all look like the same.

Asher Larmie: So you are a diabetes expert. I am diabetic. I feel like this is a perfect moment for me to come to you and say, "Hey, by the way, diabetic patients get treated like garbage." I'm not saying that we have it worse than other people. However, if you had to pick one illness that is associated with being a bad fatty, I think diabetes will be in the top 5. I reckon we're top, but top 5 at least.

And so at the moment, my A1c is quite high. It's not well managed. I'm one of these people that got diabetes after Covid, and they blame, "Oh, it was because in the Covid pandemic you were being lazy, and you weren't exercising." I'm like, in the Covid pandemic, I was busier than I've ever been in my life because we were sorting out Covid, right? I didn't rest. I was constantly on the go, which may well explain it. I was also on a diet during Covid, because, of course, I was. But anyway, so I'm that diabetic.

And I go and see my doctor. Actually, I don't get to see a doctor. I see a nurse, and the nurse does 3 things. First of all, asks me a whole bunch of questions about my diet. Am I adding sugar to my coffee? Am I using low fat spread or butter? Am I using the right oils? Do I cut the fat off my meat? I mean off my steak? Actually, I was asked. I was like, "Wow, you think I eat steak. Amazing." And I was asked all sorts of questions. Do I get enough exercise?

And then there is the whole like "we need to weigh you, and you need to consider weight loss." And then the third thing is, "Oh, and now we have to treat you, and we have to give you treatments that are going to reduce your weight" like we can't just treat you like a diabetic. We have to treat you like a fat diabetic, like there's a different route of treatment for diabetics versus fat diabetics, and it really pisses me off. I think I'm experiencing a lot of weight stigma, and as somebody who is an expert in both weight stigma and diabetes, I wonder, do you think that diabetics experience weight stigma?

Dra. Mónica Peralta: 125%. That's why I went into diabetes. Because I thought there's no other diagnosis that experiences the amount of shame that comes with diabetes. Because I think if we take out for a second the weight stigma, just the shame surrounding diabetes, because it's "self-induced." "You did this to yourself because you ate too much carbs, too much sugar," and then, if you live in a fat body, of course, I mean, "look at you."

Because I had a life experience that I'm always telling people about. I went with a friend to a doctor, and the doctor saw us, saw some labs, and he just started talking like, "Oh, hey!" He was talking to me straight, and he was, "See, you have diabetes, high cholesterol. Well, this is no surprise, Mónica," because I introduced myself first, but he didn't see the name on the labs, I guess. And I mean, "look how you obviously had yourself let go, and why you're not taking care of yourself, and if you're not taking care of yourself, you're not taking care of your family, your kids." Because again, the context, Latin America. I'm a woman. I'm supposed to be a mother. I'm of a certain age. I'm married. I have a family. I don't have any of that. I don't even have a live plant.

And at that time I was like, what's going on? This is worth $60? All of these things went through my head, and then, when he was finished, of course, he opened a folder. He gave me a diet, lifestyle changes and an exercise regimen, and I was like, "You know what? I'm not the patient. This is the patient, my thin cisgender friend with the straight hair." His face went through so many rainbow colors. I think he almost got his blood sugar higher than my friend, and he was not ashamed. You know what he told me? "Well, I just gave you a free consultation, because eventually you will be where she is."

And I'm not one to shy from a fight, because when you live in advocacy world in weight stigma awareness, I think we're always like ready. One minute away. And I was like, "Oh, no, you're gonna get schooled, you're gonna get a free webinar about what you're doing wrong in your consultation."

And that's just an example. Every doctor, we all have weight stigma. We all have weight bias. But the difference is that we treat people. We treat human beings as doctors, and you took an oath and said that you will do no harm to people. And then, ironically, when people get ill and go to you because you willingly went to medical school and said, "Oh, I want to treat people," and they willingly go to you, and you treat them like trash, and you blame everything on them. And diabetes, I mean the discourse surrounding the disease and the pre-diabetes bullshit, we have all this fear mongering, giving people, instead of hope, instead of things to do, we're just giving them fear and shame.

