As noted in Chapter 1, it is now over two decades since the field of DOHaD was established, as an extension of the epidemiological findings of Barker and colleagues and their integration with new ideas in developmental physiology, evolutionary biology and medicine. Despite the widespread acceptance of both the underlying science and phenomena of DOHaD, as evidenced in each of the previous 19 Chapters of this book and the range of scientists now engaged in relevant research, the field has had less impact than it warrants on public health, clinical practice or public policy. Here, we review the reasons for this, and suggest some possible solutions.

Two of the pathways by which evolutionary processes can influence disease risk are evolutionary mismatch, where the individual’s evolved coping mechanisms are overwhelmed by a novel or severe cue, and developmental mismatch, where the individual is exposed to an environment that is not matched to its adaptively developed phenotype. Both pathways draw on the evolutionary principle that selection operates to sustain and promote Darwinian fitness, irrespective of the impact on health during the post-reproductive age. In this chapter we will frame DOHaD phenomena within an evolutionary context, showing that human health and disease risk are dependent on our both evolutionary and developmental histories. We also discuss the contributory role of a unique human activity to not only construct a niche but also continually modify it. Using nutrition as the exemplar, we demonstrate how the DOHaD phenomenon is underpinned by both evolutionary and developmental mismatches, and discuss the evidence for how developmental anticipatory responses may confer adaptive advantage in humans.

This chapter provides a high-level overview of the following 19 Chapters, which together create the 2nd Edition of the Developmental Origins of Health and Disease. We encapsulate not only the vastly expanded evidence base and mechanistic understanding underlying DOHaD but also the challenges faced when trying to embed life course ‘thinking’ into environmental, social, educational and health care policies.

Providing the healthiest and safest environment in the first 1,000 days of life is the greatest gift which parents can give to their children. We return to the theme of control over our lives to ask who is in control of this gift, and whether today’s medicine and public health hold the answers. We explore the dilemmas facing today’s governments and the decisions that individuals make in terms of personal responsibility when maternal and child health are not prioritised by health policy-makers. We discuss sexual and reproductive rights, why women’s health has not been prioritised – especially during the pandemic – and reasons for high maternal mortality in some countries. We offer an optimistic close to the book; a call to action. We explain that, while planning for parenthood is important, the actions needed do not have to be sustained over a long period. We emphasise the many opportunities which adolescents and young people can seize as the parents of the future. This hope can generate the resolve to make the first 1,000 days of life as good as possible for the next generation. Knowing the secrets of our first 1,000 days is a vital part of this.