A Sociology of Diabetes: Chronic Disease, Institutions, and the Production of Medical Knowledge

Claudia Chaufan

doi:10.20944/preprints202604.0588.v1

Submitted:

07 April 2026

Posted:

09 April 2026

You are already at the latest version

Abstract

This paper proposes a sociological approach to chronic disease using diabetes as an exemplary case. It examines how biological mechanisms, clinical practices, and institutional frameworks are intertwined in shaping how diabetes is defined, studied, and managed. Rather than treating biological and social domains as separate, the analysis emphasizes their mutual embeddedness. Decisions about what counts as evidence, which mechanisms are emphasized, and how uncertainty is interpreted have technical dimensions, but they are also shaped by governance structures, professional norms, and policy contexts. Understanding chronic disease, therefore, requires attention both to biological processes and to the conditions under which these processes are investigated, interpreted, and translated into medical knowledge and practice.

Keywords:

sociology of health

;

chronic disease

;

diabetes

;

medical knowledge

;

governance

;

evidence

;

institutional analysis

Subject:

Social Sciences - Sociology

Introduction: From “Social Determinants” to a “Sociology of Diabetes”

Diabetes is typically discussed as a biomedical condition whose prevalence and outcomes are shaped by social factors such as income, education, and access to care. While acknowledging the role of these factors in the distribution of diabetes—the social epidemiological approach—is a welcome development, such acknowledgments often remain largely descriptive. Social factors, operationalized as social determinants, tend to be treated as contextual variables that modify an otherwise individual disease occurrence, analytically and empirically separable from its broader political ecology.

A sociology of diabetes, by contrast, treats diabetes itself as an embodied, socially organized, and politically shaped phenomenon: a site where knowledge, responsibility, risk, and intervention are produced through clinical practice, institutional arrangements, and political–economic processes. This distinction is not merely semantic. Approaches focused on social determinants, while acknowledging structure and not individualistic in intent, tend to organize explanations through pathways in which social conditions are conceptualized as variables acting upon health outcomes. This orientation is understandable, given the conceptual and methodological difficulty of documenting the non-additive, relational effects through which social processes shape disease. It is precisely here, however, that a sociological approach departs, shifting the analytic focus to how diabetes is understood, governed, and acted upon in particular ways, and how these ways of knowing and acting reproduce patterned social inequalities.

Of note, a sociological perspective need not deny the importance of biomedical advances or high-quality medical care—both of which have dramatically transformed the prognosis and lived realities of diabetes. Nor does it need to deny the clinical effectiveness of behavioural and lifestyle interventions, which have been transformative for some individuals. The sociological critique developed here is therefore not directed at biomedicine, nor at the clinical use of lifestyle approaches, but at their elevation into dominant explanatory and policy frameworks. It therefore interrogates how biomedical knowledge, including behavioural approaches, is mobilized and translated into dominant explanations of diabetes and its management at the population level.

An important clarification concerns the heterogeneity of diabetes itself. Type 1 diabetes is an autoimmune condition with no known behavioural triggers; its management depends on access to insulin, technologies for glucose monitoring, and intensive self-care aimed at matching insulin delivery to physiological needs. Type 2 diabetes, by contrast, is the form of diabetes whose incidence and distribution are strongly socially patterned, and whose dominant explanations and prevention strategies are most often framed in behavioural and lifestyle terms. While both forms of diabetes require substantial patient self-management, the sociological analysis of risk, responsibility, and prevention developed in this entry applies primarily to Type 2 diabetes, the only form for which diabetes has been widely constructed as preventable through individual behaviour modification and lifestyle changes.

Drawing on classic work in medical sociology on medicalization, social control, and the political economy of health, as well as related fields, including early formulations of the political ecology of disease, this entry situates diabetes within broader political–economic and ecological processes shaping chronic disease. It examines diabetes across interconnected levels of analysis, considering how risk and responsibility are constructed in everyday clinical encounters (micro level), how institutional and professional practices delimit what counts as feasible intervention (mezzo level), and how broader political–economic arrangements and governance structures shape dominant explanations of diabetes and its distribution (macro level). Taken together, these processes position diabetes as a paradigmatic case for understanding the social production and governance of chronic disease in contemporary societies.

Toward a Sociological Framework for Diabetes

The Clinical Encounter and the Micro-Politics of Responsibility

The clinical encounter represents a key micro-level site where broader discourses of individual responsibility are enacted and reproduced (Waitzkin, 1989). Sociological studies of diabetes care show that interactions between patients and clinicians are shaped not only by biomedical imperatives but also by moral and cultural expectations surrounding self-management.

