What is the relationship between cannabis use and diabetes/metabolic health?

The cannabis-diabetes relationship is paradoxical: despite cannabis increasing appetite and being associated with higher caloric intake, epidemiological studies consistently find lower rates of obesity, diabetes, and metabolic syndrome in cannabis users. The NHANES analysis (Penner et al., 2013) found cannabis users had lower fasting insulin levels, smaller waist circumference, and higher HDL cholesterol than non-users. Proposed mechanisms: (1) THCV acts as a CB1 antagonist, reducing appetite and improving insulin sensitivity. (2) CBD activates PPAR-γ receptors, improving insulin sensitivity. (3) Cannabis users may have lower stress-related cortisol (which drives metabolic dysfunction). (4) Selection bias — healthier people may be more likely to use cannabis. The only RCT specifically targeting diabetes: a 2016 trial (Jadoon et al.) found THCV (5mg twice daily) significantly reduced fasting glucose and improved pancreatic beta cell function in type 2 diabetes patients. This is one of the most compelling cannabinoid RCTs outside of epilepsy. Long-term metabolic effects of chronic cannabis use remain unclear.