Premises: Obesity is a chronic, multifactorial disease associated with multiple comorbidities with relative reduction in quality and life expectancy whose prevalence is constantly increasing. Currently, the obesity treatment is one of the most difficult challenges. Very low calorie ketogenic diet (VLCKD) has recently been proposed as a valid nutritional strategy characterized by a low carbohydrate content (<50 g/day), 1-1,5 g of protein/kg of ideal body weight, 15-30 g of fat per day and a daily caloric intake of approximately 500-800 Kcal. Descritption of case report: This case is about a 49 years old male patient who presented to our hospital with severe obesity associated to glyco-metabolic decompensation. His body weight was 121 kg (BMI 41.4 kg/m2), fasting blood glucose was 149 mg/dl, glycosylated hemoglobin was 10%, triglycerides was 217 mg/dl and LDL cholesterol was 130 mg/dl. His past medical history included arterial hypertension and recent type 2 diabetes mellitus. His therapy included basal insulin, dulaglutide, metformin and ramipril. Diagnostic investigations showed severe hepatic steatosis, severe OSAS and hypertensive heart disease. VLCKD was prescrived. After six months of VLCKD, the patient had reached normal weight (body weight 74 kg and BMI 25.3 kg/m2) and comorbidities were in remission. Specifically, the diabetes was in remission (HbA1c 5.4%) and hepatic steatosis, arterial hypertension and dyslipidemia were no longer present. OSAS were also mild. Patient was not taking any drug therapy. At follow-up one year later, the patient enjoys good health and has healthy lifestyle. Conclusion: VLCKD is effective in achieving rapid and significant weight loss associated with resolution of obesity-related comorbidities through an easily reversible intervention that could be repeated, if necessary. Muscle mass is preserved, hunger and mood are improved through nutritional re-education program. Therefore, in patients with obesity or diabetes mellitus 2, who are adequately selected and highly motivated, VLCKD should be considered as an excellent first-line therapy, to be carried out under close medical supervision. In fact, VLCKD could represent a potential tipping point for the remission of recent onset type 2 diabetes.