In diabetes care, clinicians routinely emphasize patient responsibility, often framing outcomes as contingent on adherence to prescribed regimens. Empirical research in diabetes clinics demonstrates how this dynamic can lead individuals to internalize expectations for outcomes that are structurally constrained. Patients may attribute difficulties in disease management to personal failure rather than to social or institutional barriers, engaging in self-blame that obscures the broader conditions shaping their care (Chaufan et al., 2015). This internalization is not simply a psychological response but a socially produced outcome of dominant care models that prioritize individual self-management. Even when clinicians recognize structural barriers—such as language, work schedules, or limited access to resources—these barriers are frequently treated as background conditions rather than as targets of intervention. As a result, the burden of navigating these constraints is implicitly shifted onto patients themselves.

In response to the individualizing dynamics of responsibility that characterize clinical encounters, the concept of patient empowerment has emerged as a significant and, in many respects, progressive reorientation of diabetes care. Developed in explicit critique of paternalistic medical models, empowerment frameworks emphasize patient agency, shared decision-making, and the legitimacy of patients’ experiential knowledge in managing a complex chronic condition (Anderson, 1995). In clinical practice, these approaches have often improved communication, enhanced patients’ sense of control, and fostered more collaborative forms of care. From a sociological perspective, however, empowerment also warrants critical scrutiny. When abstracted from the social conditions shaping patients’ lives, empowerment risks reframing structurally constrained choices as matters of individual will, capacity, motivation, or even autonomy, thereby obscuring the social and political conditions under which autonomy can be exercised. In contexts marked by socioeconomic disadvantage, unstable work conditions, food insecurity, or limited access to care, the language of empowerment may inadvertently intensify expectations of responsibility and autonomy without expanding the material conditions necessary for their exercise. Thus, while empowerment represents an important corrective to passive models of patienthood, it may also participate—albeit unintentionally—in the individualization of responsibility that characterizes contemporary approaches to chronic disease management.

From a sociological standpoint, the clinical encounter thus functions as a site of micro-politics, where structural inequalities are translated into individualized narratives of responsibility. This process helps explain why diabetes is so often experienced as a personal burden, even among individuals who are acutely aware of the social conditions affecting their health. By focusing analytic attention on the interactional production of responsibility, a sociology of diabetes moves beyond accounts of “patient experience” that abstract feelings and perceptions from the institutional contexts in which they arise.

Institutions and the Mezzo Level of Diabetes Care

Between individual clinical encounters and broader political–economic structures lies a critical mezzo level: the institutional organization of diabetes care and the professional discourses that shape what is considered feasible, legitimate, or actionable. Sociological analyses at this level focus not on individual intentions or motivations, but on how organizational routines, professional norms, and institutional imperatives structure responses to diabetes and delimit the scope of medical action.

Health care institutions, governments, and international agencies increasingly acknowledge that social and economic conditions shape health outcomes (Commission on Social Determinants of Health, 2008), including diabetes. Clinicians may recognize that people with diabetes face barriers related to work schedules, income insecurity, housing conditions, or food access. However, institutional frameworks typically lack mechanisms to translate this recognition into meaningful structural intervention. As a result, social conditions are acknowledged rhetorically but remain external to the formal domain of medical action.

This institutional pattern has important consequences. Professional roles in diabetes care are largely defined around biomedical management and behavioural counselling, reinforcing a practical division between what is considered “medical” and what is designated as “social.” Structural determinants may be acknowledged, but responsibility for addressing them is either displaced onto patients or deferred to other sectors beyond the reach of clinical practice.

From a sociological perspective, this configuration should not be understood as a failure of individual practitioners, nor as evidence that medicine ought to assume responsibility for remaking the social world. In fact, the medicalization tradition within the sociology of health classic has long drawn attention to the problematic implications for individual autonomy of medicine’s tendency to extend its authority into social, cultural, moral, legal, and political domains under the guise of technical expertise (Zola, 1975). The issue, therefore, is not that medicine fails to govern or influence the social, but that it operates within an enduring tension: while the social production of disease is increasingly recognized, the institutional scope of medical action remains limited. At the mezzo level, this tension is managed through institutional logics that translate social problems into individualized responsibilities, thereby delimiting professional jurisdiction while reproducing individualizing explanations of disease. The result is a form of diabetes care that is highly developed in technical terms yet constrained in its reach, capable of managing disease within existing arrangements while leaving broader structures of inequality largely beyond its remit.