And we think people are going to make lifestyle changes because of the fear. And maybe for a good month, two months, people are going to be like, "Oh, my God, I have to go to the doctor. So I'm gonna do this, this, this," and they are going to spend their whole salary on this lifestyle change behaviors. But diabetes is for life. It's not a short race. You're here for the long race. You're not here for the 10 to 15 pounds that people lose in the 3 months that you gave them a diet. What about the regaining weight? Do these doctors know about weight cycling and the impact on diabetes?

Asher Larmie: I've tried to have these conversations where I've said, "You're telling me that if I lose a lot of weight, I'm going to put my diabetes into remission," and I'm like, "I get you're basing that on a trial that I have studied in great detail, and I've looked at the evidence, and I'm telling you that that was wishful thinking in the first year, and a bit of a reality check in the second year, and by the 5th year of the DIRECT trial it was like, 'Oh, yeah, probably only temporarily, right?'" And I don't want to put my diabetes in remission temporarily, because the weight cycling is going to make that worse. I truly believe that.

I mean, I lost the most amount of weight just prior to my diabetes diagnosis, maybe a few months, maybe 6 months, and I genuinely believe that that, in combination with Covid, and hey, I was genetically predisposed, because of family history and I had a history of gestational diabetes, so I knew I was insulin resistant. It had been almost 10 years. It was kind of my time, right? I was expecting it. I knew it was coming.

But in spite of that knowledge and understanding, I struggle so hard to get my doctors to understand the most basic science like the weight cycling. I say to them, "Every person that goes on a diet, they regain the weight, right?" And they're like, "Yes," and I'm like, "so why are you telling me to do it?" They don't have an answer, but they just revert back, "But that's what the evidence says." And it's like, you can't have these conversations because they're not logical. They're illogical, based on weight stigma, and disbelief.

But it's a hard fight. What would you say to somebody who's saying to you, "I'm not lucky enough to have you as my doctor, and I'm just struggling, and it's a fight, and I just don't want to go. I'd rather not go, so I keep putting off my appointments." What do you say to people in that situation?

Dra. Mónica Peralta: One of the most common advices that I hear is that you ask your doctor, "If I were a thin person, what would you say?" I just hate that because I don't want to be treated as a thin person. I want to be treated as a human being that is in front of you.

So when you are facing a diabetes diagnosis, as you said, "I'm here for the long run." I'm not the one to say, lie to your doctor. Do not, please. We need all the information, but sometimes you can modify a little bit how you ask the questions, and you can say, "You know what? I'm doing everything you are telling me. Of course I'm on my weight loss journey, but, as you can see, my numbers are not changing. Is there something more? Is there anything else that we can focus on? I am 100% focusing on weight loss and doing everything that I can. But in the meantime, before I shed off those pounds, can we do something else?"

"Do you know about any combinations of food that would help me to have a more stable blood sugar? Why are you recommending fasting when you know basic science that's gonna mess with my blood sugar?"

So these little questions - if you go to a doctor and you know that they're a weight-centric professional, and of course it's a privilege to go to someone who is weight-inclusive, so if you know that they are weight-centric and have a weight-centric approach, sadly, you have to go with that. You don't have to, but sadly, you have to go in that route and just try to navigate that without telling them like, "I don't believe in weight loss."

I mean, you certainly can do that. But the doctor is going to be apprehensive, like, "I'm telling you that you're not getting better because you are not working on the weight loss." So if you ask the right question, "Is there something else that I could be doing? I'm focusing on weight loss. But is there something else? Maybe having more structure is going to help me? Do you know something about that?" And truly asking the doctor, "Do you know about this?" Because then doctors are like, "I know everything."

Asher Larmie: Of course.

Dra. Mónica Peralta: "I know everything," and they have all these sheets that they give you, the same for everyone. If you don't know anymore, if you don't have any more tools, if you don't have any more resources, can you refer me to someone? Should I be having a more integral management of this diabetes? Should I be going to a nutritionist?

Asher Larmie: Because, you know, doctors are...

Dra. Mónica Peralta: Always talking about nutrition and diets and weight loss, and we don't have the academic background for that. We don't study nutrition, I mean, maybe 20 hours, 25.

