Improved Diabetic Control in Obese Patient with Type 2 Diabetes (T2D) By Less Carbohydrate and Equmet (Vildagliptin/Metformin)

Bando H, Sakamoto K, Ogawa T, Iwatsuki N, Okada M and Kondo N

Published on: 2025-04-30

Abstract

The case is 77-year-old elderly male with obesity, type 2 diabetes (T2D) and ischemic heart disease (IHD). His weight increased from 55kg to 86kg during 20s to 60s. As health check-up in autumn 2023, his HbA1c was 8.0%. He started petite low carbohydrate diet (LCD) and vildagliptin/Metformin (EquMet), and then HbA1c became stable about 6.7%. Electrocardiogram (ECG) showed ischemic flat T waves.?For pulse wave velocity (PWV), ankle brachial pressure index (ABI) 1.08/1.18 and cardio-ankle vascular index (CAVI) 9.3/9.0 as right/left were noted. This case will be followed up with attention, through the research of Japan LCD promotion Association (JLCDPA).

Keywords

Petite low carbohydrate diet (LCD); Vildagliptin/Metformin (EquMet); Japan LCD promotion Association (JLCDPA); ischemic heart disease (IHD); Pulse wave velocity (PWV)

Introduction

Clinical problems of obesity and diabetes mellitus (DM) has been crucial. The prevalence of overweight, obese, or DM are increasing until now, and it would be more than one-third in the world [1]. In addition, the number of DM patients is rapidly increasing as 537 million to 783 million from 2021 to 2045 [2]. In such patients, the development of atherosclerotic cardiovascular disease (ASCVD) will become the cause of morbidity and mortality [3]. Main purpose of diabetic treatment will be the preventive measures for ASCVD [4].

DM is known to have clinical macroangiopathy and microangiopathy. The former will develop cerebral vascular accident (CVA), ischemic heart disease (IHD), and peripheral artery disease (PAD). The exacerbation possibility of these macroangiopathy would be reduced by weight reduction and treatment of diabetes. Fundamental therapy include adequate nutritional therapy for DM. Formerly, calorie restriction (CR) had been rather standard measure for diet therapy, but recent tendency has shown the predominance of low carbohydrate diet (LCD) for decades [5,6]. LCD was originally introduced by two doctors of Atkins and Bernstein in Western countries [7,8]. In clinical and health care regions, LCD has been known widely. Authors and colleagues began LCD movement through Japan LCD promotion association (JLCDPA). We have developed LCD medically and socially by books, papers, workshops and other opportunities [9]. As simple and convenient idea, we have suggested three kinds of LCD, that are petite-LCD, standard-LCD and super-LCD. They include carbohydrate ratio as 40%, 26%, and 12%, respectively [10].

Authors diabetes group have continued clinical practice and research for years, and treated various types of diabetic patients. Recently, we have experienced an impressive male case with obesity, type 2 diabetes (T2D) and possible IHD due to electrocardiogram (ECG) changes. He started LCD and medication of EquMet (Vildagliptin/Metformin), where his glucose variability has been improved and stable. In this report, his general clinical course associated with related perspectives would be described.

Presentation of Cases

History and physicals

The patient is 77-year-old male with obesity, hyperuricemia, hypertension and T2D for about 8-10 years. He was provided sitagliptin for T2D. When he received health check-up in autumn 2023, he was advised to visit diabetes department for further evaluation. The HbA1c value was 8.0%, and he came to our clinic in November 2023, because he wanted to be treated by the specialist in diabetes. For his treatment at that time, several oral medication was found, including sitagliptin 50mg, amlodipine 5mg and allopurinol 100mg.

The physical examination revealed in the following: His vital signs were unremarkable for BP 134/74, pulse 70/min and SpO₂ 97%. His statue showed height 163cm, weight 78kg, and BMI 29.4 kg/m². Consciousness, conversation, and general situation were normal. His face, head, neck, heart, lung and abdomen were unremarkable, and neurological exams were intact. He did not complain of any dizziness, neurological abnormalities, chest oppression, dyspnea, or any symptoms of lower extremities.

Several Exams

Recent biochemistry exams were summarized in Table 1, in which liver, renal, lipids and CBC were almost negative without liver function test in April 2024. The chest X-ray revealed negative result. The electrocardiogram (ECG) findings showed slightly ischemic flat T waves in II, V₄, V₅, and V₆(Figure 1). Follow up of ECG would be scheduled, despite no symptoms. Plethysmography was performed in January 2024 [11]. The results showed that ankle brachial pressure index (ABI) values 1.08/1.18 (right/left), and cardio-ankle vascular index (CAVI) 9.3/9.0 (right/left), respectively (Figure 2). Pulse wave velocity (PWV) test revealed unremarkable findings with PEP 81, ET 296, R-AI 0.84, and PEP/ET 0.27. From these, the results of PWV was unremarkable.

Table 1: Changes in biochemistry.

