The rising prevalence of youth-onset type 2 diabetes (T2D) in children necessitates early intervention with tight glycemic control, obesity medications, and metabolic and bariatric surgery (MBS). Insulin and metformin are standard treatments, but additional therapies for obesity in youth are needed. A 4-year-old Hispanic female with early-onset obesity and newly diagnosed T2D presented with a hemoglobin A1c (HbA1c) level of 8.0% (reference: < 5.7%), a fasting glucose of 147 mg/dL (SI units: 8.17 mmol/L) (reference: 70-115 mg/dL [3.33-6.39 mmol/L]), and a body mass index (BMI) of 41 kg/m². She had rapid weight gain and hyperphagia. Initially, insulin therapy was started, and her HbA1c decreased to 6.7% over 6 months. Insulin was discontinued and metformin 1000 mg twice daily was started. Topiramate 75 mg nightly was prescribed for obesity with minimal effect and so semaglutide was started and titrated to 2 mg weekly. By 27 months, her HbA1c improved to 5.1%, and overall, she had a 12% reduction in her percent above the 95th percentile (%BMI; BMI 41 kg/m²→35 kg/m²; %BMI= 205%→190%). This case underscores the importance of a multi-modal approach to managing pediatric T2D and obesity and highlights the effectiveness of semaglutide in improving both obesity and glycemic control.