The Simplest Way to Start a Ketogenic Diet (And Why It Actually Matters)

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Most people think a keto diet is about bacon obsession and butter in your coffee. I get it. The internet has made this whole thing way more complicated than it needs to be. But what I see every day in my clinic is something different — people reversing diabetes, getting off blood pressure meds, watching their brain fog disappear, and losing weight they'd been fighting for years. All from changing what they eat.

So here's the thing: I'm not going to sell you on some trendy diet. I'm going to walk you through what the research actually shows, how I use this therapeutically with my patients, and the dead-simple approach that makes it actually doable.

Why Keto? The Short Version

When I talk about a ketogenic diet, I'm really talking about one thing: getting your body to run on a different fuel source. Your body can burn sugar or it can burn fat. Most people's bodies have been running on sugar for so long that they've sort of forgotten how to burn fat. We call this being metabolically inflexible.

When you restrict carbohydrates enough, your liver starts producing something called ketones from fat. And it turns out ketones are kind of incredible. They're anti-inflammatory. They're a cleaner fuel for your brain. And the process of generating them means your body is actually burning through stored fat.

So we're not just talking about weight loss — though that happens. We're talking about reducing inflammation, improving energy production, and giving your brain fuel it actually prefers.

The Page Four Diet: Three Rules, No Counting

I use a specific approach in my clinic that comes from Dr. Eric Westman at Duke University. He's been doing research into low-carb diets for over 25 years. He runs the keto clinic at Duke, and his whole thing is reversing diabetes and high blood pressure. The surgeons at Duke literally send him their sickest patients — the ones who are too obese or too metabolically unhealthy for surgery — and say, "Fix them so we can operate." And he does.

He came up with something called the Page Four Diet. It's on page four of his book, and it's the most dead-simple diet you can come up with. Three rules:

Rule 1: If you're hungry, eat meat and eggs. Protein and fat. That's your foundation.

Rule 2: You get two cups of leafy greens every day — spinach, lettuce, mixed greens, whatever you like.

Rule 3: You get one cup of non-starchy vegetables every day — things like onions, bell peppers, zucchini, broccoli, Brussels sprouts.

That's it. No carb counting. No macros. No apps. If you follow those three rules strictly, you'll never break 20 grams of total carbohydrates in a day. And 20 grams of total carbs is the target.

Now, one thing I'm firm on that differs from some internet keto advice: I count total carbs, not net carbs. A lot of the internet keto guys will tell you to subtract your dietary fiber from the total. I say no. Total carbs are total carbs. But on the Page Four Diet, you don't even have to think about it — the math just works if you follow the rules.

What's NOT on the List

Let me be direct. There is no bread, pasta, rice, or grain of any kind on this diet. No fruit either — at least not while we're in the therapeutic phase. No potatoes, no tortillas, no oatmeal. Period.

But here's the thing — you don't have to give up your life. I'll use myself as an example. I go to the little food truck across from my clinic and get tacos. I just dump out all the filling — eggs, bacon, cheese, sausage — eat all of it, and leave the tortilla behind. I don't have to give up my breakfast taco. I just give up the taco part.

A little bit of cream and cheese in your world is fine. Butter on your vegetables? Please put butter on your vegetables. Coffee? I don't care. Just not a frappuccino. Get an americano with some heavy cream, no sweetener. Or use stevia if you want something sweet. If you're craving something sweet, a few bites of keto ice cream are fine — get your hit and move on. Then go back to eating your meat and eggs.

Two Flavors of Keto

There are two versions of a ketogenic diet out there. The first is what Dr. Westman uses — protein-heavy, where you eat plenty of protein, keep carbs under 20, and whatever fat comes along with your food is fine. I don't set fat goals for my patients. I set carb limits and protein targets.

The second is the internet version — extremely high fat, moderate to low protein, where people are taking in 70 to 80 percent of their calories from fat. There are benefits to driving ketone levels higher for therapeutic use — seizures, serious autoimmune conditions — but for weight loss and metabolic health? The protein-heavy version works just as well. And it's something you can actually live with.

The Sodium Problem (Why "Keto Flu" Isn't Real)

Here's where most people crash and burn, and it has nothing to do with willpower. It has to do with salt.

When you go low-carb, your insulin levels drop. That's the whole point. But insulin does more than just manage blood sugar — it also tells your kidneys to hold on to sodium. Less insulin means you start dumping sodium. Fast.

What people call "keto flu" — the headaches, the fatigue, feeling like you're going to pass out, brain fog, legs feeling like bricks — that's not your body rejecting the diet. That's a sodium problem. Every time a patient comes in telling me they feel terrible on low-carb, I say one word: salt. And they come back a week later and say, "Yep. That was it."

