Effects of Lifestyle Changes on Semen Quality in Healthy Young Men Living in Highly Polluted Areas (FAST)
Condition: Fertility Disorders
Study type: Interventional

Summary: 
      We planned a randomized controlled trial (RCT) with the main aim to evaluate the effects of
      lifestyle changes on semen quality in healthy young men living in polluted areas in Italy.
      Secondary aims are to assess: a) the association between semen quality and biomarkers of
      early damage or inflammation; b) the associations between biomarkers of exposure to heavy
      metals and semen quality and biomarkers of early damage or inflammation; c) the associations
      between diet and physical activity and semen quality and biomarkers of early damage or
      inflammation; d) the effects of lifestyle changes on the blood and semen levels of heavy
      metals.

      The RCT includes 450 young men living in one of the following three polluted areas:

        1. a polychlorinated biphenyls (PCBs) polluted area in Brescia province, Lombardy region;

        2. the valley of the Sacco river, with high levels of beta-hexachlorocyclohexane (β-HCH)
           originated by toxic waste dumps of industrial origin.

        3. the "Land of Fires" in the Campania region, with a high concentration of illegal waste
           dumping and uncontrolled burning near cultivated fields.

      Inclusion criteria are: a) healthy males aged 18- 22 years; b) residents in the area since at
      least 5 years; c) non smokers; d) non alcohol or drug users; e) normo-weight (18.5<
      BMI<24.99); f) no occupationally exposed to fertility toxics; g) not affected by chronic
      diseases. Subjects will be randomly assigned to an intervention or control group. The
      intervention group will follow a nutritional pathway and receive suggestions on practice of
      physical activity for 4 months, under the guide of some nutritionists, who will establish
      individualized diets for each subject. The control group will receive only a booklet
      including the dietary recommendations by the Italian National Institute for Research on Food
      and Nutrition. All subjects will undergo urologic examination, measurement of weight, height
      and abdominal circumference, an interview on demographic data, lifestyle variables, dietary
      habits, adherence to Mediterranean diet and physical activity, and will provide blood and
      semen samples in fasting conditions, at the enrollment (baseline), at the end of the
      intervention phase (after 4 months) and at the end of follow-up (after 8 months).

      Laboratory analyses include the following:

        -  hematological parameters;

        -  semen quality parameters;

        -  prostate-specific antigen (PSA) in blood and semen;

        -  RedOx status parameters in semen;

        -  epigenetic analyses (DNA methylation) in blood lymphocytes and spermatozoa;

        -  content of heavy metals in blood and semen. The project has been approved by the local
           Ethics Committees. Differences of means and proportions of all variables between the
           intervention and control group and the associations between diet, physical activity and
           sperm and blood parameters will be assessed using common statistical tests for
           comparisons of means and proportions as a first step.
    

Detailed description: 
      Human semen quality is affected by genetic, metabolic, lifestyle and environmental factors.
      It is a sensitive marker of the general health status of an individual and a predictor of
      disease occurrence and mortality. Some studies suggested that a diet rich in anti-oxidant
      compounds and regular physical activity could improve semen quality. We planned a randomized
      controlled trial (RCT) with the main aim to evaluate the effects of lifestyle changes on
      semen quality in healthy young men living in three polluted areas in North, Centre and South
      Italy. Secondary aims are to assess: a) the association between semen quality and biomarkers
      of early damage or inflammation (prostate-specific antigen, RedOx status, epigenetic
      changes); b) the associations between biomarkers of exposure to toxic agents (heavy metals)
      and semen quality and biomarkers of early damage or inflammation; c) the associations between
      diet and physical activity and semen quality and biomarkers of early damage or inflammation;
      d) the effects of lifestyle changes on the blood and semen levels of heavy metals.

      This RCT includes 450 healthy young men, aged 18-22 years, living in one of the following
      three polluted areas:

        1. a polychlorinated biphenyls (PCBs) polluted area in Brescia province, Lombardy region;

        2. the valley of the Sacco river, with high levels of beta-hexachlorocyclohexane (β-HCH)
           originated by toxic waste dumps of industrial origin.

        3. the "Land of Fires" in the Campania region, with a high concentration of illegal waste
           dumping and uncontrolled burning near cultivated fields.

      According to a 1:1 randomization plan, the young men will be assigned to an intervention or
      control group.

      The subjects will be enrolled among high school and university students, after a 20 minute
      meeting with students in each class, during a lesson, and in the presence of the teacher, for
      explaining the study design and inviting them to participate. After a short self-administered
      screening questionnaire for excluding subject not suitable to the research, the potential
      candidates are invited to undergo a urologic visit, in a Urology and Fertility Unit,
      including a clinical examination and spermiogram analysis. In the same time, participant
      undergo a fasting blood sample for the analysis of common parameters (glycemia,
      cholesterolemia, ecc.), and measures of height, weight and abdominal circumference by trained
      dieticians. Then each dietician evaluated each participant's dietary habits and physical
      activity using the European Prospective Investigation into Cancer (EPIC) and nutrition
      questionnaire, the PREvención con DIeta MEDiterránea (PREDIMED), and the International
      Physical Activity Questionnaire (IPAQ).

