Every day brings three insulin injections plus a half-dozen blood tests for 8-year-old Grace Garber, and it’s been that way since before she can remember. The youngest child of Scott and Kristy Garber of rural Marshalltown, Grace has been treated for juvenile diabetes since shortly after her first birthday.

For now, the family’s treatment alternatives are to keep giving her shots or to switch over to a pump that Grace could wear full-time like a fanny pack. But because Grace is part of a rapidly expanding group of people with Type 1 diabetes, research is constant and intense. In the foreseeable future, Grace and the rest might have more options, including islet cell transplants and implanted insulin pumps, or at least might have the option of using inhalable insulin instead of getting shots.

Implantable pumps could be available to the general population of diabetics “within five years,” said Dr. Jennifer Cook at Blank Children’s Hospital. “But we don’t know when the Food and Drug Administration will approve them. There are clinical trials going on now involving adults, and some people in Des Moines are participating,” although they have to travel to Denver or other cities to do so.

Once approved, “they would be used in kids eventually,” said Cook, who has worked as a pediatric endocrinologist at Blank since 1994. In that time, the diabetes caseload has increased dramatically, she said.

Iowans have only two choices for thorough diabetes treatment for children, she said: Blank and the University of Iowa Hospitals and Clinics in Iowa City. “It takes a team to do this,” Cook said. “No one physician can do it alone.”

Diabetes is a disease caused by a lack of naturally produced insulin in the blood. Insulin “acts like a key to let sugar move from the blood into the body’s cells,” said Dan Sleiter, a pediatric nurse practitioner at Blank. For some unknown reason, Type 1 diabetes cases worldwide are skyrocketing worldwide; new cases have increased 5 percent annually for the past 10 years. Such growth translates into about 50 new Type 1 diabetes patients a year at Blank, or about one per week. Because of the increasing caseload, the hospital has offered a position to a second pediatric endocrinologist, hoping to bring that doctor on board next summer.

In addition to the perplexing growth in Type 1 diabetes, Type 2 cases are increasing too. Type 2 diabetes develops over time, and is generally attributed to obesity and a lack of exercise.

“It used to be that 3 percent of our patients were Type 2,” Sleiter said. “Now it’s 10 percent. We get a lot of obesity referrals, where the patient has no endocrine problems but does have elevated insulin levels.

“A lot of families come and don’t hear what they want to hear. We have them see our dietitian, but the families want an easier fix.” In many cases, Sleiter said, medical insurance doesn’t cover visits to a dietitian.

Blank and Mercy Medical Center work together on a project called “Trim Kids,” aimed at teaching overweight children about healthy lifestyles. “They have Saturday meetings at the YMCA,” Sleiter said. “I saw a patient recently, and it was the first time he hadn’t gained weight between appointments. He really talked a lot about Trim Kids.”

Blank also plans to start a “Metabolic Clinic” to handle obesity referrals. It would hold a weekly session and focus on education and initial testing of thyroid function and insulin levels.

The hospital continues to take part in a diabetes prevention study called TrialNet. “We’ve been participating in that for 12 years,” said Sherry Trunnel, a registered nurse who has worked at Blank for 30 years. “Over that time, we’ve screened 500 or 600 people who were at high risk for diabetes” because of a family history of the disease.

In the general U.S. population, Type 1 diabetes occurs in about one of every 400 children. “If a sibling has diabetes, your risk is somewhere between 1 in 12 and 1 in 20,” Trunnel said.

TrialNet is an international study with a goal of screening 200,000 people. “It will take a lot to find enough subjects who are at high risk and also are willing to participate in the trial,” Trunnel said. “A lot of parents do have concerns about giving medication and experimentation involving children.”

Still, the basic treatment for diabetes has remained the same for quite a while. Insulin levels must be regulated with regular injections or with a pump.

However, “treatment is becoming more aggressive,” Trunnel said. “Almost all children are on three or more shots per day.”

Pump technology has improved “significantly” in recent years, she said. “The pump is able to do some math calculations, but you have to enter data throughout the day. Usually, by the age of 9 or 10, a child is able to enter the correct information into the pump.”

Trunnel said inhaled insulin has recently received FDA approval and is coming onto the market now. “It’s not recommended for children yet, but it might happen,” she said.

A huge amount of research is going into islet cell transplants, but that technique is not being used with children yet. “You can get islet cells from cadavers or through stem cell research,” Trunnel said. She called islet transplantation the “best hope” for curing diabetes.