PURPOSE OF REVIEW: The Duke Healthy Lifestyles Program (HL), established in 2006, has treated over 15,000 pediatric patients with obesity. A subset of patients with obesity do not respond to dietary and lifestyle changes. Development of the Staged Transitional Eating Plan (STEP) in 2012 provided a ketogenic advanced dietary option for these specific patients. RECENT FINDINGS: The goal of STEP is to facilitate weight loss, while assuring adequacy and the promotion of health through the abundant inclusion of vegetables, fatty fish, nuts, olive oil, and other foods consistent with the Mediterranean Diet. STEP is a three-phase eating plan, each with a defined carbohydrate limit. STEP is ideal for patients eager to try a low carbohydrate diet, those with good vegetable acceptance, and those with families who are able to participate in the same eating plan as them. SUMMARY: STEP, the HL version of low carbohydrate high fat eating, is a safe dietary intervention for a carefully selected subset of pediatric patients with obesity who are trying to lose weight.