Asher Larmie: That's generous. I didn't have 20. That's way too much. I did not even have that. And I agree with you, and one of the things I do say is, "Oh, I'm working with a nutritionist" because I have worked with a nutritionist in the past. Again, that's a privilege. But also my working with a nutritionist is following a couple of diabetic nutritionists, weight-inclusive diabetic nutritionists on Instagram. As far as I'm concerned, that's good enough.

I also lie, and I don't lie about the things I know I shouldn't lie about like I'm not going to try and deceive my doctors, because that only harms me, but when they ask me about how much sugar I put in my coffee, I'm not answering that. I mean, I don't drink coffee, which is really easy. I'm like, "Oh, I don't drink coffee," but if they ask me about like, "Do you use low-fat spread?" I don't have any problem lying about that. "Sure, yeah, healthy or Mediterranean diet. Of course I do Mediterranean," because I know that that is completely irrelevant to my life. And also it's really bullshit medical advice, because I don't think the Mediterranean diet is the best diet for diabetics.

I want to ask you about GLP-1s, but in the context of diabetes, because I know a lot of people know that Ozempic and all the other ones (there are other ones, by the way, for those who are listening, it's not just Ozempic) - these drugs were originally designed for diabetes and used to treat diabetes, and I have seen them in my practice, and you probably see more diabetics than me, but I have seen them produce incredible results in terms of reducing blood sugars. I've also had patients that were like, "Meh, not really." It depends. I mean, they're not perfect for every patient, but I have seen that they are effective in many patients, but they are very difficult to tolerate. There are very few patients that come back that say, "Yeah, no symptoms or side effects whatsoever."

So a lot of my patients will have been started on medications like Ozempic. They'll be on them for years. Their blood sugars are either reasonable or sometimes still out of control. But they're on this drug that is making them miserable because it is a weight loss drug. And it's the weight loss and the curbing of the appetite - because I was just prescribed it yesterday. "But this is really good for you, because it curbs your appetite." And I was like, "How is that good for me? Can you explain to me why that's good for me?" "Because you won't eat as much, and you won't be as fat." And I was like, "But in terms of my diabetes, how is that good for me?" "Oh, because it's a treatment for diabetes."

And so then you're like, okay, I'm stuck now between a rock and a hard place, and I made the choice to just say, "Sure, I'll take it," and then turn around after a couple of weeks and say, "I can't tolerate it, because it makes me feel sick." But I'm curious what you think about GLP-1s or just medications to treat diabetes, and how we, as doctors now will have preferences based on our patient's weight. If that makes sense.

Dra. Mónica Peralta: Yes, so GLP-1s are not new. They have been with us for so many years, but of course the weight loss industry found a way to have them work for them. I'm always saying the GLP-1s now switched, and they are working with the weight loss industry. They are no longer working with the diabetes industry.

So the main function of the GLP-1s for the weight loss industry is, as you said, they curb your appetite, and you basically stop eating. Your hunger cues are gone. Something important for me to mention is that medication within the diabetes treatment world really sucks. The side effects really suck, and we have this lifelong condition, and we have shitty treatment, shitty pills, shitty injections.

But then we are willing to put healthy patients, because being fat is not a disease, we are willing to put healthy patients with healthy pancreases through these side effects. And when a person is diabetic and the GLP-1s are working, the patient will say, like, "Okay, this is working. This is lowering or making my blood sugar more stable. But I have all these side effects. But I'm gonna live with it because it's literally saving my life."

Is it working right with my glucose? And we actually have to inform the patient about all these side effects. You don't give a patient a pill or an injection and say, "Just have it." No, you have to get informed consent. Are they willing to live with these side effects? But then, as I said at the beginning, weight loss companies saw these weight loss injections, and said, "Oh, if we add the dose, or if we do this and that, we can make people stop eating, making them feel fuller for a longer time, so of course they will lose weight, and of course we can profit off of it." And these big pharma companies, when they see opportunity, they are not letting that opportunity go anywhere.