Risk, Responsibility, and the Distribution of Diabetes in the Population

Central to the sociological analysis of diabetes is the concept of risk. In dominant biomedical and public health discourse, diabetes risk is most often framed in behavioural terms: diet, physical activity, body weight, and adherence to treatment regimens. Even when social gradients in the distribution of diabetes are acknowledged, risk is typically translated into strategies aimed at modifying individual behaviour—sometimes at a population scale through health promotion and prevention programs promoted by governments (Government of Canada, 2020) and international agencies (World Health Organization, 2024). While such initiatives may offer practical benefits and are not without value, they nonetheless reinforce the idea that diabetes risk is primarily a matter of personal choice and self-regulation.

From a sociological perspective, this framing operates by translating structurally produced risks into matters of individual action. Social and economic conditions are rendered relevant only insofar as they can be acted upon through personal behaviour, such as dietary choices, physical activity, or adherence to self-management regimes. While such frameworks may be clinically useful and, for some individuals, facilitate meaningful improvements in health and reduced reliance on pharmacotherapy, they can obscure the structural constraints under which lifestyles are adopted. In doing so, they shift responsibility for the emergence and subsequent management of diabetes onto individuals and may inadvertently reproduce forms of moral attribution long identified by sociologists as “blaming the victim” (Ryan, 1976), while leaving the social organization of risk largely intact.

This transformation of risk prevention into a moral obligation has been a central concern of medical sociologists analyzing chronic disease. Classic analyses of medicalization have shown how the expansion of medical jurisdiction is accompanied by heightened expectations of self-surveillance and self-regulation (Conrad, 1979; Lupton, 1993). In diabetes, these expectations are intensified by the condition’s chronicity and the centrality of ongoing self-care. Risk prevention thus becomes not only a probabilistic assessment but also a moralized metric through which individuals are evaluated—as responsible or irresponsible, compliant or noncompliant, adherent or non adherent.

Importantly, the behavioural framing of diabetes risk persists despite substantial evidence that diabetes incidence and prevalence are strongly patterned by socioeconomic position, labour conditions, food systems, policy environments, and intergenerational processes that operate at the level of biology from conception onward—processes that are themselves socially patterned and historically shaped (Benyshek et al., 2001) and that will be taken up more fully in the following section. Sociological analyses suggest that this disjunction is not accidental, but reflects broader political–economic arrangements that privilege individualized intervention over collective reorganization. By locating responsibility for diabetes prevention primarily at the level of personal behaviour, dominant approaches narrow the public imagination, rendering alternative ways of organizing social life, work, and provision largely invisible, while deflecting attention from the upstream conditions through which risk is systematically produced.

Political Economy, Embodiment, and the Social Production of Diabetes

At the macro level, a sociology of diabetes situates the disease within broader political–economic arrangements that shape patterns of exposure, vulnerability, and access to care. Diabetes prevalence and outcomes are not randomly distributed; they are systematically patterned by what sociological scholarship has conceptualized as fundamental social causes—enduring social conditions that structure access to resources such as income, power, knowledge, and security, and that continue to generate health inequalities even as specific risk factors or treatments change (Link & Phelan, 1995). These patterns reflect the unequal organization of material and ideological resources organised along multiple axes—class, race, gender and the like—and structured by political arrangements that can sharply constrain popular influence over policy, even under formally democratic institutions, thereby constraining collective capacity to alter the conditions that generate unequal disease burdens in the first place (Navarro, 2003).

Sociological and political–economic (or political-ecologic) analyses emphasize that such inequalities are not merely external influences on otherwise biological disease. Rather, they enter into the production of disease itself, through processes of embodiment that unfold over time and across settings (Turshen, 1977). What is often named “risk” is therefore not a property of isolated bodies or individual behaviours, but a patterned exposure to material deprivation, constrained living conditions, chronic stress, and unequal access to protective resources—exposures that become biologically consequential. In this light, the causal question is not whether diabetes is “social” or “biological,” but how social organization “gets under the skin,” expressing itself in patterned differences in diabetes risk and distribution across populations.

Importantly, the social production of diabetes also operates across generations. Early-life environments—including conditions shaping fetal development—can produce lasting physiological effects that alter susceptibility to metabolic dysregulation later in life. These processes are not merely “biological” in the narrow sense, because the conditions that shape early development are themselves socially patterned and historically structured. The intergenerational dimension of diabetes risk thus reinforces the core sociological point: what appears as individual pathology often reflects accumulated and transmitted exposure to unequal conditions, beginning as early as conception (Benyshek et al., 2001).

