NCDs, including diet-related NCDs such as cardiovascular diseases and diabetes, constitute one of the major challenges for development in the 21st century. They are the leading cause of mortality in the world, causing an estimated 71% of global deaths, with 85% of premature NCD deaths estimated to occur in low- and middle-income countries. The lost economic contribution of people harmed by NCDs, the costs of treatment, and the impacts on families threaten international development and the achievement of the Sustainable Development Goals (SDGs).

Despite the considerable progress made in 2000–2010 in the prevention, control and management of NCDs, the momentum of change has decreased. The annual decline of the risk of dying from a major NCD between the ages of 30 and 70 is slowing. SDG target 3.4 – to reduce by one-third premature mortality from NCDs through prevention and treatment and promote mental health and wellbeing on NCDs by 2030 – is off track for all but 14 countries. Further, evidence has demonstrated that people with NCDs, as well as people living with obesity, are more vulnerable to becoming severely ill or dying from COVID-19. 

The WHO NCD progress monitor report 2017, the WHO 2^nd Global nutrition policy review 2016–2017 and the assessment of progress on implementation of GAPPA show uneven progress by countries in reducing modifiable risk factors, particularly unhealthy diets and insufficient physical activity. For example:

• Despite its endorsement by the World Health Assembly (WHA) in 2010, no country has comprehensively implemented the WHO Set of recommendations on the marketing of foods and non-alcoholic beverages to children.
• An insufficient number of countries apply fiscal policies to stimulate healthier diets. Although approximately 80 countries now implement taxation on sugar-sweetened beverages (SSBs) to reduce the consumption of free sugars, product coverage varies.
• Nutrition labelling has not been implemented comprehensively by many countries and, even where implemented, mandatory nutrients to be declared are often not in line with Codex guidelines on nutrition labelling. Few countries have embarked on front-of-pack labelling (FoPL).
• Reformulation of food products to remove industrially produced trans fats, or to contain less salt, has been implemented by a growing number of countries but most often it is voluntary rather than mandatory.
• An assessment of barriers to progress on promoting physical activity and the impact of COVID-19 undertaken in 2021 identified the need for stronger regulatory frameworks to ensure provision and access to safe places for physical activity. 

One of the main bottlenecks identified of these shortcomings is the lack of regulatory and fiscal awareness and capacity to address NCD risk factors, in particular unhealthy diets and physical inactivity. A combination of an uncertain evidence base, lack of technical legal capacity and the possibility of legal challenge from industry can create what is referred to as regulatory chill, whereby legal uncertainty and hard policy choices dissuade governments from acting. Support in designing evidence-informed, well designed, appropriately targeted regulatory and fiscal policies to reduce the risk factors for NCDs would therefore be beneficial in countries lacking such awareness and capacity.

In September 2018 at the 3rd high-level meeting of the United Nations General Assembly (UNGA), Member States committed to scale up actions to, inter alia, “promote and implement policy, legislative, and regulatory measures, including fiscal measures as appropriate, aiming at minimizing the impact of the main risk factors for non-communicable diseases, and promote healthy diets and lifestyles…”. The United Nations Food Systems Summit (FSS) has also highlighted the need for healthy diets based on safe foods produced sustainably and the Global action plan on physical activity 2018–2030 (GAPPA) reinforces the need for countries to accelerate use of regulatory and fiscal measures to promote healthy diets and physical activity. The WHO Global Action Plan on the Prevention and Control of NCDs recommends, in the Best Buys at Appendix 3, use of legal and fiscal approaches to address specific NCD risk factors and to promote supportive environments that protect physical health and promote healthy behaviour and implement effective policy measures.

NCD risk factors in a population are driven by social and commercial determinants of health, including broader trends such as urbanization and globalization, which influence individual behaviours and metabolic factors causatively linked with NCDs.

• Social determinants of health are non-medical factors that influence health outcomes through the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life, including economic policies and systems, development agendas, social norms, social policies and political systems.
• Commercial determinants of health are private sector activities that affect people’s health positively or negatively by influencing social, physical and cultural environments through business actions and societal engagements; for example, supply chains, labour conditions, product design and packaging, research funding, lobbying and preference shaping. Commercial determinants of health impact a wide range of health outcomes including obesity, diabetes, cardiovascular health, cancer, road traffic injuries and mental health. Everyone is affected, but young people are especially at risk, and unhealthy commodities worsen pre-existing economic, social and racial inequities. LMICs can face greater pressure from multinational actors.

Legal, regulatory and fiscal policy approaches can be effective in addressing social and commercial determinants of health which influence NCD risk factors by mandating and enforcing compliance with evidence-based measures designed to meet public health objectives which are applied in a standardized way across key settings and markets. Governments have a unique capacity to enact legislation, issue mandatory legal instruments such as regulations and standards, implement taxes and other fiscal measures designed to meet both public health and revenue objectives, and enforce compliance with these measures within their jurisdictions. The democratic process of developing, implementing and enforcing legal and fiscal measures requires governments to balance competing interests and allows input from stakeholders, including private actors. Accordingly, it is important to ensure that these processes have effective mechanisms in place to identify, manage and avoid potential conflicts of interest and capacities for good governance. Good governance is epitomized by predictable, open and transparent decision-making; a professional and ethical bureaucracy; an executive arm of government accountable for its actions; and a strong civil society participating in public affairs; all operating under the rule of law.