And now GLP-1s have all this research, I think the longer study is 5 years as of now. So we have all this research for weight loss. And we have people that are healthy on these GLP-1 injections for weight loss. And they are experiencing all these "benefits" - they're not hungry. But also they have all these gastric side effects, but it's worth it because they're losing weight. But what people are not getting, or doctors are not telling their patients, is that you're not going to be able to get off the GLP-1 if you want to maintain that success.

And I read an article a few days ago that people who are going on GLP-1s are having better mental health, and they are getting off depression. And I was like, "they are being treated better because they are losing weight. Their surroundings, their families, their friends, are treating them better, and maybe they're getting opportunities that when they were fat they were not getting." So are we really doing the right research about linking less alcohol consumption, better mental health, to GLP-1s?

Asher Larmie: Because of the GLP-1s? Because of the substance of the GLP-1s? Or because of the surrounding of that patient? Yeah.

Dra. Mónica Peralta: All this research and all this money that went into making GLP-1s for weight loss, I just imagine what all that money could have done, making those GLP-1s better for diabetic people.

Asher Larmie: Right, because here's the thing. If there's a drug that's going to bring my blood glucose down, I'm going to take it. I'm going to try it. When they said, "Take Metformin," I took it. Did it make me go to the toilet a million times? Yes, I learned to deal with it. I found a way through it. And then they said, "Here's an SGLT-2. Here's dapagliflozin" - that's the one that's used in my neck of the woods at the moment. It's the best one, apparently. "Here's a medication. It's going to make you pee all the time. You're going to get up in the night, you're going to have thrush. It's going to be never ending. It's very unpleasant, but it will help your blood sugar." I said, "Give it to me. I'll take it. It's no problem. I'll have it."

Then I was given sitagliptin, Januvia. I was given that. I was given 3 months. "It didn't work. Stop it immediately." I was like, "Dude. It's going to take a bit more time." But they didn't care.

And then they said, "Go on a GLP-1." And what's interesting, we can't get the injectable forms in where I live because there's not enough to go around, so we have to use the oral tablets as opposed to the injectable. And again, we have to use semaglutide, not any of the other ones. And it's being pushed as, "Oh, the benefit is, you won't be hungry, you will lose your appetite." And as someone who believes very much in Body Trust and has been practicing intuitive eating, and it's not just intuitive eating - intuitive living where I have spent the last few years learning to tune back into my body, to listen to what it's telling me, to be kind to my body, to give my body a chance to trust me again, because for the longest time my body would tell me stuff, I would ignore it, and my body lost trust in me, let alone me being able to trust my body, right?

So I don't want to lose my hunger cues. You're messing with something that is integral to my well-being. Hunger for me is really important. It's part of my life, and I don't want you to take that away from me. But I sound like, for all intents and purposes, I sound like a crazy person when I say that. "What do you mean? You don't want to get rid of hunger? But then you'll lose weight." "But I don't want to." And that isn't seen as good enough. And of course, the moment you say no, you become the non-compliant patient. I hate that word "non-compliant." That's it. Now you're "a pain, touchy about your weight, has an issue, is difficult to manage, needs to see somebody else." People just get really horrible about it.

And so I'm really glad that you said, by the way, diabetic medications suck because they do. None of them are well tolerated, and if you told me there was a GLP-1 out there that wouldn't cause so many side effects, I would take it. I would be like, "Yes, give me that. I want that one. I don't care about weight loss. Give me the one that I could tolerate, so that my blood sugar is better." But thank you for saying that. I don't want to focus too much on GLP-1s, because I feel like that's all we talk about nowadays.

Dra. Mónica Peralta: But it amazes me, because also, people are not doing the right research, or we're not talking enough about eating disorders and GLP-1s. And diabetes and eating disorders go hand in hand. There is so much correlation between eating disorders and diabetes.

Asher Larmie: Yes, thank you for saying that, for naming that out loud. It's so true, and we are prescribing eating disorders to diabetics. We're like...

Dra. Mónica Peralta: We would not prescribe disorder eating behaviors to thin people. So what we diagnose as eating disorder or as disordered eating in thin people, we are prescribing as treatment for fat people.

