The Effect of Selenium Supplementation on Musculoskeletal Health in Older Women Double-blind, Randomised, Placebo-controlled Trial
Phase: PHASE3
Conditions: Osteoporosis
Sponsor: Sheffield Teaching Hospitals NHS Foundation Trust

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The Effect of Selenium Supplementation on Musculoskeletal 
Health in Older Women 
Double-blind, randomised, placebo-controlled trial 
 
Acronym: SeMS 
Protocol  v1.1 16Feb 2017 
 
 
 
 
 
SPONSOR 
 
 
 
Sheffield Teaching Hospitals NHS Foundation Trust 
SPONSOR’S REFERENCE 
 
 
STH19102 
CHIEF INVESTIGATOR 
 
 
Dr Jennifer Walsh 
 
IRAS 
 
 
 
200308 
EUDRACT 
 
 
 
2016-002964-15 
 
 
 
Clinicaltrials.gov 
 
 
 
NCT02832648 
REC 
 
 
 
16/YH/0393 
 
 
 
 
FUNDER 
 
 
 
NIHR EME 14-200-20 
 
 
KEY WORDS 
selenium, osteoporosis, bone turnover, muscle 
 

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Contents 
SIGNATURE PAGE .................................................................................................................................... 4 
KEY TRIAL CONTACTSs............................................................................................................................. 5 
TRIAL SUMMARY ..................................................................................................................................... 7 
TRIAL FLOW CHART ................................................................................................................................. 8 
LIST OF ABBREVIATIONS ......................................................................................................................... 9 
1. RESEARCH QUESTION ....................................................................................................................... 11 
2. LAY SUMMARY .................................................................................................................................. 11 
3. BACKGROUND ................................................................................................................................... 11 
5. HYPOTHESIS AND OBJECTIVES .......................................................................................................... 13 
6. RESEARCH DESIGN SUMMARY .......................................................................................................... 13 
7. STUDY POPULATION ......................................................................................................................... 14 
7.1 Inclusion criteria .......................................................................................................................... 14 
7.2 Exclusions .................................................................................................................................... 14 
7.3 Bone density definitions ............................................................................................................. 15 
7.4 Generalisability ........................................................................................................................... 16 
8. PLANNED INTERVENTIONS ................................................................................................................ 16 
9. OUTCOME MEASURES ...................................................................................................................... 17 
10. ASSESSMENT AND FOLLOW-UP ...................................................................................................... 17 
10.1 Assessment of efficacy/effectiveness ....................................................................................... 17 
10.2 Assessment of safety ................................................................................................................ 18 
10.3 Timing of assessments .............................................................................................................. 19 
11. TRIAL MEDICATION ......................................................................................................................... 19 
12. RISKS AND BENEFITS ....................................................................................................................... 22 
13. STATISTICS ....................................................................................................................................... 23 
13.1 Power calculation ...................................................................................................................... 23 
13.2 Analysis plan ............................................................................................................................. 24 
14. STUDY SETTING ............................................................................................................................... 25 
15. ETHICAL CONSIDERATIONS ............................................................................................................. 25 
16.  RECRUITMENT ................................................................................................................................ 26 
16.1 Participant identification .......................................................................................................... 26 
16.2  Screening requirements ........................................................................................................... 27 
16.3  Consent .................................................................................................................................... 28 
17. RANDOMISATION ............................................................................................................................ 28 
18.  BLINDING ........................................................................................................................................ 28 

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19. PHARMACOVIGILANCE .................................................................................................................... 29 
19.1 Reporting Period ....................................................................................................................... 29 
19.2 Definitions ................................................................................................................................. 29 
19.3 Causality .................................................................................................................................... 29 
19.4 Responsibilities ......................................................................................................................... 30 
20. WITHDRAWAL ................................................................................................................................. 31 
21. SAMPLE STORAGE AND ANALYSIS .................................................................................................. 31 
22. DATA PROTECTION .......................................................................................................................... 32 
23. GOVERNANCE AND MANAGEMENT ............................................................................................... 32 
24. TIMELINES ....................................................................................................................................... 33 
25. PATIENT AND PUBLIC INVOLVEMENT ............................................................................................. 34 
REFERENCES .......................................................................................................................................... 35 
APPENDIX 1 – Physical function tests ................................................................................................... 38 
APPENDIX 2 – Schedule of procedures ................................................................................................. 41 
 
 
 
 

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SIGNATURE PAGE 
The undersigned confirm that the following protocol has been agreed and accepted and that the 
Chief Investigator agrees to conduct the trial in compliance with the approved protocol and will 
adhere to the principles outlined in the Medicines for Human Use (Clinical Trials) Regulations 2004 
(SI 2004/1031), amended regulations (SI 2006/1928) and any subsequent amendments of the clinical 
trial regulations, GCP guidelines, the Sponsor’s SOPs, and other regulatory requirements as 
amended. 
I agree to ensure that the confidential information contained in this document will not be used for 
any other purpose other than the evaluation or conduct of the clinical investigation without the 
prior written consent of the Sponsor 
I also confirm that I will make the findings of the study publically available through publication or 
other dissemination tools without any unnecessary delay and that an honest accurate and 
transparent account of the study will be given; and that any discrepancies from the study as planned 
in this protocol will be explained. 
 
For and on behalf of the Study Sponsor: 
Signature:  
...................................................................................................... 
 
Date: 
....../....../...... 
Name (please print): 
...................................................................................................... 
 
 
Position: 
...................................................................................................... 
 
 
 
 
Chief Investigator: 
Signature: 
...................................................................................................... 
 
Date: 
....../....../...... 
Name: (please print): 
...................................................................................................... 
 
 
 
 
Statistician: 
 
 
Signature: 
...................................................................................................... 
 
 
Name: (please print): 
...................................................................................................... 
 
 
 
 
 

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KEY TRIAL CONTACTS 
Chief Investigator 
Dr Jennifer Walsh 
Senior Clinical Lecturer 
Mellanby Centre for Bone Research 
University of Sheffield 
 
Metabolic Bone Centre 
Sorby Wing 
Northern General Hospital 
Herries Road 
Sheffield 
S5 7AU 
 
0114 2714705 
j.walsh@sheffield.ac.uk 
Trial Co-ordinator 
Selina Bratherton 
Metabolic Bone Centre 
Sorby Wing 
Northern General Hospital 
Herries Road 
Sheffield 
S5 7AU 
 
0114 3052005 
s.bratherton@sheffield.ac.uk 
Sponsor 
Sheffield Teaching Hospitals NHS Foundation Trust 
 
Clinical Research Office 
D floor 
Royal Hallamshire Hospital 
Glossop Road 
Sheffield 
S10 2JF 
 
0114 2265945 
 
Funder(s) 
National Institute for Health Research (EME) 
 
Evaluation, Trials and Studies Coordinating Centre 
University of Southampton 
Alpha House, Enterprise Road 
Southampton 
SO16 7NS 
 
02380 594309 
m.r.shergill@soton.ac.uk 
 

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Key Protocol Contributors 
Professor Richard Eastell 
Mellanby Centre for Bone Research 
University of Sheffield 
 
Professor John Mathers  
Institute for Ageing and Health 
University of Newcastle 
 
Dr Tom Hill 
School of Agriculture, Food and Rural Development 
University of Newcastle 
 
Professor Graham Williams 
Department of Medicine 
Imperial College, London 
 
Statistician 
Dr Richard Jacques 
ScHARR 
University of Sheffield 
 
0114 2220813 
r.jacques@sheffield.ac.uk 
Trials pharmacist 
Kim Ryalls 
Sheffield Teaching Hospitals NHS Foundation Trust 
 
0114 2715456 
kim.ryalls@sth.nhs.uk 
Research Ethics Committee 
Yorkshire and the Humber – Sheffield 
 

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TRIAL SUMMARY 
 
Trial Title 
The Effect of Selenium Supplementation on Musculoskeletal Health in Older 
Women 
Short Title 
SeMS 
Trial Design 
Double-blind, randomised, placebo controlled 
Trial Participants 
Postmenopausal women with osteopenia or osteoporosis 
Planned Sample Size 
120 (max 165) 
Treatment duration 
6 months 
Planned Trial Period 
26 months 
 
Objectives 
Outcome Measures 
Primary 
 
Decrease in bone resorption 
Urine NTX 
 
Secondary 
 
Increased selenium  
Decrease in bone turnover 
Increase in physical functioning 
Increased antioxidant activity 
Decreased inflammatory markers 
Serum Se, SePP 
Serum CTX, PINP, osteocalcin 
SPPB score, grip strength 
Glutathione peroxidase, hydroperoxidase 
IL-6, hsCRP 
Investigational Medicinal 
Product(s) 
Selenase (Biosyn, Germany) 
Sodium selenite pentahydrate 
Dose 
Route of Administration 
200mcg daily, 50mcg daily, placebo 
Oral 
 
 
 

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Patients attending for fracture risk assessment 
Sheffield Metabolic Bone Centre 
Email and poster adverts 
Volunteer database 
Academic Unit of Bone Metabolism 
Mailing from primary care 
Sheffield General Practices 
Participant identification 
Selenium 200mcg  
3 month assessment 
6 month assessment 
Final AE collection 
(28 days after end 
of treatment) 
Selenium 50mcg  
3 month assessment 
6 month assessment 
Final AE collection 
(28 days after end 
of treatment) 
Placebo 
3 month assessment 
6 month assessment 
Final AE collection 
(28 days after end 
of treatment) 
Randomisation 
Informed consent and screening 
Baseline assessments 
TRIAL FLOW CHART 
 
 
 
 

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LIST OF ABBREVIATIONS 
AE 
Adverse Event 
AR 
Adverse Reaction 
AUBM 
Academic Unit of Bone Metabolism, Sheffield 
BMD 
Bone Mineral Density 
CRF 
Case Report Form 
CRF  
Clinical Research Facility 
CTA 
Clinical Trial Authorisation 
CTIMP 
Clinical Trial of Investigational Medicinal Product 
 
CTX 
C-terminal cross-linking telopeptide of type I collagen 
DMEC 
Data Monitoring Committee 
DSUR 
Development Safety Update Report 
DXA 
Dual Energy X-ray Absorptiometry 
EudraCT 
European Clinical Trials Database 
GCP 
Good Clinical Practice 
GMP 
Good Manufacturing Practice  
HbA1c 
Gylcated haemoglobin 
HRA 
Health Research Authority 
HRT 
Hormone Replacement Therapy 
hsCRP 
highly sensitive C-Reactive Protein 
HTA 
Human Tissue Act 
IB 
Investigator Brochure 
ICH 
International Conference on Harmonisation of technical 
requirements for registration of pharmaceuticals for 
human use. 
IL-6 
Interleukin-6 
IMP 
Investigational Medicinal Product 
IMPD 
Investigational Medicinal Product Dossier 
ISF 
Investigator Site File 
ITT 
Intention to Treat 
MHRA 
Medicines and Healthcare products Regulatory Agency 
NHS R&D 
National Health Service Research & Development 

