Non-communicable diseases (NCDs) have been crucial worldwide and they account for 74% of global mortality [1]. The theory-based behavior change interventions (BCIs) seem to be promising, but their practical application has been not easy. They have several factors from medical, social, cultural and other points of view. Among them, usual intake of carbohydrate has attracted attention, in which carbohydrate causes hyperglycemia leading to diabetes and NCDs. In addition to the public information of carbohydrate, research for healthcare and nutrition has been found concerning the potential phytochemical or other materials like dietary fiber, leading to health benefit [2]. For example, finger millet (FM) has been known for lowering the rate of developing type 2 diabetes (T2D), hypertension and gastro-intestinal (GI) disorders.

For decades, aging has become crucial problem worldwide, and hyperglycemia would be concern in addition to the diet-related diseases. Some possible strategies include i) employing vitamin B1 for inhibiting biochemical pathways to hyperglycemia, ii) choosing sugar substitutes for decreasing elevated blood glucose, and iii) applying some kinds of legumes for lowering glucose responses and regulating blood glucose [3]. Thus, appropriate dietary nutrition would be required for elderly cases with T2D. Adequate QOL and ADL for elderly person requires stable diet therapy and physical activity. For patients with NCDs, clinical effect of physical therapy was studied aiming at physical activity promotion (PAP) direction [4]. The method was searching the literatures for 14 systematic reviews. As a result, the strategy of PAP would be effective for the improvement of physical activity for patients with NCDs in the short and also long term. Both systematic reviews and high-quality primary studies will be necessary for confirming results.

American Diabetes Association (ADA) has announced the latest Standard of Care (SoC)-2025 for informing applicable diagnosis and treatment for diabetes and arteriosclerosis in January, 2025 [5]. This annual edition has become the fundamental guideline for primary care (PC) medicine, including ASCVD [6]. Authors and collaborators have continued clinical practice including NCD, diabetes, and PC medicine. We have encountered an impressive elderly case who has been diabetic with stable lifestyle, but unstable period due to taking care of great-grandchild. In this article, general progress and related perspectives are described.

Medical History

The patient is an 87-year-old male with T2D. For his social history, he has been the president of a company for long. At the age of 80, his son became the president, and he has become the consultant of the company. His role changed in coming to the office for consulting with staffs and taking care of his great-grandchild with educating and playing together every day. His office is situated in the 3rd floor of the building, and he always go up and down the stairway 20 times a day, because he wants to smoke 20 cigarettes per day.

He has visited diabetic department of our hospital for years, and could continue to have stable HbA1c value until 2021. From spring 2022, his HbA1c has increased to 9.7% (Figure 1). The episode was an unexpected phenomena. Authors and staffs asked him the reason. His reply was “I think too many cakes would be the main reason.” After that, we advised him to go back to his previous healthy and ideal life style. During 12 months in 2023, his HbA1c was stable for 5.7-6.2%.

Figure 1: Clinical Progress of the Case for Hba1c and Treatment.

Physical and Several Exams

A physical examination in Sept 2024 showed unremarkable findings in speech, consciousness, heart, lung, abdomen, and neurological exams. His vital signs were within normal limits as pulse 72/min, regular, BP 134/78 mmHg and SpO₂ 97%. The patient's stature was height 165.5 cm, weight was 60.5 kg, and BMI was 22.1 kg/m². The biochemical blood tests are summarized in Table 1. It shows unremarkable changes in the liver, kidneys, lipids, or complete blood count (CBC). His chest X-ray was negative. The electrocardiogram (ECG) showed pulse 72/min, incomplete RBBB, horizontal ST-T depression in V₄ and V₅, indicating probable ischemic findings (Figure 2).

Table 1: Changes in Biochemical Blood Tests.

Figure 2: The Finding of Electrocardiogram (ECG) Horizontal ST-T Depression in V4 And V5 Is Found.

He underwent the pulse wave velocity (PWV) exam. As a result, ankle-brachial index (ABI) was 1.21/1.17 (right/left), and cardio ankle vascular index (CAVI) was 13.0/12.4 (R/L). These findings showed no apparent arteriosclerotic changes in lower extremities by PWV (Figure 3a,b).