Asher Larmie: Yes, yes.

Speaking of Novo Nordisk, I don't want to give them too much air time, because I'm sick and tired of talking about them. However, March the 4th is World Obesity Day. We're allowed to swear on this podcast but we try not to use that word, but it is the name of the day. It's the 4th of March this year. Tell me your thoughts. What do you think about this wonderful day that is coming? Should we celebrate?

Dra. Mónica Peralta: Oh, my God! It really surprised me that as human beings, we are okay with having a day to eradicate a type of human being, a type of person, a body type. We are okay with telling people, "Hey, March 4th, we want to eradicate you. We don't want you to exist. Welcome to World Obesity Day! What the fuck?"

Are we okay as human beings to tell people, "We have a special day when we don't want you to exist anymore. And we have all these recommendations for you to stop existing"?

I mean, and then the audacity, the audacity of a white man. Because there's a white man behind that. If you go into their website, they talk about weight stigma on the landing page - "we have to stop weight stigma." And they have this beautiful chart of how weight stigma impacts obesity. And how if we - they say, like, if we keep treating people that live with obesity bad, they're gonna keep being fat. And we don't want that. And that's why we have this day, because we don't want you to exist.

But also, "Weight stigma is bad, and it's gonna impact your health." The weight stigma that doctors have. So, "Weight stigma, but we have this whole day to tell you why you shouldn't be fat, and that's not perpetuating weight stigma?" You are giving them permission to perpetrate that weight stigma. You have a whole day to give people permission to go on social media and every channel, "Hey, happy World Obesity Day! Here are all these recommendations for you to not exist anymore. Because you're not allowed diversity. That's not a thing."

Asher Larmie: This was a mic drop moment if ever I've heard it. I just wrote on a piece of paper "this clip - you need to immortalize this clip right now." Basically saying about to cease to exist. It is exactly right. No one has ever put it like that before, and I love you for it. I have nothing to say.

Dra. Mónica Peralta: I mean, are we okay with having a day to eradicate another diversity in the human species? No, we're not. But we're okay with telling fat people, "Stop existing."

Asher Larmie: Yep, because we can control it. I don't know if you know that, like, it's absolutely...

Dra. Mónica Peralta: Oh, yeah, I just forget about that. Oh, my God, yeah. You know what? Today, I'm gonna stop being fat.

Asher Larmie: Oh, me, too! Let's make a decision together. Let's shake on it virtually. That's it. We are - tomorrow.

Dra. Mónica Peralta: This is gonna be the time that everything works. This is the last diet. Everything is gonna work out.

Asher Larmie: Absolutely, that's a hundred percent gonna happen, I'm sure.

Dra. Mónica Peralta: We are gonna on a World Obesity Day be the champions because we're going to stop existing.

Asher Larmie: Yes, they can. We can be a before and after picture - before, and then like no longer here after. Done, gone.

Dra. Mónica Peralta: Then they have ended weight stigma with us to stop being existent.

Asher Larmie: Yeah, it's interesting. I always find this really interesting. You read a study that says, you know, like you said, "Depression. You're more likely to be fat and depressed," and of course you are, because if you're fat you get treated like garbage by your family, you know that you're different. You have fewer social interactions because it's harder to live outside of your home. You can't get the clothes, and you can't travel, and people stigmatize you all the time, and chances are you have a lower income, and all of that stuff, all the stuff we know. So yeah, of course, that's going to make me depressed.

Dra. Mónica Peralta: Your weight is keeping you away from getting that mental health treatment.

Asher Larmie: Exactly.

Dra. Mónica Peralta: That's the cycle. Depressed because of the weight stigma around me, and because of how people treat fat people. And then I have, of course, someone saying that I'm playing the victim, and that I just should shake it off. And then I don't have access to mental health because of my BMI.

And if we go a little bit back to World Obesity Day, obesity is only - I mean the origin of the word is horrible. But then it's a diagnosis based on BMI that doesn't work for shit.

Asher Larmie: Yeah.

Dra. Mónica Peralta: And of course they have a day based on a misdiagnosis, because when you don't have another tool to confirm an obesity diagnosis, that's not a good diagnosis.