A sociology of diabetes must also address the recurring tendency to translate socially patterned disease into genetic explanation. This does not require denying genetic—often wrongly conflated with biological—variation. Rather, it requires clarity about what genetic claims can and cannot mean for complex disorders. A foundational problem, articulated in classic critiques of genetic explanation, lies in the conflation of analysis of variance with analysis of causes. However, statistical partitioning of variation within a population does not identify causal processes in individuals, nor does it justify reifying “genes”—whether single loci or aggregated into polygenic profiles—and “environment” as separable, additive contributors to disease. As Lewontin argued, phenotypes, including disease phenotypes, are not merely the product of genotypes and environments, but of relations between these and developmental processes, including contingent biological processes internal to development itself, that unfold across sequences of environments as these relations are realized over time (Lewontin, 1974).

Contemporary diabetes genetics frequently reproduces the same conceptual slippage through heritability language. But heritability is not a measure of “how much of diabetes is genetic”: it is a population-specific ratio of variances, contingent on the genetic composition of the sample and the range and sequence of environments in which variation is measured. It follows that heritability estimates are intrinsically local and can shift as either genetic variability or environmental variability shifts—without any change in what causes diabetes in any particular person (Chaufan & Joseph, 2013). This is why genetic framings can be both technically elaborate and causally thin: they offer a vocabulary for attributing disease to “genetic contribution” while leaving the developmental and political–economic production of relevant environments analytically under-specified.

The sociological point, then, is not that genetics or behaviours are irrelevant, but that the processes through which diabetes develops, is managed, and is reproduced cannot be understood apart from the historically organised environments within which bodies develop over time. Yet despite this evidence, dominant diabetes prevention strategies continue to prioritize behaviour modification—often framed as physiologically rational, cost-effective, or politically neutral—and investments in genetic research whose social benefits remain uncertain. From a sociological standpoint, the prominence of these approaches reflects broader policy orientations that favour framing inequalities in behavioural and genetic terms—thereby rendering them, at least in appearance, technically tractable—over approaches aimed at transforming the social conditions that shape exposure, vulnerability, and bodily development. The persistence of behavioural and genetic framings thus contributes to the depoliticization of diabetes, rendering its social production less visible, less contestable, and less amenable to collective action.

Governance and the Organization of Diabetes Discourse

Beyond health care institutions, diabetes is governed through a complex network of advocacy organizations, public health agencies, and policy actors that shape how the disease is publicly understood. These actors play a central role in defining priorities, mobilizing resources, and delimiting the range of solutions considered appropriate or feasible.

Sociological analyses of governance draw attention to how advocacy and nonprofit organizations can simultaneously raise awareness of diabetes while reinforcing individualizing narratives (Chaufan & Saliba, 2019). Campaigns that emphasize personal responsibility, self-care, and “healthy choices” often coexist with acknowledgments of social inequality; however, these acknowledgments are frequently articulated in ways that do not disrupt prevailing assumptions about individual responsibility or challenge underlying political–economic arrangements. From a sociological perspective, the ideological work of these forms of diabetes governance lies in how they translate structural determinants into diffuse background conditions, while localizing responsibility for prevention and management at the level of individual behaviour. In this sense, diabetes governance operates as a form of social regulation. Through policy discourse, advocacy practices, and public health messaging, populations are organized around norms of risk management, self-monitoring, and self-discipline, while the range of interventions deemed legitimate is narrowed. Interventions that act upon individuals are privileged over those that would alter the social organization of risk itself. Diabetes is thus governed not only as a clinical condition but also as a political object, through discursive and institutional arrangements that shape how responsibility, prevention, and collective possibility are imagined.

Conclusions: Diabetes and the Contribution of Medical Sociology

Taken together, these analyses show why diabetes constitutes a particularly revealing case for medical sociology. As a chronic condition requiring continuous monitoring, treatment, and self-management, diabetes concentrates key sociological processes—medicalization, self-surveillance, moral evaluation, and governance—into everyday practice. At the same time, its pronounced social patterning exposes the limits of explanations and interventions that locate causality primarily at the level of individual behaviour or genetics.