Figure 3: The Findings of Pulse Wave Velocity (PWV) A). Pulse Wave Is Unremarkable With Normal AB. B). Elevated Value Of CAVI With Arteriosclerosis.

Clinical Progress

The HbA1c value has been again increasing from spring, 2024, and low back pain (LBP) started from July, 2024. Then, his oral intake of much cakes were increased during summer 2024. During this time, he had to take of his great-grandchild for long time every day. Such circumstances have influenced his daily life for eating more cakes together and exercising less opportunities. The summer 2024 was extraordinary hot during 2 months, and he was admitted to the hospital for dehydration and hyperglycemia with HbA1c 9.7% in September, 2024. He was treated by administering insulin and then general situation was improved with HbA1c 6.7% in December 2024.

Ethical Standards

This report complied with Declaration of Helsinki [7]. Furthermore, some commentaries existed for the regulation of the information. The principle was the ethical regulation for clinical research. The guidelines were applied from Japanese Ministry of Education, Culture, Sports, Science Technology and Ministry of Health, Labor and Welfare. Current authors established our ethical committee, that was in Sakamoto Hospital, Kagawa, Japan. The members were the hospital director, doctors, nurses, pharmacist, dietician, and legal professional. We discussed enough and agreed the protocol. The informed consent was received from the patient as the document.

This patient has some medical problems and social/economic characteristics. Their outlines can be summarized as the following. They are i) T2D, ii) arteriosclerosis, iii) the president of the company for long, iv) ability of continuing regular lifestyle of diet and exercise, v) climbing the stairway to 3rd floor 20 times a day, vii) taking care of his great-grandchild and viii) inability of regular life due to predominance for great-grandchild. Among them, some perspectives are discussed in the following.

 According to the findings of ECG and PWV, he has arteriosclerosis for probable coronary heart disease (CHD) and possible peripheral artery disease (PAD) [8]. He has not complained of dyspnea, chest oppression or discomfort so far, even if he always goes up and down until 3rd floor of the building. However, he is highly aged person, and then his cardiovascular situation would be followed with close attention. Furthremore, LDL-C value would be an important factor for the risk of ASCVD. In his case, LDL-C has been in normal range, and then it may be one of the reasons for his stable cardiovascular situation for long [9].

 From the medical history, he has uncontrolled period of glucose variability twice, which were summer 2022, and summer 2024. During the period, he had to take care of his great-grandchild, in which he always keep accompanying, helping study, watching TV and eating cakes together. Such behavior may bring the worse diabetic control. In particular, he experienced also low back pain in the summer 2024, and then it also exacerbated the glucose control.

There have been common tendency of seasonal HbA1c changes. T2D patients usually show higher HbA1c level during winter, because they tend to take food and cakes more, and move less. From previous report, as the temperature decreases 1 degree Centigrade, the risk of HbA1c more than 7% may increase in the diabetic practice [10]. For seasonal HbA1c changes, authors et al. reported the detail HbA1c fluctuation a year. Yaounger generation apt to show higher HbA1c probably due to taking ice-cream and sugary juice during summer time [11]. On the other hand, elder generation usually stay at home in air-conditioned room, leading to lower HbA1c than winter. Furthermore, seasonal changes of HbA1c, BP, and LDL-C were investigated [12]. As a result, the achievement of 3 markers to the target value showed the lowest in winter, suggesting the required perspectives for diabetic practice in the future.

There are some possible ways to improve carbohydrate intake. The trial of replacing sugar in the pastry with functional ingredients would be better measure for food manufacturers [13]. Reducing carbohydrates in bakery and pastry products will be beneficial for decreasing several diseases including diabetes, obesity, tooth decay, cardiovascular disease (CVD), mild cognitive impairment (MCI) and dementia. In the light of consumer perception and food technology, adequate substitutes include inulin, apple puree, stevia, oligofructose, polydextrose and apple pomace.

