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This 1978 JAMA paper by Bruce Bistrian is the canonical clinical introduction of the protein-sparing modified fast (PSMF). PSMF was developed by Bistrian and George Blackburn at Harvard in the early 1970s as a safer alternative to the total-starvation diets that were popular for severe obesity at the time. The protocol replaces calories with high-quality protein — typically around 1.2 to 1.5 grams per kilogram of ideal body weight — plus vitamin and mineral supplementation, allowing the patient to remain in nutritional ketosis while preserving lean body mass much more effectively than a water-only fast. The paper synthesizes the early clinical experience with this approach: rapid weight loss with substantially less muscle loss than total fasts produced, and reasonable tolerability in supervised clinical settings. Bistrian's clinical framework — protein as the spare, total-calorie restriction, supplementation, supervision — is the framework most modern PSMF protocols and protein-led short fasts (including the Sardine Protocol's mechanism) descend from.