Cardiovascular disease is the leading cause of death in the Western world ; indeed, in 2008 it was the cause of 31.8% of all deaths registered. In Spain, in that same year, ischaemic heart disease (IHD) was the most common cause of death among men (20,369 fatalities), while in women, stroke was the major cause of demise (18,312 deaths). The second cause of death among women was, again, IHD (15,519 fatalities) . Numerous epidemiological studies have shown associations between different cardiovascular risk factors (CRF) and the appearance of these diseases and several of the classic CRFs (diabetes, obesity, high blood pressure and high cholesterol) are known to be influenced by poor dietary habits and the undertaking of little physical activity. These habits are hard to modify in adult life; it is therefore important to improve the development of lasting healthy habits during childhood [3, 4].
Obesity is a CRF that has increased alarmingly in importance in recent years; indeed, the world is now faced with an obesity pandemic . The World Health Organization (WHO) estimates there to be 1000 million overweight people worldwide, of which 300 million are obese . Although the appearance of obesity is complex and influenced by genetic and other biological factors, poor diet and the undertaking of little physical inactivity are also involved. According to the National Health and Nutrition Examination Survey (NHANES) , obesity affects 17% of children and adolescents in the US. In fact, over the last 30 years the prevalence of obesity has nearly tripled in Australia, Brazil, Canada, the USA, Germany, France, Greece, the UK, and Japan (although it would now appear to be stabilizing in Sweden, the USA and the UK). In 2010, the prevalence of overweight/obesity was estimated at 40% for North America and the countries of the Eastern Mediterranean, at 38% for Europe, at 27% for the Western Pacific, and at 22% for Southeast Asia . It is now known that overweight and obesity in childhood are associated with an increased risk of hypertension, diabetes, dyslipidemia and obesity in adulthood [9, 10]. A number of studies from the USA (including the Bogalusa Heart Study) [11, 12] and Finland [13, 14] have shown that diseases that appear during older age may have their origin in earlier stages of life.
In Spain, the EnKid study showed the prevalence of overweight/obesity to be 30.4% among children aged 6–9 years (overweight alone = 14.5%, obesity alone = 15.9%) , while the Spanish National Health Survey showed 25.7% of girls and 29.3% of boys (aged 2–17 years) to be overweight/obese . The International Obesity Taskforce (IOT) experts group reported the prevalence of childhood obesity in Spain to be among the highest in Europe , and in 2009, the Spanish system for the surveillance of risk factors associated with non-communicable diseases (SIVFRENT) highlighted the need to prioritise the surveillance of indicators related to energy balance given the increase observed in the prevalence of overweight/obesity, especially in girls . Obesity, sedentary lifestyles, and poor nutritional and dietary habits are all increasing among the child population . This age group should therefore be considered a priority for interventions aimed at promoting healthier lifestyles .
A review by the Cochrane Collaboration , in which 22 studies on improving either dietary habits or physical activity in children were analysed, concluded there to be insufficient data to affirm that the interventions undertaken helped prevent obesity. However, when changes were made to both the diet and physical activity, a small but positive effect on body mass index (BMI) was confirmed. However, other authors , who examined 158 studies mostly conducted in schools, emphasized the importance of exercise in achieving weight loss and preventing the appearance of chronic diseases in later life (note that some of these studies were reported to have problems in terms of their methodological quality).
In Spain, the Catalan Agency for Technology and Medical Research (AATRM) recently published a clinical practice guide for the prevention and treatment of childhood obesity . This guide offers 64 evidence-based recommendations, 37 of which include the promotion of healthy eating habits and physical activity via educational programs that involve families and institutions. Spanish interventions aimed at preventing obesity take their inspiration in the home-grown PERSEO programme and the international NAOS strategy (Strategy for Nutrition, Physical Activity and Obesity Prevention) . Both encourage information campaigns and agreements between public and private institutions in the health sector and beyond that could help goals be attained.
Townsend et al. reported that children make better food choices if schools promote healthy eating , and many studies have shown that inadequate breakfasts cannot be compensated for by other meals during the day [26–31].
One of the obesity prevention programmes promoted in schools is the “Healthy Breakfast Programme” . This involves teaching primary schoolchildren the importance of having a good breakfast and of undertaking exercise. Public health workers, nurses and doctors at nearby health centres come to schools to teach – in the school dining room - that an adequate breakfast is important for all age groups, but especially for children. The Healthy Breakfast programme promotes 1) a breakfast consisting of a glass of full fat milk, two slice of bread with virgin olive oil, and a fruit (all key elements of the Mediterranean diet and representative of four food groups), and 2) physical activity through games in the playground. Primary school pupils usually aged 7–8 years receive a class on the importance of these points (see Intervention Groups, Healthy Breakfast Group below for a more detailed description), and take a reinforcing information pamphlet home. The programme has reached 37000 children over its 14 years of existence and has improved eating habits, e.g., the percentage of schoolchildren who have breakfast everyday has risen from 88% to 91.5% over this period . Further, among those who already took breakfast, the composition of this meal has improved, with 84.4% now including four or more foods in this meal compared to a prior 77.4%. The motto of the campaign is “First eat your breakfast, and then eat your day” .
Music interventions have often been used to promote learning, communication and even to attain clinical goals [33–36]. In recent years, music has been used as part of cardiovascular health education. Williams et al.  showed that education via hip-hop music, used as a medium to deliver health messages to teenagers regarding strokes, reduced the time for assistance to be sought for adult stroke victims. In 2001, Marconato et al.  showed that including classical music in health education sessions reduced anxiety levels in students aged >18 years, increased personal happiness, promoted the consumption of fibre-rich foods, and reduced the intake of high cholesterol foods. Thus, music could be used to deliver educational messages in interventions aimed at promoting obesity prevention and the adoption of good cardiovascular health habits. In the present work, this music will be offered as an eduentertainment package , and will be provided by specialist musicians who have been involved in this type of project for some three years in the Madrid Region [40, 41].
The proposed project aims to compare the effectiveness – in terms of knowledge and attitudes regarding obesity prevention/good cardiovascular health practices – of a health promotion strategy involving an Healthy Breakfast with that of an educational concert that delivers the same health messages via the vehicle of music and storytelling.
The main aim of the proposed trial is to determine whether a health promotion strategy involving an educational music concert for schoolchildren aged 7–8 years improves knowledge of, and attitudes towards, obesity prevention/good cardiovascular health habits (as suggested by the NAOS strategy) better than a health promotion strategy involving an Healthy Breakfast.
The secondary aim is to compare the two interventions, at 6 months, in terms of the reduction achieved in BMI percentile by children who are overweight/obese prior to the start of the study.