The Pacific Island countries experience some of the highest rates of obesity in the world in part due to substantial dietary changes that mirror changes in the food supply in the region. Economic and political ties, donor aid, and trade links are key drivers of the changing availability and accessibility of processed and imported foods. Pacific Island countries have been innovative in developing trade-related policy approaches to create a less obesogenic food environment. Taxation-based approaches that affect pricing in the region include increased import and excise tariffs on sugared beverages and other high-sugar products, monosodium glutamate, and palm oil and lowered tariffs on fruits and vegetables. Other approaches highlight some higher-fat products through labeling and controlling the supply of high-fat meats. The bans on high-fat turkey tails and mutton flaps highlight the politics, trade agreements and donor influences that can be significant barriers to the pursuit of policy options. Countries that are not signatories to trade agreements may have more policy space for innovative action. However, potential effectiveness and practicality require consideration. The health sector's active engagement in the negotiation of trade agreements is a key way to support healthier trade in the region.