Dr. Adrian Lau, Dr. Rowena Ridout, Dr. Claudia Gagnon, Dr. Zahra Bardai, and Dr. Emma Billington.
Recommendations from Osteoporosis Canada Rapid Response Team.

The Canadian Centre on Substance Use and Addiction (CCSA) recently published “Canada’s Guidance on Alcohol and Health: Final Report” (1). 

The key points from CCSA’s guidelines, published in January 2023, are:

• Among healthy individuals, there is a continuum of risk for alcohol-related harms where the risk is:
  • Negligible to low for individuals who consume two standard drinks (see note) or less per week;
  • Moderate for those who consume between three and six standard drinks per week; and
  • Increasingly high for those who consume more than six standard drinks per week.

The 2023 guidelines are an update to the 2011 “Low-Risk Alcohol Drinking Guidelines” (2), which previously recommended:

• Reduce your long-term health risks by drinking no more than:
  • 10 drinks a week for women, with no more than 2 drinks a day most days
  • 15 drinks a week for men, with no more than 3 drinks a day most days

Osteoporosis Canada’s guidance with regards to alcohol was in line with CCSA’s 2011 guidelines.  It states, “Research shows an increased risk of osteoporosis for those who regularly consume 3 or more alcoholic drinks per day.  Increased alcohol intake also contributes to increased risk for falls and is often associated with poor nutrition.” (3)

This recommendation stemmed from the results of a study by Kanis et. al. in 2005 (4), which analyzed the results of three prospective cohorts, including The Canadian Multicentre Osteoporosis Study (CaMOS).  It observed that there was no significant increase in the risk of osteoporotic or hip fractures when daily alcohol intake was 2 units or less.   At this time, there are no studies available that provide any information on whether lower alcohol intake (2 drinks per week or less), results in a reduced fracture risk.  The Fracture Risk Assessment Tool (FRAX) (5), a commonly used tool in clinical practice endorsed by Osteoporosis Canada (6,7), considers daily alcohol consumption of 3 or more units to be a risk factor for fractures, as its modelling is based on data from Kanis et. al. (4).  

The association between alcohol intake and bone density or osteoporosis is less clear.  A meta-analysis by Godos et. al.(8), showed that consumption of up to two drinks per day was correlated with higher lumbar and femoral neck bone mineral density (BMD) values, while up to one drink was correlated with higher hip BMD compared to no alcohol consumption.  On the other hand, a meta-analysis by Cheraghi et. al. (9) found that those consuming 0.5 to 1 alcoholic beverages per day had 1.38 times the risk of developing osteoporosis, while those consuming 1 to 2 per day had 1.34 times the risk of developing osteoporosis.  Certainly, there are limitations of meta-analyses of observational studies.  As well, BMD alone may not be the best indicator of overall bone health.

Although CCSA’s new guidelines (1) suggest that consuming more than 2 alcoholic drinks per week is associated with an increased risk of alcohol-related consequences, they did not specifically address the amount of alcohol intake that is associated with fractures or other bone-related consequences.  Their research found that 3 to 6 standard drinks per week was associated with an increased risk of several types of cancer, while 7 or more was associated with an increased risk of heart disease or stroke.

Even though an increased risk of fractures was not seen with 2 drinks per day (or 14 drinks per week), we recommend that individuals discuss the new 2023 CCSA recommendations with their physicians, to review their targets on alcohol consumption to reduce the risk of alcohol-related consequences.

Note: In Canada (10), a standard drink is 17.05 millilitres or 13.45 grams of pure alcohol, which is the equivalent of:

·     A bottle of beer (12 oz., 341 ml, 5% alcohol)

·     A bottle of cider (12 oz., 341 ml, 5% alcohol)

·     A glass of wine (5 oz., 142 ml, 12% alcohol)

·     A shot glass of spirits (1.5 oz., 43 ml, 40% alcohol)

References:

1. Paradis, C., Butt, P., Shield, K., Poole, N., Wells, S., Naimi, T., Sherk, A. et. al.  The Low-Risk Alcohol Drinking Guidelines Scientific Expert Panels. (2023). Canada’s Guidance on Alcohol and Health: Final Report. Ottawa, Ont.: Canadian Centre on Substance Use and Addiction.
2. Butt, P., Beirness, D., Gliksman, L., Paradis, C., & Stockwell, T. (2011). Alcohol and health in Canada: A summary of evidence and guidelines for low-risk drinking. Ottawa, Ont.: Canadian Centre on Substance Abuse.
3. https://osteoporosis.ca/risk-factors/
4. Kanis JA, Johansson H, Johnell O, Oden A, De Laet C, Eisman JA, Pols H & Tenenhouse A.  Alcohol intake as a risk factor for fracture.  (2005). Osteoporosis International.  16: 737–742
5. https://frax.shef.ac.uk/FRAX/index.aspx
6. Papaioannou A, Morin S, Cheung AM, et al. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. (2010). CMAJ. 182:1864–73.
7. Lentle B, Cheung AM, Hanley DA, et al. Osteoporosis Canada 2010 Guidelines for the Assessment of Fracture Risk.  (2011). Can Assoc Radiol J. 62(4): 243–250.
8. Godos J, Giampieri F, Chisari E, Micek A, Paladino N, Forbes-Hernández TY, Quiles JL, Battino M, La Vignera S, Musumeci G, et al.  Alcohol Consumption, Bone Mineral Density, and Risk of Osteoporotic Fractures: A Dose–Response Meta-Analysis. (2022). International Journal of Environmental Research and Public Health. 19:1515.
9. Cheraghia Z, Doosti-Iranib A, Almasi-Hashianid A, Baigie V, Mansourniaf N, Etminang M, Mansourniah MA.  The effect of alcohol on osteoporosis: A systematic review and meta-analysis.  (2019). Drug and Alcohol Dependence. 197:197-202.
10. https://www.canada.ca/en/health-canada/services/substance-use/alcohol/low-risk-alcohol-drinking-guidelines.html