Asher Larmie: A medical condition, not just a medical condition, in which the only diagnostic tool that we have to confirm this diagnosis, this condition is, as you say, the BMI which we have all universally agreed is not fit for purpose. It doesn't work.

Dra. Mónica Peralta: And maybe if these scientist people wake up tomorrow angry, they just can change the table and the markers. And maybe you and me just go higher and higher, because they had a really shitty dinner and they wake up angry, and they decide to change it.

Asher Larmie: And what can we do to stop it? But what fascinates me is then we say, "Okay, so we know that weight stigma is a problem. And we know that it's actually impacting healthcare. And we know that that's making people depressed." And so the treatment is to make them thinner?

Because why is it not obvious that we could just work on the weight stigma instead? That would just be as effective. In fact, it would be more effective because weight loss is only temporary. So this is going to be like fixing the underlying condition. Isn't that what we're told to do as doctors - treat the underlying condition? If the underlying condition is weight stigma, if that's what's driving the depression, then the solution is not to make them thinner. The solution is to treat the weight stigma, but that would include us.

Dra. Mónica Peralta: It's too much work, actually.

Asher Larmie: Right. It's too much work, and it would mean that we were in the wrong.

Dra. Mónica Peralta: Yes, and if you see that with a cultural lens, with a Latin American lens - in Latin America, doctors are God. Whatever the White Coat says goes.

Asher Larmie: Yes.

Dra. Mónica Peralta: And so that's even bigger here, because doctors are never wrong. Never, never, never. So when you say, "Oh, they have to work on their weight stigma," or, "There's some inner work that you have to do." "What? I'm a doctor. What do you mean? I have to do the work? You are the patient, little girl. You have to do the work because I am the doctor. I know everything. I have the white coat."

So I think, getting health professionals to admit, because if I talk from my transition from being weight-centric to weight-inclusive, it was really hard for me to admit that I've been doing harm. And for me to say, "What a shitty person! What was I doing? Did I go through all this medical training for this?"

So many things, not only about weight loss, but my privileges and my racism, and my everything. And it's also a privilege to take that time to say, "Okay, I have to work on this to be able to help in the best way I can." But that inner reflection that you have to take - it's better just to yell to a patient and say, "Hey, you're not doing what you're supposed to do."

Asher Larmie: Takes all of a few seconds to do that, whereas unlearning, and all of that stuff, deconstructing - oh, that's hard work.

Dra. Mónica Peralta: And with a patient, you have 15 minutes. I mean, it's easier.

Asher Larmie: I think we should end this podcast with a bit of hope. We talked in the beginning about the Association for Weight and Size Inclusive Medicine. I have recently joined the board, but obviously you've been there longer. So tell me about your journey to this organization.

Dra. Mónica Peralta: So Lisa is the president and founder of AWESOME, the Association for Weight and Size Inclusive Medicine. Lisa and I connected through ASDAH, which is the Association for Size Diversity and Health, who own the trademark for HAES. Lisa and I, at that moment, were the only physicians on their list.

So she contacted me, and I said, "An association where we are all weight-inclusive clinical physicians? Count me in." And we had a Zoom, and she told us her idea, and it was perfect for me. I mean, it's something that I've long hoped for.

Because I live in Latin America. Here, things are in diapers, you know, weight stigma and fatphobia talk. We have a long road ahead. And then, well, AWESOME was created. We are all a volunteer board, as you know. All our work is volunteer, and what we're effectively doing is creating this space to have networking opportunities, to have community, to be as safe as we can be - a space for healthcare professionals, not only physicians, to share their doubts.

The transition between a weight-centric and a weight-inclusive approach can get really lonely, can get really confusing, because we are used to weight loss. And when you're doing that shifting, it's like, "What am I supposed to do? All my career I've been prescribing weight loss and saying fat is a disease."

And now that we can center all of these healthcare professionals and have this community, it's easier. And this association opens your world to different perspectives because we are not all gonna be agreeing on everything.

Asher Larmie: Yep.