This case has an impressive daily habit. He continues climbing stairs 20 times every day until 3rd floor. The reason is smoking, where he must come down to the ground floor for every 1 cigarette. Continuing such daily behavior will provide health for diet and exercise [14]. He seemed to obtain enough ability, confidence, and continuity from the experience of the company president for long. Currently, he has played a role as an advisor, educating his staffs in the company. On the other hand, he inevitably brought bad diabetic control worse, because he had to take care of great-grandchild for eating sweets together.

 Some limitation may be present in this case. There are some problems so far, including arteriosclerosis and his daily social life for both working in the company and taking care of his great-grandchild. He has been an intelligent person, and the we can accompany him with adequate medical and social advises.

 In summary, 87-year-old male case with T2D was described here. His characteristic aspects include regular life style of meal and exercise, working as former president to current consultant, and taking care of great-grandchild. From medical point of view, we will follow arteriosclerotic problems with close attention. Current report will be hopefully useful for future development of primary care medicine and diabetes.

Conflict of Interest: The authors declare no conflict of interest.

Funding: There was no funding received for this paper.

1. Darukaradhya TB and Krishnamurthy J. Modifying Non-communicable Disease Behaviours through Effective Health Communication and Behaviour Change: A Systematic Review. Preventive Med Res and Rev. 2025; 2: 24-39.
2. Gupta P, Neetu S and Alka N. Nutritional Profiling and Characterization of Developed Cake Premix Using Finger Millets (Eleusine coracana) and Sweet Potato (Ipomea batatas L.). European J Nutrition and Food Safety. 2024; 16: 1-11.
3. Ma S. Dietary nutrition treatment for the elderly with hyperglycemia. 3rd International Conference on Biological Engineering and Medical Science (ICBioMed2023): 2024; 129243F (2024).
4. Jung A, Geidl W, Matting L, Hoessel LM, Siemens W, Sudeck et al. Efficacy of Physical Activity Promoting Interventions in Physical Therapy and Exercise Therapy for Persons With Noncommunicable Diseases: An Overview of Systematic Reviews. Phys Ther. 2024; 104: pzae053.
5. American Diabetes Association Professional Practice Committee. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2025. Diabetes Care. 2025; 48 (Suppl. 1): S207-S238.
6. Bruun K and Mortensen MB. Rethinking atherosclerotic cardiovascular disease prevention in the era of expanding therapies: could plaque stabilization reduce the need for lifelong treatments and polypharmacy? Curr Opin Cardiol. 2025; 40: 50-55.
7. General Assembly of the World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. J Am Coll Dent. 2014; 81: 14-8.
8. Zhao Y, D’Agostino R, Malik S, Watson KE, Bertoni AG, Budoff MJ et al. United States Pooled Cohort Cardiovascular Disease Risk Scores in Adults With Diabetes Mellitus. JACC Adv. 2025; 4.
9. Shah NP, Mulder H, Lydon E, Chiswell K, Hu X, Lampron Z et al. Real-world exploration of LDL-cholesterol management in patients with atherosclerotic cardiovascular disease. Am Heart J. 2025; 279: 50-58.
10. Tien KJ, Yang CY, Weng SF, Liu SY, Hsieh MC and Chou CW. The impact of ambient temperature on HbA1c in Taiwanese type 2 diabetic patients: The most vulnerable subgroup. J Formos Med Asso. 2016; 115: 343-349.
11. Kato Y, Bando H, Yamashita H, Yada S, Tokuhara S, Tokuhara H et al. Seasonal changes in HbA1c values from young to elderly diabetic patients. J Diabetes Metab Disord Control. 2019; 6: 89-92.
12. Sakamoto M, Matsutani D, Minato S, Tsujimoto Y, Kayama Y, Takeda N et al. Seasonal Variations in the Achievement of Guideline Targets for HbA1c Blood Pressure and Cholesterol Among Type 2 Diabetic Patients: A Nationwide Population-Based Study (ABC study) (JDDM49). Diabetes Care. 2019; 42: 816-823.
13. Dana H and Sonia A. Substituting Sugar in Pastry and Bakery Products with Functional Ingredients. Applied Sciences. 2024; 14: 8563.
14. Lin Y, Sun Y, Zhang Z,et al. A cross-sectional study of optimal exercise combinations for type 2 diabetes. J Public Health (Berl.)2024; 32: 1347-1357.