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NIHR 
National Institute for Health Research   
NTX 
N-terminal cross-linking telopeptide of type I collagen 
OC 
Osteocalcin 
PINP 
Procollagen type I N propeptide 
PI 
Principal Investigator 
PIC 
Participant Identification Centre 
PIS 
Participant Information Sheet 
PPI 
Patient and Public Involvement 
QA 
Quality Assurance 
QC 
Quality Control 
RCT 
Randomised Control Trial 
REC 
Research Ethics Committee 
RSI 
Reference Safety Information 
SAE 
Serious Adverse Event 
SAR 
Serious Adverse Reaction 
SePP 
Selenoprotein P 
SERM 
Selective Estrogen Receptor Modulator 
SOP 
Standard Operating Procedure  
SmPC 
Summary of Product Characteristics  
SPPB 
Short Physical Performance Battery 
STH 
Sheffield Teaching Hospitals 
SUSAR 
Suspected Unexpected Serious Adverse Reaction  
TMG 
Trial Management Group 
TSH 
Thyroid Stimulating Hormone 
TSC 
Trial Steering Committee 
 

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1. RESEARCH QUESTION 
Does selenium supplementation decrease bone turnover or improve muscle function in 
postmenopausal women with osteopenia or osteoporosis? 
2. LAY SUMMARY 
This research aims to determine whether selenium supplements improve bone and muscle health in 
older women at risk of osteoporosis (low bone density or weak bones) and fracture (broken bones).  
Osteoporosis is a major public health problem. One in two women and one in five men over age 50 
will have a fracture. Fractures cause pain, disability and reduce life-expectancy. Women with below-
average bone density around the time of the menopause might have previously taken hormone 
replacement (HRT) to prevent osteoporosis, but HRT is much less used now due to side effects. 
Therefore there is a need for safe, effective and inexpensive preventative interventions for women 
at risk of osteoporosis. 
Selenium is a chemical nutrient present in several human proteins, including anti-oxidants. Anti-
oxidants may protect against ageing of tissues, including bone, by mopping up damaging reactive 
oxygen molecules (sometimes called ‘free radicals’). Selenium is present in soil, and so is obtained 
from many foods. However, soil selenium levels are low in Europe, and dietary intake in the UK is 
below recommended levels. 
We previously found that women with higher blood selenium levels have stronger bones, but this 
doesn’t prove that giving selenium will improve bone strength.  
We propose a randomised controlled trial to compare selenium supplements with a placebo 
(dummy treatment) in women with below-average bone density. We will give selenium (at two 
different doses) or placebo to 120 women for six months and use blood and urine tests and bone 
density scans to see if giving selenium does have any effect on bone. We will also do muscle function 
tests and measurements of free radical molecules. 
3. BACKGROUND 
One in two women and one in five men over the age of fifty will have a fragility fracture. Fractures 
lead to pain, disability, loss of independence and increased mortality. This is a huge health burden 
for affected individuals, the NHS and social care which is increasing as the population ages.  
About 30% of women aged over 65 are osteopenic (below-average bone density), and at risk of 
developing osteoporosis and fractures. More than 50% of all fractures in postmenopausal women 
occur in women with osteopenia. These women are not eligible for osteoporosis treatment at 
present because of the individual risk/benefit ratio and economic factors. Previously, these women 
could have been offered hormone replacement therapy (HRT) for bone protection, but adverse 
effects of HRT have limited its use. 
Therefore there is a need for an effective, safe, well-tolerated, inexpensive and widely applicable 
preventative option for osteopenic women. 
Selenium is a chemical element present in several human proteins. Twenty-five human 
selenoproteins have been identified (1). Known functions of selenoproteins include thyroid hormone 
synthesis (iodothyronine deiodinases) and antioxidants (thioredoxin reductases and glutathione 

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peroxidases) (2, 3). Selenoproteins are anti-inflammatory and antioxidant; they reduce interleukin-6 
and reactive oxygen species both of which are potent stimuli for bone resorption (4-6). 
Selenium is obtained from the diet and it is rich in seafood, meat and cereals. The main determinant 
of food selenium content is soil selenium content. The recommended adequate intake for adults 
aged over 50 in the UK is 75ug/d for men and 60ug/d for women (7), but in the UK, the mean intake 
is only 40mcg/day (8). Selenium intakes have been declining in the UK in the past few decades, and 
are generally low in Europe compared with the USA. The main reason for the decreasing intake in 
the UK is a change in the source of flour for bread-making from North America (which contains 
higher selenium) to Europe due to economic and consumer demands.  More recently, the levels of 
selenium in UK soils have declined as a result of changes in fertiliser practice (e.g. replacing single 
superphosphate with triple superphosphate) and reduced industrial emissions. 
We recently reported that in 1144 older women from the UK, France and Germany, higher serum 
selenium or selenoprotein P was associated with higher bone mineral density of the lumbar spine 
and total hip, and lower biochemical markers of bone turnover (9). High bone turnover is the 
principal mechanism of osteoporotic bone loss. We also noted associations of selenium levels with 
balance, grip strength and pulse rate. Others have reported an association of selenium with muscle 
strength (10), but we were the first to explore bone turnover or bone density. Selenium status was 
inversely related to thyroid hormone status (selenium is required for thyroid hormone synthesis), 
but the associations of selenium with bone measures were independent of thyroid hormones. 
It is plausible that selenium would affect bone metabolism. Selenoproteins are found in osteoblasts 
and osteoclasts (11). Selenoproteins are anti-inflammatory and reduce interleukin-6, a potent 
stimulus for bone resorption (5). Selenoproteins are anti-oxidant and reduce reactive oxygen 
species; these also stimulate bone resorption via increased RANK-L signalling (11). An increase in 
reactive oxygen species has been proposed as a key mechanism by which sex hormone deficiency 
causes age-related bone loss through the same RANK pathway (12). Therefore is possible that 
selenium could directly antagonise the cellular mechanism of postmenopausal osteoporosis. 
There is experimental animal evidence to support the hypothesis that selenium has a role in bone 
and reduces bone turnover. Selenium deficient mice have poorer bone microarchitecture, higher 
bone resorption markers and higher inflammatory markers than selenium supplemented mice (13). 
Selenium deficient rats have poor bone microarchitecture and abnormal skeletal growth (14, 15). 
There may also be an epidemiological association between selenium deficiency and bone health. In a 
study of US hip fracture risk in women over age 65 years, the counties with highest rates were in a 
belt across the south of the USA and the lowest rates were in the north (16). In contrast, a current 
map of soil selenium content in the USA shows the highest selenium content in the north of the USA 
and the lowest in a belt across the south of the USA 
(http://mrdata.usgs.gov/geochem/doc/averages/se/usa.html).  
Endemic selenium deficiency in humans has been associated with the osteoarthropathy Kashin-Beck 
disease (17). 
Several other age-related disorders are linked to inadequate selenium status, including poor 
cognitive function (4) and selenium may be an independent predictor of mortality among older 
community-dwelling adults (18).  

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The possible adverse effects of selenium supplementation are thyroid dysfunction (because some 
selenoproteins are involved in thyroid hormone synthesis) and increased risk of type 2 diabetes 
mellitus (although in a previous study at the same dose and duration of treatment as this protocol 
there was no increase in diabetes (19)). 
 
4. RATIONALE FOR CURRENT STUDY  
If selenium supplementation were effective in reducing bone turnover and increasing BMD, this 
would offer an affordable, low risk prevention strategy that could be attractive to patients because it 
is a nutritional supplement, rather than a ‘medicine’. 
This study will give clear evidence of efficacy, and if positive, will identify the likely effective dose. 
If this study is positive, we will immediately apply for funding to take the best dose (the lowest dose 
with a clinically significant clinical effect on bone turnover) into a longer study with bone density as 
the primary endpoint. 
5. HYPOTHESIS AND OBJECTIVES  
Hypothesis: Selenium supplementation decreases bone turnover in postmenopausal women with 
low bone density by reducing pro-resorptive reactive oxygen species. 
Purpose: to determine if selenium supplementation is beneficial for osteoporosis prevention and 
muscle function in postmenopausal women.  
Objectives: to determine if six months selenium supplementation in postmenopausal women with 
osteopenia or osteoporosis 
 
decreases bone turnover   
 
increases bone density 
 
improves physical function score and grip strength 
 
is safe (particularly for thyroid function and diabetes) 
 
is well-tolerated 
 
decreases markers of oxidative stress and inflammation 
All of these objectives will be answered at the completion of the study and analysis, with a total 
project duration of 26 months.  
6. RESEARCH DESIGN SUMMARY 
This is a double-blind, randomised, placebo controlled trial. 
We will evaluate two doses of selenium (50 and 200mcg daily) vs placebo over six months. 
Participants are postmenopausal women with osteopenia or osteoporosis (T-score -1.0 to -3.0). 
We will include participants with any baseline serum selenium concentration for generalisability, but 
the primary endpoint efficacy analysis will only include women with baseline serum selenium below 
120mcg/l. 

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Primary endpoint: Urinary N-telopeptide of type I collagen (NTX/Cr). 
Secondary endpoints: other bone turnover markers, BMD, muscle function, thyroid function, blood 
glucose, anti-oxidant activity, inflammatory markers 
We will make the primary analysis based on women with baseline serum selenium below 120mcg/l. 
To ensure adequate power for this analysis we will plan to recruit 120 women (we expect that 100 of 
the 120 will have serum selenium below 120 mcg/l based on our previous cross-sectional study). We 
will review the baseline serum selenium results when 40 women have been recruited to confirm the 
expected distribution of baseline levels, and we will adjust the total recruitment number accordingly 
to ensure at least 99 women with serum selenium below 120mcg/l have been randomised for the 
final primary endpoint intention-to-treat analysis. 
 
