Background & aims: Although it is well known dietary factors are closely correlated with bone health, the association between macronutrients intake distribution and bone mineral density (BMD) is still unclear. The aims of this study were to investigate how macronutrients distribution was correlated with BMD, and to evaluate how the substitution between macronutrients could be associated with BMD. Methods: We conducted a cross-sectional study based on data from National Health and Nutrition Examination Survey. Dietary recall method was used to assessed the intake of macronutrients. Macronutrient intake distribution including carbohydrate, protein and fat was calculated as percentages of energy intake from total energy. BMD was converted to T-score and low BMD was defined as T-score less than-1.0. The association between the percentages of energy intake from carbohydrate, protein and fat with T-score and risk of low BMD was evaluated using multivariate regression models. Isocaloric substitution analysis was conducted using the multivariate nutrient density method. Results: Data form 4447 adults aged 20 years and older who underwent BMD examination were included in this study. Higher percentage of energy intake from carbohydrate was associated with lower T-score (-0.03 [95%CI,-0.05 to-0.01]; P = 0.001) and higher risk of low BMD (1.05 [95%CI, 1.02-1.08]; P = 0.003), while higher percentage of energy intake from protein was associated with higher T-score (0.05 [95%CI, 0.01-0.08]; P = 0.009) and lower odds of low BMD (0.92 [95%CI, 0.87-0.98]; P = 0.007). The percentage of energy intake from fat seemed to be positively correlated with T-score, but the correlation became insignificant after adjusting for metabolism related confounders. Isocaloric substitution analysis showed that only the substitution between carbohydrate and protein was significantly and independently associated with T-score (-0.05 [95%CI,-0.08 to-0.01]; P = 0.01) and the risk of low BMD (1.08 [95%CI, 1.02-1.15]; P = 0.008). Conclusions: Based on the results from this study, we hypothesized that a high-protein diet coupled with low carbohydrate intake would be beneficiary for prevention of bone loss in adults. However, randomized clinical trials or longitudinal studies are needed to further assessed our findings. 0 2022 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.