Abstract
People with stimulant use disorders are usually underweight. Current accepted knowledge is that they are skinny because stimulants suppress appetite - they eat less. But is it that simple? Here we review the relationship between stimulant use, food intake, metabolism and body weight, and highlight key points that may challenge current knowledge: 1) Stimulants interact with the hormonal signals that regulate appetite including ghrelin and leptin, and can produce long-term alterations in the ability to monitor and compensate energy deficits. 2) The diet of people with stimulant use disorders might be characterised by altered nutritional geometry, rather than overall reduction of food intake. 3) Long-term changes in homeostatic signals and nutrient intake can produce metabolic deficits that contribute to unhealthy low weight. Based on this knowledge we advocate for increasing awareness about the nuances of stimulant-related nutritional and metabolic deficits among addiction clinicians, and increased research on the interaction between stimulant use, appetite signaling, and metabolic deficits.