Participants will be randomised according to a schedule produced by Sharp Clinical Services. 
Randomisation will be carried out independently of the study investigators. The blind will only be 
broken if judged by the PI as clinically necessary for the wellbeing of a participant. 
If at the interim analysis, less than 60% of women recruited have serum selenium below 120 mcg/l 
the study recruitment strategy will be reviewed and discussed with the funder to determine if the 
trial should proceed.  
The study may be stopped early if the investigators, sponsor or DMEC identify a safety concern.  
Trial management will be done by the Academic Unit of Bone Metabolism CTIMP group (who meet 
monthly), and progress reported to the AUBM management group and Lay Panel. We will establish a 
TSC and DMEC. 
7. STUDY POPULATION 
Participants will be recruited from an existing volunteer database, patients attending the Sheffield 
Metabolic Bone Centre, mailing from GP surgeries and email and poster adverts. 
7.1 Inclusion criteria 
 
Women  
 
Aged over 55, and at least 5 years since last menstrual period. 
 
Osteopenia or osteoporosis (DXA BMD lowest T-score between -1.0 and -3.0 at lumbar spine or 
total hip), who do not require pharmacological treatment for fracture prevention  
 
Willing and able to give informed consent 
7.2 Exclusions  
 
Diabetes mellitus 
 
Thyroid dysfunction (history of hyper- or hypothyroidism, or TSH outside the STH reference 
range) 
 
any conditions known to affect bone metabolism  
o inflammatory disease (inflammatory arthritis, inflammatory bowel disease) 
o parathyroid disease 
o malabsorption (coeliac disease, pancreatic exocrine insufficiency) 
o alcohol intake >21 units per week 

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o prolonged immobility (in bed or using a wheelchair for more than three months within 
the last five years) 
o fracture in the last year 
o major orthopaedic surgery in the last year 
 
Taken selenium supplements in the last 60 days (women who are taking selenium supplements 
but want to participate in the trial will be offered the option to stop their supplement and have a 
60 day washout before screening). 
 
Previous adverse reaction to selenium or any of the IMP or placebo excipients 
 
Current or recent medications known to affect bone metabolism  
o Bisphosphonates (12m before) 
o Teriparatide (12m before) 
o Denosumab (12m before) 
o Oestrogen or any sex steroids (12m before) 
o Aromatase inhibitors (12m before) 
o Tamoxifen or raloxifene (12m before) 
o Active vitamin D metabolites; calcitriol, 1α-calcidol (6m before) 
o Anti-epileptics; phenytoin, carbamazepine, primidone, valproate (6m before). Low dose 
use for migraine or neuralgia is not an exclusion. 
o Oral, IM or IV glucocorticoids (6m before) 
 
Women taking calcium and vitamin D supplements will not be excluded as long as they have 
been taking the calcium and vitamin D for at least 60 days and are planning to continue 
throughout the trial. 
 
7.3 Bone density definitions 
Normal bone density is defined as T-score above -1.0.  
Women with normal bone density are not eligible to enter the study. 
Osteopenia is defined as T-score -1.0 to -2.5.  
Most women with osteopenia do not receive treatment with bisphosphates or other medication 
because their fracture risk is not high enough to justify the cost and exposure to side-effects. These 
women will be eligible to enter the study.  
Some women with osteopenia (T-score -1.0 to -2.5) do require pharmacological treatment because 
factors other than BMD indicate a high risk of further fracture (eg prevalent vertebral fracture). 
These women will not be eligible to enter the study.  
Osteoporosis is defined as T-score below -2.5.  
Treatment with bisphosphonates or other medication is advised for most women with osteoporosis. 
These women will not be eligible to enter the study.  
Some women with osteoporosis do not require pharmacological treatment because factors other 
than BMD indicate that they are not yet at high risk of fracture (eg relatively young age with no 
previous fractures, no other risk factors). These women will be eligible to enter the study.  

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Some women with osteoporosis are recommended to receive treatment with bisphosphonates or 
other medication, but decide not to take treatment (eg because of concerns about side-effects). 
These women will be eligible to enter the study. 
Patients recruited through the Metabolic Bone Centre will have already have had BMD 
measurement with fracture risk assessment and a treatment recommendation from a Metabolic 
Bone Centre doctor.  
Potential participants (from GP mailing and adverts) who have not previously had BMD and fracture 
risk assessment will have BMD and fracture risk assessment at screening. The PI (who is also a 
Metabolic Bone Centre doctor) will make the assessment according the same criteria as patients 
attending the Metabolic Bone Centre. If the potential participant is at high risk of fracture and 
requires treatment they will be excluded from the study and the PI will write to the patient and their 
GP with treatment advice. 
7.4 Generalisability 
We will measure baseline serum selenium levels to explore the relationship between baseline 
selenium levels and response to supplementation, but we will not exclude participants based on 
their serum levels. By having an unselected group can we explore whether there is a subset that 
should be targeted or whether everyone benefits. If selenium supplementation proves to be an 
effective preventative measure for women with osteopenia, a requirement for baseline selenium 
measurement might impede widespread adoption, and potential implementation as a public health 
measure. 
To ensure all participants are vitamin D replete, they will be given a single oral dose of 100,000IU 
colecalciferol at the screening visit (NIMP). 
8. PLANNED INTERVENTIONS  
The intervention is a medicinal product containing sodium selenite. We will study two doses: 50 and 
200mcg daily. The preparation is sodium selenite tablets ‘Selenase’ 50mcg and 200mcg (Biosyn, 
Germany). The tablets will be overencapsulated and a matching placebo will be manufactured to 
maintain the blind. 
The mean difference between selenium levels in a replete population (USA) and the UK is about 
60mcg/L. The mean increase in serum selenium with 200mcg/day is 90 mcg/L (19). 200mcg/day is a 
clinically effective dose in Graves’ ophthalmopathy. Therefore 200mcg will be enough to achieve 
repletion in the majority of subjects and to determine whether selenium repletion has a clinically 
significant effect on bone turnover. If we see no effect at this dose we will be confident to accept the 
null hypothesis. 
The 50mcg dose will assess whether a lower dose might be effective for musculoskeletal health – if 
its effect on bone turnover is similar to the 200mcg dose we could recommend the 50mcg dose for 
clinical use, at lower cost and lower risk of adverse effects.  
This is a short, low risk study of a medication that we expect to be well tolerated. We are very 
experienced in recruiting and retaining patients in clinical trials. We expect compliance to be good 
and loss to follow-up to be low (less than 10%). We will make telephone contact with participants 
between study visits (every month) to maintain their engagement and check for adverse effects.  

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The required minimum sample size for the primary endpoint is 21 per group. We will recruit 33 per 
group into the primary analysis to allow for drop-out, group imbalance and secondary endpoint 
analysis.  
9. OUTCOME MEASURES 
Primary endpoint:  
Between-group difference in urinary N-telopeptide of type I collagen (NTX) at six months 
Bone turnover markers change much more rapidly than BMD, so we can determine quickly and cost-
effectively if selenium is likely to have beneficial effects, and if it is well tolerated and safe in the 
short term.  
We chose NTX because we know how change in NTX relates to fracture risk reduction with 
bisphosphonates (20): a 30% decrease in NTX is associated with a 40% reduction in spine fracture 
and 66% of the vertebral fracture risk reduction at three years is explained by change in NTX. Also, 
NTX was the marker mostly strongly related to selenium status in our observational study (9).  
Secondary endpoints:  
Change in serum selenium, selenoprotein P (SePP). Systematic review identified blood selenium and 
selenoprotein P as robust biomarkers of selenium status, over the range of deficiency to repletion 
(21). 
Change in other bone turnover markers: PINP, osteocalcin, CTX 
Change in bone mineral density: lumbar spine and total hip by DXA 
Change in muscle function: short physical performance battery (SPPB), hand grip strength. SPPB 
score is a measure of lower limb strength and balance. It predicts falls, loss of function in activities of 
daily living, nursing home admission and mortality (22-24).   
Change in anti-oxidant activity: glutathione peroxidase activity (a selenium-containing anti-oxidant 
which is increased in postmenopausal women with osteopenia (25)), hydroperoxides (an oxidative 
stress marker shown to be associated with bone resorption (26)) 
Change in inflammatory markers: the pro-resorptive inflammatory cytokine interleukin-6 and highly-
sensitive C-reactive protein. 
10. ASSESSMENT AND FOLLOW-UP  
10.1 Assessment of efficacy/effectiveness 
Efficacy measurements will be obtained at baseline, three months and six months.  
Blood samples for biochemical measurements will be taken fasted. The approximate maximum 
blood sample volume at each visit will be 50ml. Urine samples will be obtained as triplicate samples 
from fasted second morning voids on three days before or including the study visit, and kept 
refrigerated until the study visit. Equal volume aliquots from the urine samples will be pooled into a 
single sample by the study team. Samples will processed according to a sample handling SOP. 
Real-time baseline serum selenium will be measured in the Chemical Pathology laboratory, Sheffield 
Teaching Hospitals.  

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All other samples will be frozen at -80°C, and analysed in batches at the end of the study. 
Urine NTX/Cr will be measured by automated assay (EC Vitros) in the laboratory of the Sheffield 
Academic Unit of Bone Metabolism or Chemical Pathology laboratory, Sheffield Teaching Hospitals. 
Serum selenium at all time points will be measured by X-ray fluorescence spectroscopy (27), 
selenoprotein P will be measured by immunoassay (28) and glutathione peroxidase by enzyme 
analysis by Prof Lutz Schonberg, Institute for Experimental Endocrinology, Charité - University 
Medical School Berlin. 
Other biochemical markers of bone turnover (serum CTX, PINP and osteocalcin) will be measured by 
automated assay in the laboratory of the Sheffield Academic Unit of Bone Metabolism. 
HsCRP and IL-6 will be measured by the Sheffield Teaching Hospitals Clinical Immunology laboratory.  
Hydroperoxidases will be measured using commercially available manual assay kits in the laboratory 
of the Sheffield Academic Unit of Bone Metabolism.  
Grip strength will be assessed using a digital hand dynamometer (Saehan Corporation, Masan, 
Korea). Three measurements will be taken and the best value used for analysis. Short physical 
performance battery (SPPB) score will be calculated from a chair stand and narrow walk test (22). 
See Appendix 1 – Physical function tests. 
Height and weight will be measured with an electric scale and stadiometer. 
Pulse and blood pressure will be measured with an automated sphygmomanometer (Dynamap). 
Bone mineral density will be assessed by DXA of the spine and hip (Hologic) at baseline and six 
months according to standard scanning protocols, by specialist DXA scan technicians in the Sheffield 
Clinical Research Facility. 
Habitual dietary selenium and other nutrient intake (calcium, vitamin D, vitamin E and iodine) will be 
assessed with seven-day diet diaries. The purpose of the food diaries is to describe participants’ 
habitual dietary intake of selenium and nutrients which influence bone turnover or interact with 
selenium during the study. The diaries will be analysed using DIETQ (Tinuviel Software, Warrington, 
UK) by a nutritionist with experience in clinical research. 
DNA will be stored for later analysis. There is evidence of glutathione peroxidase genotype influence 
on selenium action (29). If selenium does reduce bone turnover we can study genotype interactions 
to better understand its mechanism of action. 
10.2 Assessment of safety 
Safety assessments for diabetes and thyroid function will be made at screening, baseline, three 
months and six months. The measurements will be made in real time by Sheffield Teaching Hospitals 
pathology laboratories. Any parameters outside the reference range will be assessed by the PI or a 
delegated study doctor for a decision on whether a participant can safely continue, and clinical 
advice will be given to the participant and GP as required. 
Adverse events (including questioning for possible symptoms of selenium toxicity) will be collected 
from the time of consent, at monthly participant telephone contact throughout the treatment 
period and by telephone four weeks after the end of treatment. 

