You have been caring for Elena, a 63-year-old accountant of Filipino descent, since she was diagnosed with Type 2 diabetes (T2DM) 10 years ago. She has a family history of osteoporosis and a personal history of Grave's disease, which was successfully treated with radioactive iodine therapy when she was in her early 30s. She now takes levothyroxine (100 mcg daily) together with metformin (1,000 mg BID). She says she has never smoked and drinks a glass of wine or two a day, plus an occasional cocktail on social occasions. She takes a daily multivitamin supplement that includes calcium and vitamin D.

 

Elena used to bike regularly but, after a spill last year that left her with a broken arm, has decided that her biking years are behind her. She would like to take up something like yoga or jazzercise or join a walking group, but hasn't found time in her schedule to make that happen. Her fracture raised concerns about osteoporosis, especially because she remembers her grandmother bent over with spinal osteoporosis and her mother breaking her hip a few years ago at the age of 81.

 

Elena weighs 161 pounds (73 kg) and measures just over 5'2" (158 cm), giving her a BMI of 29.2 kg/m2. Her physical examination is otherwise unremarkable. Labs reveal an A1C of 7.3% (up from 7.1% three months ago), an LDL of 178 mg/dL, an HDL of 34 mg/dL, triglycerides of 256 mg/dL, vitamin D of 30 ng/mL, and a TSH of 2.4 (in the normal range).

 

How would you assess Elena's osteoporotic fracture risk?