	2024	2025
	Apr	Oct	Units
Liver
AST	42	27	(U/L)
ALT	56	36	(U/L)
GGT	57	35	(U/L)
Renal
UA	5.5	5.7	(mg/dL)
BUN	13	14	(mg/dL)
Cre	0.89	0.91	(mg/dL)
Lipids
HDL	48	47	(mg/dL)
LDL	94	91	(mg/dL)
TG	96	111	(mg/dL)
CBC
WBC	75	79	(x10*2/μL)
RBC	494	484	(x10*4/μL)
Hb	15.5	15.2	(g/dL)
PLT	22.5	22.1	(x10*4/μL)

Figure 1: Electrocardiogram (ECG) findings.

Clinical Progress

On the first contact, he was given sitagliptin for T2D. He was advised to start LCD for the possible degree that he can continue. We proposed three kinds of LCD, including super-LCD, standard-LCD and petite-LCD for the ratio of carbohydrate ratio as 12%, 26%, and 40%, respectively. He chose petite-LCD and could continue for several months.

For the management of oral hypoglycemic agents (OHAs), metformin was added at the first stage. After that, DPP4-i was changed from sitagliptin to Equa (vildagliptin), and then HbA1c showed rapid reduction (Figure 3). Successively, combined OHA of EquMet (vildagliptin/metformin) was continued for several months. His HbA1c showed stable progress from April 2024 to April 2025. During these period, he did not feel or show any signs or symptoms of gastro-intestinal adverse effects (GI-AE). He can tolerate the current treatment of EquMet well, and any other clinical problems were not found until now.

Figure 3: Clinical progress of the case.

Ethical Standards

This article complied with the guideline of Declaration of Helsinki [12]. The principle was accompanied by the ethic regulation for clinical research. The guideline is observed in Japanese Ministry, as Ministry of Education, Culture, Sports, Science Technology (MEXT) and Ministry of Health, Labor and Welfare (MHLW) in Japan. The authors established the ethical committee in our hospital, that included director, doctors, registered nurse, dietician, pharmacist, and legal professional. The members discussed he current protocol and agreed. The informed consent was taken from the patient by the document style.

Discussion

Concerning the current case, clinical problems and characteristic aspects included T2D, obesity, hypertension, hyperuricemia, probable existence of IHD, unremarkable PAD, 36kg weight gain during 20s to 60s. Remarkable weight gain has been known to develop the onset of T2D so far. T2D cases who were newly diagnosed aged ≥30 years were studied (n=2164) [13]. Weight at (20year/max) were 59.9kg/72.9kg and the rate (max_wt) was 0.56+/- 0.50 kg/year. As a result, greater Wt increase and higher rate (max_wt) showed significantly association with earlier age of T2D and higher HbA1c value. Systematic review was conducted (n=15) about T2D risk and weight gain [14]. Weight gain was divided into early age (18-24 years) and late age (after cohort entry). The border of gain was set as 5.0 increment of BMI value. As a result, relative ratio (RR) showed 3.07 for early gain, and 2.12 for late gain. The relationship between weight change and risk of developing T2D was evaluated [15]. A weight increase with >5% increased the T2D risk by more than 60%. On the other hand, a weight loss with >5% reduced the risk by more than 40%. For details, odd ratios (ORs) showed 1.58, 1.76, and 1.70 for 3-, 6-, 9-year follow-ups, respectively in multivariable analysis. Similarly, weight loss ≥ 5% showed 0.48, 0.57, and 0.51 for 3 period follow-ups.

When this patient has changed DPP4-i agent from sitagliptin to vildagliptin, HbA1c has decreased acutely. The difference of both agents showed once or twice administration a day. In the previous study, glucose variability between vildagliptin twice daily vs. sitagliptin once daily were investigated, where the same situation can be found in this case [16]. As a result, vildagliptin twice a day could reduce the mean amplitude of glycemic excursions (MAGE) compared with that of sitagliptin. It seems to be advantageous aspect of Equa and EquMet [17,18]. Furthermore, the case is elderly male, and he continued petite LCD according to his hope. He could eat certain amount of rice at supper, then vildagliptin may suppress the glucose elevation during midnight to morning.

Concerning clinical effect of LCD, various RCT research was performed so far, in which resent report showed impressive findings [19]. From the results, LCD showed improved HbA1c and decreased fasting plasma glucose (FPG) for -0.36% and -10.7 mg/dL, respectively. Moreover, HDL and TG showed significant improvement for +2.49 mg/dL,and -19.9 mg/dL, respectively. From 33 RCTs with 2821 cases, people with daily take <100g of carbohydrate did not show the reduction of fatty mass (FM) [20]. When adults with obesity or overweight limit carbohydrate <50g daily for >1 month duration of ketogenic diet (KD) and LCD, they showed the improvement of all biomarkers including FM. Then, less than 50g of carbohydrate daily would be recommended for the treatment.

Some limitation may exist in this report. It presented only one elderly who had T2D, obesity and other clinical problems. His treatment seems to be satisfactory with LCD continuation and EquMet administration. Probable ischemic ST-T changes in ECG will be followed up with attention, since T2D will bring a variety of impaired function of ASCVD.

In summary, 77-year-old male with obesity, T2D and probable ASCVD with relate perspectives are described. Such T2D cases will be increased, and adequate medical management will be required. This article is expected to become useful clinical data for applicable diabetic care from now on.

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

Funding: There was no funding received for this paper.

Journal of Biomedical Science and Research