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10.3 Timing of assessments 
Baseline and randomisation - within 28 days of screening visit 
4W - baseline +28 days (+/-7 days) 
8W - baseline +56 days (+/-7 days) 
13W - baseline +91 days (window +73 to +94 days)  
17W - baseline +119 days (+/-7 days) 
21W - baseline +147 days (+/-7 days) 
26W - baseline + 182 days (window +172 to +187 days) 
30W - 26W + 28 days (+7 days)  
See Appendix 2 – Schedule of procedures 
 
 
11. TRIAL MEDICATION 
11.1 
Name and description of investigational medicinal product(s) 
Selenase 50mcg and Selenase 200mcg (Biosyn, Germany) 
Sodium selenite pentahydrate tablets, over-encapsulated. 
11.2 
Legal status of the drug  
The trial is being carried out under a Clinical Trial Authorisation (CTA). The drug is therefore only to 
be used by the named investigators, for the patients specified in this protocol, and within the trial. 
11.3 
Summary of Product Characteristics (SmPC) 
An IMPD will be submitted to the MHRA who will approve its use in this study. It will be provided by 
Sharp Clinical Services UK and contain the SmPC for Selenase (translated to English).  
The SmPC will be used as the reference safety information (RSI) for assessment of adverse events 
and classification of expectedness of serious adverse reactions for purposes of SUSAR reporting. 
The IMPD and SmPC will be stored in the site file. If it is necessary to update the IMPD and SmPC, the 
new version will be filed in the site file, old versions will be superseded, and the study team will be 
informed. 
11.4  
Preparation and labelling of Investigational Medicinal Product 
The IMP will be prepared and labelled by Sharp Clinical Services UK. The process will be Annex 13 GMP 
compliant. 
 
Selenase 50mcg 
o De-blister Selenase 50mcg tablets. 
o Over-encapsulate one Selenase 50mcg tablet into DBAA el capsules with added 
Microcrystalline Cellulose  
o Count 93 Selenase 50mcg capsules into child-resistant tamper-evident containers and 
apply a randomised label to each container. 

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o Pack two Selenase 50mcg containers, both with the same randomisation number, 
intocartons and apply the same randomised number label to each carton to produce  
patient packs and one QA pack 
 
 
Selenase 200mcg 
o De-blister Selenase 200mcg tablets. 
o Split one Selenase 200mcg tablet and over-encapsulate both halves into DBAA el 
capsules with added Microcrystalline Cellulose 
o Count 93 Selenase 200mcg capsules into child-resistant tamper-evident containers 
and apply a randomised label to each container. 
o Pack two Selenase 200mcg containers, both with the same randomisation number, 
into cartons and apply the same randomised number label to each carton to produce 
patient packs and one QA pack 
 
 
Placebo 
o ProduceDBAA el placebo capsules (filled with appropriate excipient) 
o Count 93 Placebo capsules into child-resistant tamper-evident containers and apply 
a randomised label to each container. 
o Pack two Placebo containers, both with the same randomisation number, into 
cartons and apply the same randomised number label to each carton to produce 
patient packs and one QA pack 
 
 
 
 
Apply tamper evident seals to patient pack cartons. 
 
Take one patient pack per batch for QA destructive testing. 
 
Collate all patient packs together. 
 
Pack all patient packs into outers for shipping purposes. 
 
Carry out disintegration testing on the over-encapsulated Selenase tablets. 
 
Carry out QP final release. 
 
11.5 
Drug storage and supply  
IMP will be provided by Sharp Clinical Services as above, specifically for use in this trial. 
There are two planned manufacturing runs, to allow for possible changes to total participant number 
after the interim analysis. Further runs may be added if required based on the final sample size, 
recruitment time and shelf life of IMP. 
Each manufacturing run will be delivered to Sheffield Teaching Hospitals pharmacy, under the 
supervision of the trial pharmacist. 

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The IMP will be stored at 15 to 25C in STH pharmacy. Temperature logs will be maintained by STH 
pharmacy.  
The first bottle of 93 tablets will be dispensed at the baseline visit, and the second bottle of 93 
tablets at the 13 week visit. Bottles will be labelled with the study identifier (STH19102) and 
participant randomisation code. 
IMP will be dispensed by pharmacy on receipt of a completed study-specific prescription, signed by 
the PI or delegated registered doctor. 
STH pharmacy will retain dispensing records. 
Unused or expired IMP at STH will be sent for hazardous waste disposal as per pharmacy SOPs; a 
record will be kept by pharmacy of what is sent for disposal and reported to the Sponsor if 
requested. 
A 5% excess of patient packs will be manufactured in case a participant loses or damages their 
medication. If a replacement needs to be supplied, Sharp Clinical Services will advise which spare 
pack should be used, according to their copy of the randomisation schedule. 
Participants will be advised to keep the IMP at room temperature. 
 
11.6 
Dosage schedules 
Participants will receive one of three doses: 
 
Selenase 200mcg 
 
Selenase 50mcg 
 
Placebo 
Orally, once daily, in the morning 
The total duration of treatment will be 26 weeks. 
 
11.7 
Dosage modifications  
There are no planned dose modifications.  
If a participant develop diabetes (fasting glucose ≥7.0mmol/l) or thyroid dysfunction (TSH outside 
the reference range and determined as clinically significant by the investigator) during the study 
(identified on safety monitoring bloods, or a new diagnosis reported by participant at monthly 
contact), their treatment will be stopped. If a participant experiences other adverse effects thought 
to be related to IMP the PI will decide if that participant should stop treatment.  
 
11.8 
Known drug reactions and interaction with other therapies  
Ascorbic acid; absorption of selenium possibly reduced by ascorbic acid (give at least 4 hours apart) 
Eltrombopag: selenium possibly reduces absorption of eltrombopag (give at least 4 hours apart) 
 

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11.10 Assessment of compliance 
Compliance will be assessed by asking at each contact whether participants have missed any doses 
of treatment. Participants will also be asked to return their study medication bottles for a pill count. 
The number of reported missed doses and pill count will be recorded in the CRF. 
Patients with less than 75% compliance will continue in the trial and ITT analysis, but will be 
excluded from per-protocol analysis. 
Participants who are non-compliant with the safety monitoring at three months (do not attend or 
decline to have blood test) will be withdrawn from the trial. 
 
11.11 NIMP 
To ensure vitamin D sufficiency, all participants will be given a single bolus dose of colecalciferol 
100,000IU at the screening visit. The colecalciferol will be bulk supplied by STH pharmacy to the 
Clinical Research Facility and stored in a locked drug cupboard, solely for use in this study. A stock 
list will be maintained with the stored supply. The colecalciferol will be prescribed by the PI or 
delegated doctor on a day case prescription chart, and administered by the doctor or specialist 
research nurse. The administration will be recorded on the day case prescription and in the 
participant case report form. 
At the request of the REC committee that approved this trial, there will be an additional bottle of 
open label placebo capsules released from SHARP. This will be the ‘practice placebo’;  volunteers will 
be shown the capsules during the screening visit and offered the opportunity to try taking a placebo 
capsule if they are concerned about their ability to swallow them. These placebo capsules will be 
released from SHARP to STH pharmacy and STH pharmacy will supply the full bottle for storage in 
the Clinical Research Facility. A drug accountability log will be kept to track usage and disposal of 
each capsule. This will also be recorded on the participant case report form.    
12. RISKS AND BENEFITS 
We recognise that in moving from an association study to a clinical trial there is a risk that the trial 
will be negative.  For example, in cross-sectional studies of the effect of a diet rich in fruit and 
vegetables it appeared there was a benefit to bone (30), but this wasn't confirmed in an RCT (31). 
However, because selenium supplementation could be an effective, inexpensive, and well-tolerated 
option for a group with unmet clinical need, we think that the proof of concept from our association 
study justifies moving forward to an RCT rather than repeated observational studies.  
There have been RCTs of selenium in other disease areas so we already have some estimate of dose 
and safety. Studies have investigated the effect of selenium supplementation on a range of other 
health outcomes including cognition, immune function, cancer, cardiovascular function, diabetes, 
fertility and reproduction (8).  
Selenium is used routinely for Graves’ thyroid ophthalmopathy (GO) without side effects or effect on 
thyroid status at doses of 200 mcg/day for six months (32, 33). The UK GO guidelines recommend 
that selenium can be initiated by general practitioners or hospital general physicians, and no 
monitoring of selenium levels or other safety measures is required during the six month course (34).  