Dra. Mónica Peralta: Maybe some people think, "Oh, that idea is too radical." But you know what? Okay, I'm gonna read it, and that's it. And then you're going to think, "That's not radical enough."

So AWESOME is that - it's a place where we are creating opportunities for healthcare professionals to grow within the weight-inclusive world, and also where we can have this safe space for patients and better attention to patients. And we are trying to have all these resources uploaded every day. We are updating those resources, and we are trying to go through every channel with this message of weight-inclusive medicine.

Asher Larmie: And you're doing a very hard job. I have to say, I was so delighted when I heard about the organization. It was actually at the time of launch. So I think I found the Instagram page that you run. And I saw something, and it was like there were doctors talking about weight inclusivity, and I was like - it's not that I thought I was the only one, it's just I didn't know any other doctors. I had many dieticians and nutritionists and fitness professionals, and I knew lots of psychologists. But doctors - I didn't know. I met a few along the way who'd come and whispered in my ear, "It's really difficult for me to be like this at work," which, of course, brings its own challenges.

But it's just so wonderful to know that this organization exists, and I really believe that one day soon we will have a seat at the table. That when it comes to policy, when it comes to what is happening in the world, that we will have a louder voice. Because a lot of people, when you say to them, "Hey, how can I help you? What can I do for you?" A lot of people I've asked that, they've just said, "Go and tell your colleagues. Please go educate your colleagues," and I think that is definitely something that we and everyone at AWESOME is passionate about. So there is hope. There are doctors out there, few in numbers for now but...

Dra. Mónica Peralta: And you are the advocacy chair. So we are truly gonna make some changes. Changes are coming.

Asher Larmie: Yes, changes are coming. I believe it. We're going to try and make it as quick as possible, but also it has to be right. We have to get it right. But I just want people to know there are doctors out there that care, and there are more and more coming out, I think. They're whispering in our ear. They're coming out of the weight-inclusive closet and kind of going, "Yeah, actually, I think you might be right," and it will snowball.

Dra. Mónica Peralta: And also, I think what AWESOME is doing is planting that seed of doubt. Like, "Oh, what's this? This makes sense. I don't want to treat people badly. I'm going to look into it." If AWESOME is doing that, just planting the seed of doubt, we are doing a lot.

Asher Larmie: Amazing. This has been really one of the best talks I've ever had. I love it. Tell everybody where they can connect with you, work with you, things like that.

Dra. Mónica Peralta: Well, I think the easiest way is through my Instagram page that has my web page. So my handle is "dra.monicaperalta", and my web page is www.monicaperalta.org. And I work mainly online, and I do work in Spanish and English. So yes, through Instagram is, I think, the easiest way, because you have all the links.

Asher Larmie: That's amazing. Do you hear that, people? Are you listening? Both in Spanish and English and online! I'm going online shortly to see what I can grab, because that is just like, you know, amazing. I'm going to put your links in the show notes. Obviously, if people don't know that in Latin America it's "Dra." then you've learned something new today. But if you don't know, you're forgiven. But now you know. Don't ever forget it. We have to stop centering...

Dra. Mónica Peralta: I always try to put subtitles in English, captions in Spanish, and subtitles in English. Sometimes that translation that captions gave me is not that good, but you know, I try.

Asher Larmie: You do, and I just think it must be so much extra labor, and it puts you at such a disadvantage. It really does, and I really applaud and am so grateful for you, and also really glad that there is somebody out there whose primary language is Spanish, and is doing this work in Spanish. Because why should everybody have to do it in English? I'm just really happy that you're doing work, but also truly, honestly appreciate the fact that you take the time to include English-speaking people, which is not necessary, but certainly I am grateful for it as a non-Spanish speaking person. Although I'm determined - it didn't go so well with Duolingo, I need to find another way.

Dra. Mónica Peralta: You'll have to come to Nicaragua. An intensive course.

Asher Larmie: That's a solution. Just spend a couple of months there. I'll be fluent in no time. Two months sounds like a party to me. So, anyway, thank you so much for joining us. I hope to have you back soon, but everyone, I'm sure, will agree. This was a really fantastic conversation, and very, very helpful.