      Each urological visit, blood and semen sampling will be repeated with the same methodology in
      both intervention and control groups, at time 0 (baseline, enrollment), after 4 months (end
      of the intervention) and after 8 months (end of follow-up).

      The intervention for changing lifestyle in the experimental group has been planned on the
      basis of previous experience of educational intervention in nutritional epidemiology. It
      should be noted that the Mediterranean diet is the focus of the intervention and that the aim
      of the intervention is not to loss weight but to increase the amount of anti-oxidants and
      anti-inflammatory dietary compounds. It is well known that also motivated subjects have
      difficulties in changing dietary habits. Therefore the change will be based on the following
      points: personalized diet (according to taste and practical reasons), progressive change (one
      objective a time), frequent contacts with dieticians (weekly contacts in the first month).
      The subjects are also invited to share dieticians' indications with their parents and
      especially the person who usually cooks at home. The dietician intervention has been planned
      with the help of Dr. Stefania Ubaldi, President of the European Lifestyle Medicine
      Organization (ELMO), Geneva.

      The subjects included in the control group will receive only a booklet with present
      recommendations for Mediterranean diet at the enrollment (baseline), and will further contact
      only after 4 and 8 months.

      Blood and semen samples will be collected and stored at -80° according to a standard protocol
      up to the time of laboratory analysis. Laboratory analyses include the following:

        1. hematological parameters (whole blood count, glycemia, cholesterolemia, etc.);

        2. semen quality parameters, according to the 2010 World Health Organization (WHO)
           criteria;

        3. total and free prostate-specific antigen (PSA) in blood and semen;

        4. RedOx status parameters in semen;

        5. epigenetic analyses (DNA methylation) in blood lymphocytes and spermatozoa;

        6. ICP-MS (Inductively Coupled Plasma Mass Spectrometry) analyses of heavy metals -
           aluminum (Al), antimony (Sb), arsenic (As), barium (Ba), beryllium (Be), cadmium (Cd),
           calcium (Ca), chromium (Cr), cobalt (Co), cuprum (Cu), iron (Fe), lead (Pb), lithium
           (Li) magnesium (Mg), manganese (Mn), molybdenum (Mo), nickel (Ni), potassium (K),
           selenium (Se), sodium (Na), strontium (Sr) and zinc (Zn) in blood and semen.

      Differences of means and proportions of all variables between the intervention and control
      group and the associations between diet, physical activity and sperm and blood parameters
      will be assessed using common statistical tests for comparisons of means and proportions as a
      first step. Multivariable models, including multi-factor analysis of variance, multiple
      regression and multiple logistic regression, will then be used for assessing the associations
      when taking account of possible confounders. All the statistical tests are two-sided with
      p=0.05 as the threshold for refusal of the null hypothesis.

      The two Urology and Fertility Units: a) Unità Operativa Complessa di Urologia, Ospedale S.
      Francesco d'Assisi di Oliveto Citra (SA), Azienda Sanitaria Locale (ASL) Salerno and b) the
      Unit of Hygiene, epidemiology and biostatistics and Unit of Urology of the University of
      Brescia will provide routine hematological parameters (whole blood count, glycemia,
      cholesterolemia, etc.) and semen quality parameters, according to the 2010 WHO criteria.

      Each recruitment unit will collect and treat the biological samples, which will be sent to
      the laboratories for the specific analysis:

        -  Italian National Institute of Health, Rome: prostate-specific antigen in seminal plasma
           and in blood serum;

        -  Institute of Food Sciences, Italian National Research Council (ISA-CNR) of Avellino:
           RedOx status parameters in semen and ICP-MS analyses of heavy metals

        -  Epidemiology, Epigenetics And Toxicology (Epiget) Group of the University of Milan and
           Laboratory Biosafety and Risk Assessment of the Italian National Agency for New
           Technologies, Energy and Sustainable Economic Development (SSPT-TECS-BIORISC CR ENEA
           Casaccia): epigenetic analyses (DNA methylation) in blood lymphocytes and spermatozoa,
           respectively.

      The data management and statistical analysis will be performed by the Unit of Hygiene,
      epidemiology and biostatistics of the University of Brescia.
    

Intervention name(s): lifestyle counseling
Intervention type(s): Behavioral
Intervention description(s): Nutritional plan and Physical activity goals
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Primary purpose of the study is the improvement of semen quality in healthy young men living in highly polluted areas, operating on two specific lifestyle factors, that are nutrition and physical activity. Overall, 450 subjects will be enrolled (150 for single recruiting area) and they will be assigned by chance to one of the two arms of the study, named "Control group" and "Intervention group". Every subject is identified by means of an individual alphanumeric code that does not specifies which group they belong to, in order to mask to all the outcomes assessors the membership to one arm or another.
Masking: Single (Outcomes Assessor)
Primary purpose: Prevention
Keywords: Lifestyle; Fertility; Nutrition; Environmental Pollution