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We plan to administer selenium at a maximum dose of 200 mcg per day. The Institute of Medicine 
upper level for selenium is 400 mcg/day, which is 2.5 times below the No Observed Adverse Effect 
Level (35). Therefore the risk of adverse effects in this study is very low. 
There is a published incident of selenium poisoning in 227 people due to mislabelling of a 
supplement product in the USA. The median dose of selenium was 41,585 mcg/day for 30 days. On 
questioning 201 people had symptoms of toxicity (nausea and vomiting, brittle nails, hair loss, joint 
pain, fatigue, irritability and garlic-like taste), 118 had sought medical advice for their symptoms, but 
only one patient required hospitalisation, and none died (36). 
We will ask participants about symptoms of toxicity at each study contact. 
We will measure serum selenium concentration at screening, baseline, three months and six months 
to evaluate the magnitude of effect of the study doses on serum selenium levels. The available data 
suggest that the optimum serum selenium concentration is 130 to 150 mcg/l, and nearly everyone in 
the UK has serum selenium concentrations below this range (8). The population range of serum 
selenium in the USA is 80 to 200 mcg/l. We expect that a dose of 200mcg/day will increase serum 
selenium by an average of 90mcg/l so the number of women whose serum selenium might increase 
above 200mcg/l is small. 
Selenium has a role in thyroid function. There is a reported association of high blood selenium with 
type 2 diabetes, although this was not confirmed in a prospective study with doses of 100 to 300 
mcg/day for 6 months (19). We will exclude volunteers with diabetes or thyroid dysfunction at 
screening, and measure thyroid function, fasting glucose and insulin at screening/baseline, three 
months and six months. We will withdraw participants who develop thyroid dysfunction or diabetes 
during the study. We will analyse between-group differences in change in thyroid function tests and 
blood glucose as a secondary endpoint. 
The data on serum selenium concentration, glucose, thyroid function and any possible symptoms of 
toxicity will be reviewed by the DMEC. 
The study procedures (DXA bone densitometry, blood and urine sampling and muscle function tests) 
carry negligible risks to the participants.  
The radiation dose has been assessed by a Radiation Protection Supervisor and Clinical Radiation 
Expert. 
13. STATISTICS 
 
13.1 Power calculation  
A 20% (10nmol BCE/mmolCr) decrease in urine NTX is a plausible and clinically significant effect size. 
In a previous study, 200mcg daily for six months increased serum selenium by 90mcg/L (19).  
In our observational study of serum selenium and bone turnover markers, the regression coefficient 
of serum selenium and NTX/Cr was -0.101 (9), so if the relationship were causative we would expect 
an increase in serum selenium of 90mcg/L to be associated with a reduction in urine NTX/Cr of 9 
nmol BCE/mmolCr (approximately 20%). 
In support of this estimate, we would not expect as large a change in bone turnover as would be 
seen with a potent anti-resorptive drug such as a bisphosphonate (about 60%), but it might be 

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similar to a weaker anti-resorptive such as a SERM. In a study of six months’ treatment with the 
SERM lasofoxifene (37), NTX decreased by 29%. We have also used this study as a model for the 
likely SD (12.5) and the correlation between NTX/Cr at baseline and six months (0.7).  
A 20% decrease in NTX is clinically significant; a 20% decrease in NTX (about 1 standard deviation 
decrease) with bisphosphonate treatment is associated with a 30% decrease in incident vertebral 
fracture (38). 
To achieve 90% power to detect this mean difference at the 2.5% (two-sided) level will require 21 
patients per group.  To allow for dropout, group imbalance and the secondary endpoint analyses we 
will recruit 33 patients per group with serum selenium below 120mcg/l (99 patients in total).  
We will not exclude women with baseline serum selenium above 120mcg/l, because it is important 
that the results of this study are generalisable into practice, but it is possible that there will be no 
benefit in women who are selenium replete at baseline. Therefore we will recruit enough 
participants to ensure that at least 99 women with baseline serum selenium below 120mcg/l are 
randomised for the primary endpoint analysis. We will determine the total number required from an 
interim analysis of the distribution of baseline serum selenium in the first 40 women recruited. In 
our previous cross-sectional study, 80% of European women had serum selenium below 120mcg/l, 
so we expect that we will need to recruit 120 in total. If at the interim analysis, less than 60% of 
women recruited have serum selenium below 120 mcg/l, the study recruitment strategy will be 
reviewed and discussed with the funder to determine if the trial should proceed. Therefore the 
maximum sample size will be 165 (if 60% of women have serum selenium below 120mcg/l) 
We will conduct a secondary analysis of all participants to determine whether baseline serum 
selenium is a determinant of bone turnover response. 
The power calculation was done by Dr Richard Jacques, statistician at the Sheffield School of Health 
and Related Research (ScHaRR). 
 
13.2 Analysis plan 
 
A detailed statistical analysis plan (SAP) will be developed and finalised prior to the locking of the 
trial database in consultation with the trial steering committee.   
We will conduct an intention-to-treat analysis (all randomised participants) and per-protocol analysis 
(completing participants with 75% compliance). 
Primary endpoint: 
Urine NTX at six months in postmenopausal osteopenic or osteoporotic women with baseline serum 
selenium below 120 mcg/l 
Baseline data will be assessed for comparability between the treatment groups. NTX/Cr will be 
assessed visually for normality and if it is non-Normal a log-transform will be applied, with results 
reported as percentage difference between geometric means. Analysis of covariance (ANCOVA) will 
be used to compare mean NTX/Cr between the groups adjusting for baseline NTX/Cr measurements. 
The Hochberg procedure will be used to account for multiple comparisons; P-values are ordered 
from smallest to largest.  If the largest P-Value is less than 0.05 then all null hypotheses can be 

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rejected.  If not, if the second P-value is less than 0.05/2, then all bar the largest can be rejected, and 
so on (SA Julious, An Introduction to Statistics in Early Phase Trials). 
Secondary endpoints: 
Urine NTX at three months: analysis as described for the primary endpoint 
Serum selenium, SePP, serum CTX, PINP, osteocalcin, thyroid function, glucose and insulin at three 
and six months: analysis as described for the primary endpoint. 
BMD by DXA at six months: analysis as described for the primary endpoint. 
We will examine impact of baseline selenium levels on the NTX response to selenium 
supplementation by fitting a linear model with NTX at follow-up as the dependent variable and 
baseline selenium, baseline NTX and dose as independent variables.  With n=66 (receiving active 
treatment) the minimum correlation that can be detected with 90% power and 5% significance level 
is 0.44. 
Short physical performance battery, grip strength, hydroperoxidases, glutathione peroxidase 
activity, highly sensitive CRP, IL-6 analysis as described for the primary endpoint. 
There is no planned interim analysis of outcome measures. There will be an interim analysis of 
baseline serum selenium to determine the final sample size. 
 
14. STUDY SETTING 
This is a single centre study. 
It will be conducted in the Sheffield NIHR Clinical Research Facility at the Northern General Hospital, 
Sheffield. The CRF is a purpose-built facility, and contains all the resources needed for this study, 
including research specialist nurses, DXA and sample handling. The CRF has a high standard of 
governance and oversight. All studies are conducted as per organisational SOPs which are compliant 
with GCP and other regulatory requirements. Studies taking place in the CRF are subject to regular 
monitoring and audit. 
Participants will be identified through Sheffield Metabolic Bone Centre, but also through primary 
care Patient Identification Centres. 
15. ETHICAL CONSIDERATIONS  
The study will require REC, MHRA, HRA and local R+D approval and no study procedures will be 
undertaken until all approvals are in place. 
The study will be conducted according to GCP and ICH regulations, and the Medicines for Human 
Use (Clinical Trials) Regulations 2004. 
Written informed consent will be obtained from all participants, supported by a detailed Participant 
Information Sheet. Data and samples will be managed in accordance with the Data Protection Act 
and Human Tissue Act requirements. 
There is no standard care pathway for women with osteopenia or osteoporosis whose fracture risk is 
not yet high enough to qualify for treatment. Usual practice would be to advise on modifiable risk 

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factors (such as dietary calcium intake and smoking) and consider repeat bone densitometry in a few 
years. Therefore this intervention will be in addition to usual care, and there is no ethical concern 
about using a placebo control. 
Selenium has already been used at these doses and duration of treatment in clinical studies and in 
usual care of Graves’ ophthalmopathy without adverse events. 
The study intervention and procedures carry negligible risk to participants. The radiation dose for 
two DXA measurements of the spine and hip is 45.2microSv, equivalent to 7 days’ natural 
background radiation. 
Participants will be given travel reimbursement of £20 per visit, or provided with taxi transport for 
study visits. They will not receive any other payment for taking part in the study. 
At the end of their study participation, the PI or delegated medical practitioner will write to the 
participants GP to inform them that their patient has completed the study, and give advice on any 
further recommended treatment and follow-up. 
 
16.  RECRUITMENT 
A log will be kept of: 
- 
Number of patient records assessed for pre-eligibility in Metabolic Bone Centre 
- 
Number of patients approached from Metabolic Bone Centre and GP mailing 
- 
Number of responders from these approaches 
- 
Number of volunteers responding to adverts 
 
- 
For responders not eligible on pre-eligibility check we will record reason for ineligibility  
All volunteers who pass pre-eligibility checks and attend for consent and screening will be registered 
and allocated a study screening number. The screening number will be in the format COS001, 
COS002 etc. 
16.1 Participant identification 
Participants will be identified from four sources: 
 
AUBM volunteer database 
AUBM keeps a database of previous study participants, screen failures from previous studies and 
volunteers who have asked to be added to the database for future research opportunities. All 
participants have given consent to be approached about future studies. 
Potential participants will be sent an invitation letter and PIS, with a reply slip to request or 
decline further contact from the study team. Potential participants who do not return the reply 
slip will be contacted once by telephone to follow-up the invitation. 
On receipt of a positive reply, the study team will make contact with the volunteer to discuss the 
study, answer questions and confirm pre-eligibility according to the inclusion/exclusion criteria. 
Volunteers who are willing to participate and meet pre-eligibility criteria will be invited to a 
study visit for informed consent and screening. 
 
Metabolic Bone Centre, Northern General Hospital 

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Fracture risk assessment reports will be screened for potentially eligible participants. This will 
include identifiable personal information, but will be done by the PI (who is a member of the 
clinical care team) or other member of the clinical care team. 
Potential participants will be sent an invitation letter and PIS, with a reply slip to request or 
decline further contact from the study team. Patients who do not return the reply slip will be 
contacted once by telephone to follow-up the invitation. 
On receipt of a positive reply, the study team will make contact with the patient to discuss the 
study, answer questions and confirm pre-eligibility according to the inclusion/exclusion criteria. 
Patients who are willing to participate and meet pre-eligibility criteria will be invited to a study 
visit for informed consent and screening. 
 
 
Mailing from GP surgeries 
GPs will be asked to send an invitation letter with reply slip to women age over 55 registered 
with their practice, and to screen the mailing list to remove anyone that it would be 
inappropriate to approach (eg dementia or current serious illness).  
This will include identifiable personal information, but will be done by the clinical care team at 
the GP practice. The practice will be given a search strategy for this screening activity to ensure 
that screening is transparent and terms are defined. 
On receipt of a positive reply, the study team will make contact with the patient to discuss the 
study, send a PIS and confirm pre-eligibility according to the inclusion/exclusion criteria. Patients 
who are willing to participate and meet pre-eligibility criteria will be invited to a study visit for 
informed consent and screening. 
 
 
Posters/email/website/word of mouth 
Emails will be sent to hospital and university staff, through central IT services. The University has 
an established ‘volunteers’ mailing list. Posters will be displayed around the hospital and 
university, at patient and public events relevant to health and osteoporosis, and other public 
places such as GP surgeries and local businesses. Information on the study will be displayed on 
the hospital and university website.  
The wording of all of these media will be submitted for REC and HRA approval. 
On receipt of enquiries from these sources, the study team will make contact with the volunteer 
to discuss the study, send a PIS and confirm pre-eligibility according to the inclusion/exclusion 
criteria. Volunteers who are willing to participate and meet pre-eligibility criteria will be invited 
to a study visit for informed consent and screening. 
Volunteers through any route will not be actively asked to pass on study information to friends 
or family, but if friends or family express interest in the study they will be advised to contact the 
study team who will follow the same procedure as for poster and email responders. 
 
