Recently, medical problems for the presence of arteriosclerosis are important in the world. The number of the patients with atherosclerotic cardiovascular disease (ASCVD) is now increasing, that brings to the cause of mortality and morbidity [1]. In the light of anti-aging medicine, proper treatment and care will be necessary for cerebral vascular accident (CVA) in the brain, ischemic heart disease (IHD) in the heart, and peripheral artery disease (PAD) in the lower extremities [2]. ASCVD can include wider ranges of related diseases, such as diabetes, hypertension, hyperlipidemia and Metabolic syndrome (Met-S).

On the other hand, elderly population has been increasing in the developed countries, and then anti-aging medicine or geriatric medicine has been in focus [3]. Among them, adequate diagnosis and treatment for Met-S and related problems has been required [4]. Common therapeutic method includes changing the basic diet habit from calorie-restriction diet (CRD) to low carbohydrate diet (LCD). LCD has been introduced to healthcare and medical region by Atkins and Bernstein in Western countries [5,6]. They have developed LCD information for long by famous textbooks. By these activities, the beneficial effect of LCD has been common across the world.

Successively, authors’ research group has developed clinical research and practice for LCD until now. We have clarified the medical significance of ketone bodies and energy during LCD [7]. For useful application of LCD in daily lives, we established Japan LCD promotion association (JLCDPA) [8]. Furthermore, we planned to inform 3 practical types of LCD methods broadly in our society [9,10]. We came to have an significant older male case with type 2 diabetes (T2D) [11]. His general clinical course and related perspectives will be shown in the article.

History and Physicals

The current case is 84-year-old male. He was diagnosed as light degree of T2D about 75 years old. After that, he was followed up without oral hypoglycemic agents (OHAs). From 78 years old, he has been treated in our hospital taking some kinds of OHAs. His HbA1c has been almost stable and no remarkable physical or psychological problems were detected for 6 years.

Physical examination was underwent. He had unremarkable situations of vital signs, consciousness, lung, heart, abdomen or neurological findings. Concerning his body construction, he has been healthy from 20s to 70s period, and kept almost same body weight until now. Currently, his weight has been 48.7kg in weight, 154cm in stature, and 20.5 kg/m² in BMI.

Several Examinations

Clinical progress of biochemical exam was summarized in Table 1. He showed normal range of liver, renal, lipids and complete blood count (CBC) for years. Concerning diabetic markers, he continued to have hyperglycemia and almost stable controlled HbA1c values. Chest X-P revealed negative exam, and Electrocardiogram (ECG) showed that ordinary sinus rhythm (OSR), pulse 72/min, and unmarkable ST-T changes. Urinalysis showed negative results as protein (-), urobilinogen (+/-), glucose (-), occult blood (+/-), pH 6, bilirubin (-) and ketone bodies (-).

Table 1: Progress of Biochemistry Data.

He received the pulse wave velocity (PWV) exam (Figure 1). The value of Cardio-Ankle Vascular Index (CAVI) was 11.6/10.8 (right/left), where their values were more than standard range for 7.9 +/- 0.7. Then, the presence of arteriosclerosis was observed. The ankle-brachial index (ABI) showed 1.15/1.04 (right/left), as normal range of 0.91-1.40. The detail markers for PWV showed that L (118) = L1(60) + L2(32) + L3(26), PEP 73, ET 301, R-AI 1.17 and PEP/ET 0.24. Clinical progress for CAVI for 5 years was summarized in Figure 2. The values were 9.9-11.6 for right and 9.4-10.8 for left, that are almost stable situation.

Figure 1: Result of Pulse Wave Velocity (PWV).

Figure 2: Annual Changes in CAVI for PWV.

He underwent abdominal CT scan (Figure 3).?No space-occupying lesions (SOL) were observed in the liver. The gallbladder was slightly contracted, and no dilation of the common bile duct or pancreatic duct was observed. The pancreatic parenchyma was slightly atrophic. There was no enlargement of the adrenal glands and suggests the presence of cysts in the kidneys.?The aorta was tortuous and its wall was calcified.

Figure 3: Images of Abdomen CT scan.

1. No SOL in the Liver
2. Contracted Gall Bladder
3. Arteriosclerosis of the Aorta
4. Probable Renal Cyst

Clinical Progress and Medical Problems

This patient has been receiving treatment at our outpatient clinic for 6 years. Laboratory data, including HbA1c, renal, liver, and lipid profiles, have been stable over the long term. The patient is being treated for T2D, with taking OHAs for EquMet LD (Equa [vildagliptin] 100 mg/day combined with Metformin hydrochloride [Metgluco] 500 mg/day, bid, twice per day).