Your goal when eating low-carb is four to six grams of sodium per day. For reference, one LMNT packet has one gram of sodium. A full teaspoon of salt has 2.3 grams. I'll be transparent — I've been on a carnivore diet for four years. If I go on a long run, I'll take eight LMNT packs in a day on top of what I eat. That's over 10 grams of sodium on heavy workout days. It's what keeps me functional.

If you don't want to spend money on LMNT, just use Celtic salt or any good salt. Half a teaspoon in eight to ten ounces of water, down the hatch. That gets you a little over a gram of sodium. Do that a few times a day and you're in good shape.

What This Does to Your Brain

This is the part that honestly excites me the most, and it's personal. I have ADHD. My brain works better on ketones. It just does. And I'm not the only one seeing this.

There's an entire new field emerging within psychiatry called metabolic psychiatry. Researchers at places like Oxford, Harvard, and a group called Metabolic Mind — privately funded by the Baszucki Foundation with no pharmaceutical influence — are doing incredible work showing what ketones do for the brain.

The running theory is straightforward: ketones are a better and cleaner fuel for your brain than sugar. The ketones themselves also carry an anti-inflammatory effect that helps with neuroinflammation.

This traces back to the 1920s, when the original keto diet was developed for epilepsy. They could stop seizures with an 80 to 90 percent success rate just by changing what people ate. The diet was miserable — but it worked.

The breakthrough that launched metabolic psychiatry was when researchers took patients with schizophrenia and schizoaffective disorder — the two psychiatric diseases we've always believed meant something was fundamentally broken in the brain — put them on a ketogenic diet, pulled them off all their medications, and watched all their paranoia, hallucinations, and delusions disappear. Then they refed them carbohydrates and watched everything come back. In medicine, that's one of those "what the heck just happened" moments.

The research now covers ADHD, depression, anxiety, bipolar disorder — the whole spectrum. Studies on ADHD showed roughly 80 to 90 percent of patients had clinically relevant symptomatic improvement, and about half to 70 percent actually met criteria for remission. Not just better — no longer classifiable as ADHD.

I'll tell you my own story. Six years ago, I was 300 pounds. I started a carnivore diet and the weight came off. But what shocked me was my ADHD essentially disappeared. My brain just works on ketones. When I eat carbs, I can feel the difference — I can tolerate them after a hard workout when my muscles are begging for glycogen, but I can't sit around eating them all day. My brain won't cooperate.

The Honest Timeline

When patients ask me how long this takes, I give them the real answer: plan for six months.

What we're really doing underneath the surface is retraining your mitochondria — the little power generators inside your cells that make energy. Right now, if you're insulin resistant, your mitochondria are stuck in sugar-burning mode. They've sort of forgotten how to burn fat. The whole purpose of this diet is to teach them to be metabolically flexible again — meaning if we feed you sugar, you can burn it, and if we feed you fat, you can burn it.

That process takes about six months. That's where people see most of their weight loss and body composition change — within that first six months out to a year.

To give you context on how fast the metabolic piece moves: Dr. Westman's general rule for his diabetic patients is to cut their diabetes medication in half on day one. Day one. He can't do anything less than half because he's seen patients bottom out their blood sugars. But within the first 48 hours, your insulin numbers are dropping significantly.

This Isn't Forever

I'm not sold on keto being the best diet forever. But I am sold on the fact that it's one of the most powerful interventions we have for weight loss, inflammation, and mental health.

For a time — as we repair your metabolism — it's probably the best approach we know of. But the goal is metabolic flexibility. Once we get you there, we can expand your carbohydrate intake. My wife went through a sourdough-making phase. I ate sourdough two or three times a day. Never gained weight. Just didn't feel as sharp. I stay low-carb because my brain works better and I physically feel better. That's a personal choice. Your experience will be your own.

Getting Started: The Practical Stuff

If you're ready to try this, here's what I tell my patients:

Protein target: Take your goal body weight in pounds — that's your daily protein goal in grams. A good whey protein isolate can help you get there — look for one with close to 30 grams per scoop.

Carb limit: 20 grams total per day. Follow the Page Four Diet and you'll hit this without counting.

Fat: Whatever comes with your food is fine. I don't set fat goals.

Salt: Four to six grams of sodium daily. Non-negotiable.

Give it 90 days. Be strict. After that, we'll have a real conversation about where you are.

Here's the bottom line: I use this diet therapeutically in my clinic every single day. I've watched a 63-year-old woman with early-onset dementia walk in barely able to string five words together, on three blood pressure meds and three diabetes meds. Six months on this diet — no meds. No blood pressure meds, no diabetes meds, nothing. Speaking to me like nothing was ever wrong. Her diet fixed her dementia, hypertension, and diabetes in six months.

That's not a sales pitch. That's what I see in my practice. And it starts with three simple rules.

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Matt Altman is a Family Nurse Practitioner and the founder of Rooted Health Clinic in Harker Heights, Texas. He specializes in functional and root-cause medicine with a focus on metabolic health, hormone optimization, and therapeutic nutrition.