 
16.2  Screening requirements 
Medical history for inclusion/exclusion criteria 
BMD spine and hip by DXA (results within the last 6 months can be used) 

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Blood tests –for diabetes mellitus, thyroid dysfunction, bone profile 
Volunteers will be shown the study capsules and offered the opportunity to try taking a placebo capsule 
if they are concerned about their ability to swallow the capsules. 
Eligibility will be confirmed by the PI or delegated medical practitioner. 
16.3  Consent  
The PI retains overall responsibility for the informed consent of participants at their site and will 
ensure that any person delegated responsibility to participate in the informed consent process is 
duly authorised, trained and competent to participate according to the ethically approved protocol, 
principles of Good Clinical Practice (GCP) and Declaration of Helsinki.  
Consent will be obtained by a doctor or specialist research nurse with appropriate training and 
experience assessed and delegated by the PI 
This study will not include vulnerable participants or participants who lack capacity. 
Informed consent will be obtained prior to the participant undergoing any trial procedures. 
Each prospective participant will receive a participant information sheet giving details of the study 
and will have at least 24 hours to consider their participation in the study. All participants will also be 
given a verbal explanation of the information in the PIS and the opportunity to ask questions before 
the first visit, during the consent process and throughout the duration of the study. The consent 
process will follow the Sheffield CRF SOP for informed consent. 
Where a participant is able to consent but later becomes incapacitated, they will be withdrawn from 
the study. Data obtained up to that point will be retained and used in analysis. This is specified in the 
PIS.  
 
17. RANDOMISATION 
Participants will be block randomised equally to the three treatment arms. 
The randomisation list will be generated by Sharp Clinical Services. The list will be supplied to STH 
pharmacy and a copy retained by Sharp. 
At randomisation, participants will be allocated a study ID number which corresponds to their 
randomised medication number (the ID number will be in the format SE???, where ??? is the 
randomised medication pack number). 
The code list will be stored in STH pharmacy, in a sealed signed envelope under the supervision of the 
study pharmacist, or out-of-hours duty pharmacist. This envelope is signed when opened and resealed 
for audit purposes.  If emergency access is required out of hours, the PI or if unavailable, another 
metabolic bone consultant can be contacted through STH switchboard. If they agree that the code need 
to be broken, the duty pharmacist will access the list. 
 
18.  BLINDING 
This is a double-blind trial. The investigators, clinical study team, participants and analysing statistician 
will be blind to treatment allocation. 
The active treatment will be overencapsulated and a matched placebo manufactured to maintain the 
blind. 

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The blind will not be broken until final database lock. 
The study code will  only be broken before database lock for medical or safety reasons e.g. in the case of 
a serious adverse event where it is necessary for the investigator or treating health care professional to 
know which treatment the patient is receiving before the participant can be treated. Subject always to 
clinical need, where possible, members of the research team will remain blinded. 
If unblinding is required, a formal request will be made by the investigator/treating health care 
professional. If the person requiring the unblinding is a not a member of the investigating team, they 
should discuss the break with the investigator, unless there is a clinical emergency which requires 
immediate knowledge of the allocation.The PI will document the breaking of the code and the reasons 
for doing so on the CRF, in the site file and medical notes. It will also be documented in the final study 
report and statistical report. The Investigating team will notify the Sponsor in writing as soon as possible 
following the code break detailing the necessity of the code break. The written information will be 
disseminated to the Data Safety Monitoring Committee. 
 
19. PHARMACOVIGILANCE 
19.1 Reporting Period 
The reporting period for adverse events will be from the date of informed consent until 28 days after 
the last administration of IMP.  Any AEs that are ongoing at the close of the reporting period will be 
followed up until either resolved or stable. 
19.2 Definitions 
An Adverse Event (AE) is defined as any untoward medical occurrence in a subject during the course 
of the trial. Pre-existing conditions, although they will be recorded, will not be regarded as AEs 
unless they worsen significantly. This will be determined by PI or delegated doctor. Recognised side 
effects of the IMP are fully documented in the Summary of Product Characteristics of the IMP in 
question. All adverse events will be recorded in a Case Report Form and assessed for seriousness, 
expectedness and causality by PI or delegated doctor. 
A Serious Adverse Event (SAE) will be defined as an AE which either  
a) Results in death 
b) Is life-threatening  
c) Requires hospitalisation or prolongation of existing hospitalisation 
d) Results in persistent disability or incapacity 
e) Consists of a congenital abnormality or birth defect 
Important medical events that may not be immediately life-threatening or result in death or 
hospitalisation but may jeopardise the patient or may require intervention to prevent one of the 
other outcomes listed in the definition above will also be considered serious. 
The PI or delegated doctor will determine the seriousness of each adverse event as per these 
criteria. 
19.3 Causality 
The PI or delegated doctor will determine the causality of each adverse event as defined here: 

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Unrelated or unlikely: a clinical event including laboratory test abnormality with temporal 
relationship to trial treatment or IMP administration, that makes a causal relationship incompatible 
or for which other drugs, chemicals or disease provide a plausible explanation. This will be counted 
as “unrelated” for notification purposes. 
Possible: a clinical event, including laboratory test abnormality, with temporal relationship to trial 
treatment or IMP administration which makes a causal relationship a reasonable possibility, but 
which could also be explained by other drugs, chemicals or concurrent disease. This will be counted 
as “related” for notification purposes. 
Probable: a clinical event, including laboratory test abnormality, with temporal relationship to trial 
treatment or IMP administration which makes a causal relationship a reasonable possibility, and is 
unlikely to be due to other drugs, chemicals or concurrent disease. This will be counted as “related” 
for notification purposes. 
Definite: a clinical event, including laboratory test abnormality, with temporal relationship to trial 
treatment or IMP administration which makes a causal relationship a reasonable possibility, and 
which can definitely not be attributed to other causes. This will be counted as “related” for 
notification purposes. 
A SAE whose causal relationship to a study IMP is assessed by the Chief Investigator as “possible”, 
“probable” or “definite” will be considered ‘related’ and is an Adverse Drug Reaction. 
Suspected Unexpected Serious Adverse Reactions (SUSARs)  
A SUSAR is any event which qualifies as an SAE and meets the criteria of being judged as possibly, 
probably or definitely related to study IMP and has a nature and/or severity of which is not 
consistent with the information about the medicinal product in question as set out in the summary 
of product characteristics, investigator brochure or IMP dossier for that product (ie it is 
‘unexpected’).  
A SUSAR will require expedited reporting as per the Clinical Trials Regulations. All serious adverse 
events that fall or are suspected to fall within these criteria shall be treated as a SUSAR until deemed 
otherwise. 
 
19.4 Responsibilities 
The Principal Investigator will: 
• 
Assess the event for seriousness, expectedness and relatedness to the study IMP as set out 
above 
• 
Record all SAEs on standardised SAE forms and report them to the Sponsor by fax (STH R&D 
0114 2265937) or email (sae@sth.nhs.uk) within 24 hours of the becoming aware of the event. 
• 
Take appropriate medical action, which may include halting the trial and inform the Sponsor 
of such action 
 
The Sponsor will: 

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• 
Report SUSARs which are fatal and life-threatening to the Competent Authority within 7 
days. 
• 
Report SUSARs which are not fatal and not life-threatening to the Competent Authority 
within 15 days. 
• 
Within a further 8 days send any follow-up information and reports to the MHRA.  
• 
Make any amendments as required to the study protocol and inform the ethics and 
regulatory authorities as required 
20. WITHDRAWAL 
 
Participants will be withdrawn at the participant’s request, if they have a serious adverse reaction, if 
they develop diabetes or thyroid dysfunction, if they lose capacity, if they require treatment with 
medication on the prohibited list or if they develop any new medical problems which would render 
the study measurements invalid. 
If IMP is stopped, and if the participant is willing, wherever possible they will be asked to continue to 
complete study assessments unless the PI judges this to be inappropriate due to the participant’s 
health or personal circumstances. This decision will be documented in the CRF and site file, reported 
to the DMEC and included in the final study report. 
21. SAMPLE STORAGE AND ANALYSIS 
Biological samples collected from participants as part of this trial will be transported, stored, 
accessed and processed in accordance with national legislation relating to the use and storage of 
human tissue for research purposes and such activities shall at least meet the requirements as set 
out in the 2004 Human Tissue Act. 
Blood and urine samples will be obtained and processed according to a study-specific sample 
handling SOP. This study-specific SOP will be reviewed and approved by Sponsor and stored in the 
site file. 
Consent to use and store the samples will be obtained according to the Human Tissue Act 2004.  
Safety bloods will be measured in real-time by Sheffield Teaching Hospitals clinical laboratories. 
Other blood and urine samples will be stored frozen at -80C until completion of all visits, and 
measured in batches. Samples will also be stored for later measurement of additional biochemical 
factors relevant to the aims of this study and the interpretation of the results, such as, but not 
limited to, other bone metabolism and anti-oxidant markers.  
Some samples will be sent to collaborators at other centres for specialist measurements. Any 
samples transferred will be anonymised, and subject to a material transfer agreement. Any sample 
remaining after analysis at other centres will be returned to STH as per the terms of the material 
transfer agreement. 
Samples will be stored in the STH HTA licensed biorepository and on completion of the study will be 
adopted by the South Yorkshire and North Derbyshire Musculoskeletal Biobank (REC ref 
15/SC/0132). Additional tests relevant to and bone metabolism and musculoskeletal health may be 
carried out on these samples in the future. Any such additional testing will be reviewed and 