A sociology of diabetes demonstrates that disease management is not simply a technical or clinical undertaking but a socially organized process shaped by power, institutions, and ideology. Clinical encounters, organizational routines, and public discourses interact to produce responsibility, normalize particular forms of conduct, and delimit what counts as legitimate intervention. These dynamics help explain why diabetes inequalities persist despite substantial advances in biomedical knowledge and treatment.

By approaching diabetes not only as a disease influenced by social factors, but as a socially constituted field of practice and meaning, medical sociology offers analytic tools for understanding the broader governance of chronic illness in contemporary societies. In this sense, diabetes illuminates how health inequalities are reproduced through ordinary institutional arrangements, and why addressing them requires attention to the political and organizational conditions under which bodies, risks, and responsibilities are produced.

References

Anderson, R. M. Patient Empowerment and the Traditional Medical Model: A case of irreconcilable differences? Diabetes Care 1995, 18(3), 412–415. [Google Scholar] [CrossRef] [PubMed]
Benyshek, D. C.; Martin, J. F.; Johnston, C. S. A Reconsideration of the Origins of the Type 2 Diabetes Epidemic among Native Americans and the Implications for Intervention Policy. Medical Anthropology 2001, 20, 25–64. [Google Scholar] [CrossRef] [PubMed]
Chaufan, C.; Fielding, H.; Chesla, C.; Fernandez, A. “It’s Not the Doctor – It’s Me”: How Self-Blame Obscures Language and Other Structural Barriers to Diabetes Care among Low-Income Latinos with Limited English Proficiency. In Education, Social Factors, and Health Beliefs in Health and Health Care Services; Emerald Group Publishing Limited, 2015; Vol. 33, pp. 187–208. [Google Scholar] [CrossRef]
Chaufan, C.; Joseph, J. The ‘missing heritability’ of common disorders: Should health researchers care? International Journal of Health Services 2013, 43(2), 281–303. [Google Scholar] [CrossRef]
Chaufan, C.; Saliba, D. The global diabetes epidemic and the nonprofit state corporate complex: Equity implications of discourses, research agendas, and policy recommendations of diabetes nonprofit organizations. Social Science & Medicine (1982) 2019, 223, 77–88. [Google Scholar] [CrossRef]
Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health—Executive Summary; World Health Organization, 2008; Available online: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf.
Conrad, P. Types of medical social control. Sociology of Health & Illness 1979, 1(1), 1–11. [Google Scholar] [CrossRef] [PubMed]
Government of Canada. Physical activity and healthy eating; Canada Food Guide, 29 June 2020; Available online: https://food-guide.canada.ca/en/tips-for-healthy-eating/physical-activity-healthy-eating/.
Lewontin, R. C. Annotation: The Analysis of Variance and the Analysis of Causes. American Journal of Human Genetics 1974, 26, 400–411. [Google Scholar] [PubMed]
Link, B.; Phelan, J. Social Conditions As Fundamental Causes of Disease. Journal of Health and Social Behavior 1995, 35, 80–94. [Google Scholar] [CrossRef]
Lupton, D. Risk as moral danger: The social and political functions of risk discourse in public health. International Journal of Health Services: Planning, Administration, Evaluation 1993, 23(3), 425–435. [Google Scholar] [CrossRef] [PubMed]
Navarro, V. Policy without politics: The limits of social engineering. American Journal of Public Health 2003, 93(1), 64–67. [Google Scholar] [CrossRef] [PubMed] [PubMed Central]
Ryan, W. Blaming the victim; Random House, Inc, 1976. [Google Scholar]
Turshen, M. The Political Ecology of Disease. Review of Radical Political Economics 1977, 9(1), 45–60. [Google Scholar] [CrossRef] [PubMed]
Waitzkin, H. A Critical Theory of Medical Discourse: Ideology, Social Control, and the Processing of Social Context in Medical Encounters. Journal of Health and Social Behavior 1989, 30(2), 220. [Google Scholar] [CrossRef] [PubMed]
World Health Organization. Promote healthy diets, physical activity: WHO. 18 September 2024. Available online: https://www.who.int/southeastasia/news/detail/18-09-2024-promote-healthy-diets-physical-activity-who.
Zola, I. K. In the name of health and illness: On some socio-political consequences of medical influence. Social Science & Medicine 1975, 9, 83–87. Available online: https://pubmed.ncbi.nlm.nih.gov/1129602/.

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

© 2026 by the author. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).

Copyright: This open access article is published under a Creative Commons CC BY 4.0 license, which permit the free download, distribution, and reuse, provided that the author and preprint are cited in any reuse.