Diabetes mellitus is caused by the loss of endogenous glucose regulation, leading to fasting hyperglycemia and superimposed glucose elevations with meals. Attempts to restore glucose levels to within the narrow normoglycemic window may result in hypoglycemia, adding to fluctuations in glycemic control. This issue of JAMA is devoted to the topic of diabetes, with the cover depicting the blood glucose variability of poorly controlled diabetes as a roller coaster—the Glucose Excursion—the course of which is based on continuous glucose monitoring data. Loss of pancreatic beta cells below a threshold amount—the β-Cell Drop—triggers the onset of diabetes, causing hypoinsulinemia in type 1 diabetes and inadequate compensation for insulin resistance in type 2 diabetes. The β-Cell Drop provides an early abrupt change and a late plateau. The smoothest ride is the Insulin Coaster, which demonstrates the time course of long-acting insulin preparations.
Anne R. Cappola, Edward H. Livingston. Controlling the Metabolic Roller Coaster in Diabetes. JAMA. 2014;311(22):2277–2278. doi:10.1001/jama.2014.6675