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approved by the Biobank committee prior to testing. This is detailed in the participant information 
sheet and on the informed consent form. 
22. DATA PROTECTION 
Data will be kept secure according to the Data Protection Act 1998. All paper records will be stored 
in locked filing cabinets. DXA images will be stored on CD, identified by study number, initials and 
date of birth in locked filing cabinets. All electronic data will be identified by study number initials 
and date of birth and will be stored in a password protected database, on password protected 
computers (and encrypted laptops).  
Participants will be asked for consent for their GP to be informed of their participation in the study. 
All data reported will be fully anonymised. 
Study documentation will be stored securely for 15 years after the study has been completed as per 
Sponsor SOPs. 
23. GOVERNANCE AND MANAGEMENT 
Sheffield Teaching Hospitals NHS Foundation Trust will be the study Sponsor. The study will be 
conducted according to appropriate Sponsor SOPs, Sheffield NIHR CRF SOPs, AUBM SOPs, study 
specific SOPs which will be reviewed by Sponsor and Good Clinical Practice. The study will be 
monitored by the STH Research Department Sponsor at regular intervals according to their standard 
procedures. In addition the project will be subject to internal monitoring to ensure quality of data, 
including source data verification and review of investigator site file essential documents, informed 
consent procedures, inclusion and exclusion criteria, patient clinical documentation, case report 
form and source data consistency and safety documentation and reporting to ensure compliance 
with legislation. 
Study procedures will be carried out in the Sheffield NIHR Clinical Research Facility. All research 
personnel employed by the University of Sheffield have STH honorary contracts and research 
passports. The study will be carried out in compliance with the protocol and in accordance with the 
AUBM and CRF standard operating procedures. Any instances of non-compliance with the protocol 
will be reported to Sponsor and recorded in the Trial Master File according to SOPs. 
Jennifer Walsh (CI) (University of Sheffield) will write the protocol and regulatory submissions, 
supervise study staff, confirm subject eligibility, provide clinical oversight (including AE assessment), 
and lead report and manuscript writing. She will be a member of the TMG and attend the TSC. 
Richard Eastell (University of Sheffield). will provide expertise in clinical trial design, clinical 
oversight, supervise the biochemical measurements and contribute to data interpretation, report 
and manuscript writing. He will be a member of the TMG and attend the TSC. 
Tom Hill (Newcastle University) will provide clinical nutrition expertise, supervise the dietary 
assessments and contribute to data interpretation, report and manuscript writing. 
Graham Williams (Imperial College London) will provide expertise on the interpretation of thyroid 
function and anti-oxidant results, contribute to report and manuscript writing.  

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John Mathers (Newcastle University) will provide expertise in assessing selenium status. He will 
contribute to study design, data interpretation and manuscript writing. 
Cindy Cooper (University of Sheffield) will advise on trial design and set-up, data interpretation and 
manuscript writing. She will be invited to attend the TSC. 
Study staff will be supervised on a day-to-day basis by JW and RE, and attend the monthly CTIMP 
meeting. The nurse, co-ordinator and project manager are line managed through the Sheffield NIHR 
CRF. 
Sheffield CTRU have advised on study management and statistics. Statistical support for this study is 
provided by the School of Health and Related Research (ScHaRR), Dr Richard Jacques. 
Recruitment progress, adverse events and any relevant new information will be reviewed at the 
Sheffield AUBM monthly CTIMP management meeting. These meetings are minuted and the 
minutes pertaining to this study will be given to the TSC. 
A Trial Steering Committee will be convened for the study, with an independent chair from Sheffield 
CTRU and representation from the Sheffield Lay Advisory Panel for Bone Research. The TSC will meet 
six monthly during the two-year project period, and reports from each meeting will be submitted to 
NIHR. 
A DMEC will be convened with an independent chair and statistician. The DMEC will meet six 
monthly from the start of recruitment, to review study progress, recruitment and protocol 
adherence. A member of the investigator team will be identified who can supply the necessary 
unblinded data to the DMEC for their review whilst maintaining the blind with the rest of the 
investigator team.  The committee will receive unblinded information on serum selenium, insulin, 
glucose and thyroid function, adverse events and any possible symptoms of selenium toxicity. The 
DMEC will report summary blinded data to the TSC, unless there are any concerns which require 
consideration of unblinded information. 
If it is necessary for the protocol to be amended, the amendment and/or a new version of the study 
protocol will be notified to or approved by the ethics committee. If new information becomes 
available that may affect subject participation or safety on the study, revised patient information 
sheets will be prepared and approved by the ethics committee and Sponsor before subjects are 
provided with this new information and asked to re-consent. 
24. TIMELINES  
Milestone 1: REC, MHRA and Sheffield R+D approval: Nov 2016 
Milestone 2: First patient recruited: Dec 2016 
Milestone 3: Last patient recruited: Oct 2017 
Milestone 4: All study visits complete: Apr 2018 
Milestone 5: Biochemical measurements complete: Jun 2018 
Milestone 6: Database checked and locked 
Milestone 7: Statistical analysis complete: July 2018 

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Milestone 8: Report and manuscript complete: Sep 2018 
 
End of trial 
The end of trial will be completion of biochemical analysis (which will be the last data items, expected to 
be two months after the last patient last visit). The sponsor will notify the MHRA and main REC of the 
end of the trial within 90 days of its completion. An end of trial report will be submitted to EudraCT by 
the Sponsor. 
25. PATIENT AND PUBLIC INVOLVEMENT 
The Sheffield Lay Advisory Panel for Bone Research have reviewed this study. The Panel was 
established in 2009, and have made valuable contributions to these aspects of research in the 
Academic Unit of Bone Metabolism since then. They have received training in research methods, 
research governance and grant application processes. The Panel have presented their work at 
national PPI conferences such as INVOLVE. There are currently ten members. Their meetings are 
supported by a senior research nurse and an administrator. 
The panel are consulted at the start of study development, and advise on the prioritisation of 
possible new research.  
This study has been assessed by the Panel. These are their comments: ‘The Lay Panel has read the 
brief outlining the research proposal, and had the opportunity to receive a presentation and ask 
questions about it. The Panel feels that this is worthwhile research focussing on a group of patients 
for whom bone strength is important. It feels that participation will be attractive to patients who will 
like the idea of receiving a nutritional supplement rather than a medication. The Panel would be 
pleased to support this application.’ 
They have reviewed the lay summary. 
They review and contribute to the participant information documents and advise on recruitment 
strategy. The Panel will receive updates on study progress at their monthly meetings, where they 
have the opportunity to discuss the study with investigators and other members of the study team. 
The Lay Panel will be invited to send a representative to the TSC, and the minutes of the TSC will be 
available to the whole Lay Panel.  
The start of the study will be publicised through the University of Sheffield, Sheffield Teaching 
Hospitals and National Osteoporosis Society, with contact details for any members of the public who 
would like further information on the study protocol or conduct. 
On completion of the study the Lay Panel will write a lay summary of the results which will be sent 
to study participants, and publicised through University of Sheffield, Sheffield Teaching Hospitals and 
the National Osteoporosis Society. The Lay Panel will also be offered the opportunity to present the 
results at national PPI meetings. 
 
 

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Moghadaszadeh B, Beggs AH. Selenoproteins and their impact on human health through 
diverse physiological pathways. Physiology (Bethesda). 2006;21:307-15. 
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Kohrle J, Jakob F, Contempre B, Dumont JE. Selenium, the thyroid, and the endocrine 
system. Endocrine reviews. 2005;26(7):944-84. 
3. 
Hatfield DL, Tsuji PA, Carlson BA, Gladyshev VN. Selenium and selenocysteine: roles in 
cancer, health, and development. Trends in biochemical sciences. 2014;39(3):112-20. 
4. 
Jakob F, Becker K, Paar E, Ebert-Duemig R, Schutze N. Expression and regulation of 
thioredoxin reductases and other selenoproteins in bone. Methods in enzymology. 2002;347:168-79. 
5. 
Duntas LH. Selenium and inflammation: underlying anti-inflammatory mechanisms. 
Hormone and metabolic research = Hormon- und Stoffwechselforschung = Hormones et 
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6. 
Vaananen HK, Zhao H, Mulari M, Halleen JM. The cell biology of osteoclast function. Journal 
of cell science. 2000;113 ( Pt 3):377-81. 
7. 
Nutrition SACo. SACN position statement on selenium and health Department of Health. 
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8. 
Rayman MP. Selenium and human health. Lancet. 2012;379(9822):1256-68. 
9. 
Hoeg A, Gogakos A, Murphy E, Mueller S, Kohrle J, Reid DM, et al. Bone turnover and bone 
mineral density are independently related to selenium status in healthy euthyroid postmenopausal 
women. The Journal of clinical endocrinology and metabolism. 2012;97(11):4061-70. 
10. 
Lauretani F, Semba RD, Bandinelli S, Ray AL, Guralnik JM, Ferrucci L. Association of low 
plasma selenium concentrations with poor muscle strength in older community-dwelling adults: the 
InCHIANTI Study. The American journal of clinical nutrition. 2007;86(2):347-52. 
11. 
Zhang Z, Zhang J, Xiao J. Selenoproteins and selenium status in bone physiology and 
pathology. Biochim Biophys Acta. 2014;1840(11):3246-56. 
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Manolagas SC. From Estrogen-Centric to Aging and Oxidative Stress: A Revised Perspective 
of the Pathogenesis of Osteoporosis. EndocrRev. 2010. 
13. 
Cao JJ, Gregoire BR, Zeng H. Selenium deficiency decreases antioxidative capacity and is 
detrimental to bone microarchitecture in mice. The Journal of nutrition. 2012;142(8):1526-31. 
14. 
Min Z, Zhao W, Zhong N, Guo Y, Sun M, Wang Q, et al. Abnormality of epiphyseal plate 
induced by selenium deficiency diet in two generation DA rats. APMIS. 2015;123(8):697-705. 
15. 
Moreno-Reyes R, Egrise D, Neve J, Pasteels JL, Schoutens A. Selenium deficiency-induced 
growth retardation is associated with an impaired bone metabolism and osteopenia. Journal of bone 
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2001;16(8):1556-63. 
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Jacobsen SJ, Goldberg J, Miles TP, Brody JA, Stiers W, Rimm AA. Regional variation in the 
incidence of hip fracture - US white women aged 65 years and older. JAMA. 1990;264:500-1. 
17. 
Moreno-Reyes R, Suetens C, Mathieu F, Begaux F, Zhu D, Rivera MT, et al. Kashin-Beck 
osteoarthropathy in rural Tibet in relation to selenium and iodine status. The New England journal of 
medicine. 1998;339(16):1112-20. 
18. 
Lauretani F, Semba RD, Bandinelli S, Ray AL, Ruggiero C, Cherubini A, et al. Low plasma 
selenium concentrations and mortality among older community-dwelling adults: the InCHIANTI 
Study. Aging clinical and experimental research. 2008;20(2):153-8. 
19. 
Rayman MP, Blundell-Pound G, Pastor-Barriuso R, Guallar E, Steinbrenner H, Stranges S. A 
randomized trial of selenium supplementation and risk of type-2 diabetes, as assessed by plasma 
adiponectin. PloS one. 2012;7(9):e45269. 
20. 
Eastell R, Hannon RA, Garnero P, Campbell MJ, Delmas PD. Relationship of early changes in 
bone resorption to the reduction in fracture risk with risedronate: review of statistical analysis. 