Based on his medical history, exam results, and clinical data, this patient's medical problems can be summarized as follows: i) T2D and ii) arteriosclerosis. These two are the main issues. Otherwise, hypertension has not been previously identified. No diabetic macrovascular disorders, such as CVA, IHD, or PAD have been identified. Furthermore, no significant diabetic microvascular disorders, such as neuropathy, retinopathy, or nephropathy, have been identified to date.

Ethical Standards

This report is complied with Helsinki Declaration [12]. Certain comment shows the protection for personal information. The principle includes the ethical rules for the practice and research for human subjects. Required guideline is by Ministry of Health, Labour and Welfare (MHLW), and also Ministry of Education, Culture, Sports, Science Technology (MEXT). The authors and collaborators set up ethical committee in Sakamoto Hospital. It has the director, internists, head nurse, pharmacist and legal professional. All members has discussed fully about the case, agreed the protocol and took informed consent from the case.

The characteristics of this case are as follows: i) he is now at 83 years old, exceeding the average life expectancy in Japanese male, and cognitive ability, QOL, and ADL are well maintained [13]; ii) physical issues include T2D and arteriosclerosis, which remained stable for many years; iii) no evidence of macroangiopathy or microangiopathy associated with diabetes; iv) psychologically, the patient is very earnest, yet cheerful and enjoys daily life; v) overall, from the above physical and psychological features, the patient has a regular lifestyle and maintains good communication and relationships with people around him. Based on these findings, he appears to be in a state of daily well-being.

Current case has kept his body weight more than 40 years. He has been slender physique as BMI value 20.5 kg/m² in such slender type, DPP4-i seems to be beneficial for light degree of T2D. Furthermore, In Asian patients with T2D, DPP4-i has been known to show beneficial clinical efficacy than European people. For Asian diabetic patients, DPP4-i has showed satisfactory clinical effect of reduction in HbA1c value, associated with less risk of hypoglycemia, improved clinical events and good tolerability [14]. By the systematic review, evaluated the efficacy and safety of metformin monotherapy and combination therapy was evaluated for Asian people [15].

Concerning clinically arterial stiffness (AS), the value of brachial-ankle pulse wave velocity (baPWV) can become the useful value for the evaluation of general arteriosclerosis [16]. For characteristic clinical issues, he had diabetes but no hypertension, and arteriosclerosis had persisted with a slight level. As to the measurements of arteriosclerosis, PWV, CAVI and ABI had been stable for five years [17]. Possible contributing factors may include rather stable fundamentally lifestyle habits, proper diabetes control, and some genetic factors in his case. From the points of lifestyle and psychological issues, current case revealed several characteristic points. They are i) he has usually regular life for years, including exercise, meal, and sleep; ii) he grows vegetables and flowers in his house and then he can move around freely with his trained legs, iii) his QOL and ADL are maintained for enough degree for long, iv) his interpersonal communication skill (IPCS) for other people is likely to show excellent level with psychological perspectives.

This case showed stable diabetic control for years, in which two reasons may be included. One is constant continuation of nutrition treatment. There are 3 types of low carbohydrate diet (LCD) for practical use, where super-LCD, standard-LCD, and petite-LCD has 12%, 26% and 40% of carbohydrate ratio, respectively. For his case, petite LCD was continued for long, in which he had carbohydrate in breakfast and dinner. The other is the benefit of EquMet that is provided twice a day. In comparison with sitagliptin once daily, vildagliptin twice daily showed suppressed blood glucose variability during night [18]. Consequently, hyperglycemia after dinner may be suppressed by EquMet [19,20]. Metformin is also beneficial for providing twice daily (bid) for blood glucose controlling blood glucose. [21]. Consequently, generally combination therapeutic method of LCD and adequate OHAs can lead to satisfactory glucose variability and psychological wellness for diabetic patients [22].

In the latest review of arterial stiffness and vascular aging with 439 references, future translational arterial stiffness research will include several aspects [23]. They are clinical assessment, specific phenotypes and endotypes, underlying mechanisms and new risk factors, and tailored prevention and therapy approaches.

Some limitation may be present in this article. Current patient seems to lead stable lifestyle with light level of T2D, without CVA, IHD, PAD, or microangiopathy. Regular medication of EquMet has contributed satisfactory clinical effect for years. This case will be carefully followed up in the light of exacerbation of arteriosclerosis.

In summary, 84-year-old male with T2D and arteriosclerosis has been described in this article. The case can show several perspectives for diabetes and arteriosclerosis. It is expected that current report will become useful reference in clinical practice.

Conflict Of Interest

The authors declare no conflict of interest.

Funding

There was no funding received for this paper.

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