Obesity is a common and preventable Non-Communicable Disease (NCD) of great clinical importance and public health concern. 12 Obesity raises the risk of developing diseases such as coronary heart disease, diabetes, cancer, self-esteem, and emotional well-being. 345 Obesity also affects the health system and contributes to low productivity and economic loss. 67 In 2019, The United Arab Emirates Ministry of Health and Prevention (MOHAP) reported marked improvements in adult obesity prevalence (37.2% in 2010 to 27.8% in 2019); however, the burden of associated disease and its impact on healthcare services, healthy life expectancy, and economic productivity remains an ongoing concern. 8910 To address the health and societal costs associated with obesity, several countries have adopted a Sugar-Sweetened Beverage (SSB) tax; however, policy development and implementation approaches vary, creating complexity in adopting best practice contextually.11 In 2017, the UAE announced an excise sugar tax to reduce unhealthy consumption and harmful commodities to the environment and was fully implemented in 2019.12 The 'Logical Pathway' framework provides insight on the process and expected outcomes from SSB taxation. However, the pathway remains challenging to implement due to the unpredictability of the price pass on rates, price elasticity across different SSB products, substitution effect and lack of evidence on its effectiveness to reduce obesity prevalence (figure 1). 1314 The rationale for taxation stems from the evidence that food and drink contribute to child and adult obesity and are price elastic products; thus, taxation can impact unhealthy consumption levels.1516 Taxation (pigouvian tax) is also seen as favourable and necessary to correct the adverse health effects of unhealthy consumption and is a revenue source for developing and implementing healthier alternatives. 17 Studies have reported associations between different demographic factors and SSB consumption, but little is known about SSB behaviors in the United Arab Emirates (UAE). 18192021 SSB consumption by age and gender are key factors for research because consumption and calorific needs vary by age and gender. 22 On average, men require 600-800 more calories than women at the age of 18 years, at all activity levels (sedentary, moderately active, and active), and the difference between calorific intake by gender narrows as age increases. 23 Our Null Hypothesis (H₀) was a) Gender, Age and Nationality does not affect SSB consumption since the introduction of SSB tax and, b) Gender, Age or Nationality does not affect SSB consumption during Covid-19 lockdown. Our objectives were to 1) explore the associations between age, gender, nationality and change in SSB consumption, 2) explore SSB consumption during Covid-19 lockdown, and 3) inform policy decision making.

Our study provides new insight on the association between key demographic factors (gender, age, and nationality) and SSB consumption in the UAE. The data analysis suggests that changes in SSB consumption were not statistically significant since the introduction of the SSB tax. The percentage of sugar consumed per day from SSB indicates a statistical significance by nationality (P-value <0.001). Several factors may explain this finding. Approximately 88.53% of the UAE population are non-Emirati derived from over 200 nationalities, and tourism has been steadily rising; for example, Dubai was ranked sixth globally on the tourism index with 16.73 million visitors in 2019 and with this, an increasing need to cater for a variety of dietary needs. 3839 Studies have also highlighted higher consumption patterns among high-income countries compared to low-income countries. 40 High-income countries generally consume more sugary drinks due to greater SSB availability, a higher proportion of disposable income and purchasing power. 40 Also, the prevalence of obesity is known to be high among expats. 41

Some studies have explored the impact of taxation on SSB. Colchero et al. estimated changes in sugar-sweetened beverages (SSB) sales and plain water after a 1 peso per litre excise SSB tax were implemented in Mexico in January 2014. 42 The authors report a 7.3% decrease in SSB sales and a 5.2% increase in water sales but highlighted that change should be evaluated over the longer term. Sliver et al. examined the association of the first penny per ounce SSB excise tax in the United States, in Berkeley, California, with beverage prices, sales, store revenue/consumer spending, and usual beverage intake. 43 The authors report a price increase (but not across all settings), sales declined, and sales in untaxed products (especially water) rose. There was no overall spend per transaction and no significant self-reported SSB change from baseline. The findings from these two studies (Colchero et al. and Sliver et al.) and our findings suggest that SSB tax may promote healthier behaviours, but change may not be statistically significant or long term. The reasons for this might extend to the substitution effect, promotional offers, introduction of new products into the market or effect of technologies such as the growth of mobile platforms. Thus, decision-makers may need to account for market responses during policymaking because these responses may hinder the desired change or dilute the intended impact of policy. We found no significant change in SSB consumption following the implementation of SSB tax and therefore accept our Null Hypothesis.

The study explored SSB consumption during Covid-19 lockdown. The number of respondents who reported consuming less SSB during the Covid-19 lockdown was slightly higher than those that reported no change (574 vs 537, respectively). It is plausible that the lockdown may have restricted the temptation for SSB, led to the prioritisation of beverages, or created a false impression of price elasticity among respondents. While research on SSB during Covid-19 lockdown is limited, there is evidence to suggest restricting access and availability of SSB in school and the workplace may lead to substitution or reduction in consumption. 4445 We found no significant difference in SSB consumption during Covid-19 lockdown between the ‘yes’ and ‘no’ responses and therefore accept our Null Hypothesis. However, our findings from the group that reported ‘yes’ suggest a positive change within the group.

The study does not explore the nature of SSB taxation or its impact on obesity and health outcomes, however; the logical pathway remains relevant as a framework for understanding SSB taxation. There are challenges in implementing the framework due to a lack of consensus on the policy approach and a lack of standardised tools to quantify consumption. This means consumption may vary considerably among individuals or, indeed, population groups. Consumption may be inappropriately estimated due to insufficient knowledge or recall bias, and respondents may find it difficult to quantify their sugar consumption between food and drink. Thus the need to develop validated research tools to quantify consumption more accurately. This would provide greater insight on the effects of SSB tax within population groups and at scale. Additionally, such tools would make it possible to conduct comparative analysis across different regulatory jurisdictions and maximise opportunities to determine superior SSB policy directives.

Change in SSB consumption by gender, age or nationality was not statistically significant since the introduction of SSB tax, or during Covid-19 lock-down; thus, we accept the Null Hypothesis. Imposing a levy on frequently consumed SSB or revisiting levy by the gram, volume, or type of added sugar (or in combination) may prove to be more effective in reducing SSB consumption. Further research is needed to determine the extent other demographic factors influence SSB consumption as well as the enablers and barriers associated with SSB consumption.

Figure S1. Number and Percentage of Sugar that comes from SSB/day by Nationality.

Figure S2. Change in SSB Consumption During Covid-19 by Age.