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Journal of bone and mineral research : the official journal of the American Society for Bone and 
Mineral Research. 2007;22(11):1656-60. 
21. 
Hurst R, Collings R, Harvey LJ, King M, Hooper L, Bouwman J, et al. EURRECA-Estimating 
selenium requirements for deriving dietary reference values. Crit Rev Food Sci Nutr. 
2013;53(10):1077-96. 
22. 
Guralnik JM, Simonsick EM, Ferrucci L, Glynn RJ, Berkman LF, Blazer DG, et al. A short 
physical performance battery assessing lower extremity function: association with self-reported 
disability and prediction of mortality and nursing home admission. J Gerontol. 1994;49(2):M85-94. 
23. 
Minneci C, Mello AM, Mossello E, Baldasseroni S, Macchi L, Cipolletti S, et al. Comparative 
study of four physical performance measures as predictors of death, incident disability, and falls in 
unselected older persons: the insufficienza Cardiaca negli Anziani Residenti a Dicomano Study. 
Journal of the American Geriatrics Society. 2015;63(1):136-41. 
24. 
Veronese N, Bolzetta F, Toffanello ED, Zambon S, De Rui M, Perissinotto E, et al. Association 
between Short Physical Performance Battery and falls in older people: the Progetto Veneto Anziani 
Study. Rejuvenation Res. 2014;17(3):276-84. 
25. 
Hahn M, Conterato GM, Frizzo CP, Augusti PR, da Silva JC, Unfer TC, et al. Effects of bone 
disease and calcium supplementation on antioxidant enzymes in postmenopausal women. Clinical 
biochemistry. 2008;41(1-2):69-74. 
26. 
Cervellati C, Bonaccorsi G, Cremonini E, Romani A, Fila E, Castaldini MC, et al. Oxidative 
stress and bone resorption interplay as a possible trigger for postmenopausal osteoporosis. BioMed 
research international. 2014;2014:569563. 
27. 
Hoeflich J, Hollenbach B, Behrends T, Hoeg A, Stosnach H, Schomburg L. The choice of 
biomarkers determines the selenium status in young German vegans and vegetarians. The British 
journal of nutrition. 2010;104(11):1601-4. 
28. 
Hollenbach B, Morgenthaler NG, Struck J, Alonso C, Bergmann A, Kohrle J, et al. New assay 
for the measurement of selenoprotein P as a sepsis biomarker from serum. J Trace Elem Med Biol. 
2008;22(1):24-32. 
29. 
Crosley LK, Bashir S, Nicol F, Arthur JR, Hesketh JE, Sneddon AA. The single-nucleotide 
polymorphism (GPX4c718t) in the glutathione peroxidase 4 gene influences endothelial cell function: 
interaction with selenium and fatty acids. Mol Nutr Food Res. 2013;57(12):2185-94. 
30. 
Macdonald HM, New SA, Fraser WD, Campbell MK, Reid DM. Low dietary potassium intakes 
and high dietary estimates of net endogenous acid production are associated with low bone mineral 
density in premenopausal women and increased markers of bone resorption in postmenopausal 
women. The American journal of clinical nutrition. 2005;81(4):923-33. 
31. 
Neville CE, Young IS, Gilchrist SE, McKinley MC, Gibson A, Edgar JD, et al. Effect of increased 
fruit and vegetable consumption on bone turnover in older adults: a randomised controlled trial. 
Osteoporosis international : a journal established as result of cooperation between the European 
Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2014;25(1):223-
33. 
32. 
Marcocci C, Marino M. Treatment of mild, moderate-to-severe and very severe Graves' 
orbitopathy. Best practice & research Clinical endocrinology & metabolism. 2012;26(3):325-37. 
33. 
Marcocci C, Kahaly GJ, Krassas GE, Bartalena L, Prummel M, Stahl M, et al. Selenium and the 
course of mild Graves' orbitopathy. The New England journal of medicine. 2011;364(20):1920-31. 
34. 
Perros P, Dayan CM, Dickinson AJ, Ezra D, Estcourt S, Foley P, et al. Management of patients 
with Graves’ orbitopathy: initial assessment, management outside specialised centres and referral 
pathways. Clinical Medicine. 2015;15(2):173-8. 
35. 
Institute of Medicine. Dietary reference intakes for vitamin C, vitamin E, selenium and 
carotenoids: National Academies Press; 2000. 

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36. 
MacFarquhar JK, Broussard DL, Melstrom P, Hutchinson R, Wolkin A, Martin C, et al. Acute 
selenium toxicity associated with a dietary supplement. Archives of internal medicine. 
2010;170(3):256-61. 
37. 
Rogers A, Glover SJ, Eastell R. A randomised, double-blinded, placebo-controlled, trial to 
determine the individual response in bone turnover markers to lasofoxifene therapy. Bone. 
2009;45(6):1044-52. 
38. 
Eastell R, Barton I, Hannon RA, Chines A, Garnero P, Delmas PD. Relationship of early 
changes in bone resorption to the reduction in fracture risk with risedronate. Journal of bone and 
mineral research : the official journal of the American Society for Bone and Mineral Research. 
2003;18(6):1051-6. 
 
 
 

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APPENDIX 1 – Physical function tests 
 
Short Physical Performance Battery (SPPB) 
The SPPB score is calculated from three tests: chair stand, tandem balance and 8 feet walk. A score 
between 0 (worst performance) and 12 (best performance) is obtained by totalling the scores from 
the three tests. All of the procedures will be carried out with the participant wearing comfortable 
walking shoes with no or minimal heels to eliminate the effect of footwear on performance.  
 
Repeated Chair Stand Test 
The repeated chair stand test measures the ability of the participant to stand from a chair without 
using their arms; reflecting the strength of their legs. The participant will be asked to sit on a chair 
with their feet placed on the floor, squarely in front of them and their knees flexed slightly greater 
than 90° so that their heels are closer to the chair than the back of their knees. The participant will 
be asked to fold their arms across their chest and to keep them folded throughout the test. The 
participant will be asked to stand and sit one time to determine their capability to continue to the 
main part of the test and to familiarise them with the procedure. The participant will be asked to 
stand and sit five times without stopping, as quickly as possible. The time taken for the participant to 
complete the 5 stand and sit cycles will be recorded to the nearest one hundredth of a second. If the 
participant is unable to complete the test this will be recorded, with the number of completed 
cycles, where applicable.  
Walking aids must not be used during the test and the procedure will be carried out with the 
participant wearing comfortable walking shoes with no or minimal heels to eliminate the effect of 
footwear on performance.  
Grading:  
0 = unable 
1 = >16.7 sec 
2 = 16.6-13.7 sec 
3 = 13.6-11.2 sec 
4 = <11.1 sec 
 
 
Balance Testing 
The participant will be asked to stand, unaided, with their feet in three different positions for a 
maximum of 10 seconds per position.  
 
 
 
 
 

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a) The first position is the feet in a side by side position. Participants can hold on to the researcher’s 
arms in order to initially gain balance. When ready, the participant will be asked to hold the position, 
unaided, for a maximum of 10 seconds. Participants can move their arms, body and bend their knees 
to maintain balance but they should not move their feet. If the participant is able to hold this 
position for 10 seconds then they may progress onto the next stand position.  
b) The next stand position is a semi-tandem stand. The heel of one foot is placed by the big toe of 
another foot. Participants can hold on to the researcher’s arms in order to initially gain balance. 
Participants will be asked to hold this position, unaided, for a maximum of 10 seconds. Participants 
can move their arms, body and bend their knees to maintain balance but they should not move their 
feet. If the participant is able to hold this position for 10 seconds then they progress onto the final 
stand position.  
c) The final stand position is the full tandem stand.  The participant will be asked to stand with the 
heel of one foot in front of and touching the toes of the other foot. Participants can hold on to the 
researcher’s arms in order to initially gain balance. When ready, participants will be asked to hold 
this position, unaided, for a maximum of 10 seconds. Timing begins when the participant has let go 
of the researcher with their feet in the correct position. Participants can move their arms, body and 
bend their knees to maintain balance but they should not move their feet. 
 
Balance Score: 
0 = side by side 0-9 seconds or unable 
1 = side by side 10 seconds, <10 seconds on semi-tandem 
2 = semi-tandem 10 seconds, 0-2 seconds full tandem 
3 = semi-tandem 10 seconds, 3-9 seconds full tandem 
4 = tandem 10 seconds.  
 
 
8 feet walk course (2.44 metres) 
A 2.44 metres walk course will be marked out. Participants will be asked to walk at their usual pace 
from the start point to the other end of the course (2.44 metres). Participants will complete the test 
twice and an average time will be calculated.  
 
Gait score: 
0 = unable to complete 
1 = >5.7 seconds 
2 = 4.1-5.6seconds 
3 = 3.2-4.0 seconds 

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4 = <3.1 seconds 
Grip Strength 
Hand grip strength will be measured using a digital hand dynamometer (Seahan Corp., Masan) to 
determine the strength of the hand and forearm muscles as an indicator of neuromuscular function. 
Participants will be seated, feet flat on the floor, and instructed to hold the dynamometer with their 
upper arm in line with their body, forearm at approximately 90º and their wrist un-rotated. 
Participants will be asked to grip the dynamometer as tightly as possible for five seconds and the 
result recorded. The test will be repeated three times on each hand, starting with the right hand. At 
least thirty seconds rest will be given between each repetition. The maximal grip strength from the 
six measurements will be used for analysis. 
 
 
 

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APPENDIX 2 – Schedule of procedures 
 
 
*DXA will be done at screening for patients without BMD measurement in the last 6 months, and not repeated 
at baseline. For patients with BMD measurement within the last 6 months this measurement will be used for 
eligibility, and BMD will be measured at baseline.  
1. Glucose, , HbA1c, TSH, bone profile, creatinine (non-fasted) 
2. Selenium, selenoprotein P, PINP, OC, CTX, glutathione peroxidase, reactive oxygen species, hsCRP, IL-
6, 25OH vitamin D 
3. NTX/Cr 
4. At baseline: glucose and insulin. At 13w and 26w: glucose, insulin, HbA1c, TSH 
 
 
Screening 
Baseline 
4W 
8W 
13W 
17W 
21W 
26W 
30W 
Informed consent 
X 
 
 
 
 
 
 
 
 
Medical history for eligibility 
X 
 
 
 
 
 
 
 
 
DXA BMD* 
X 
X 
 
 
 
 
 
X 
 
Colecalciferol 100,000 units 
X 
 
 
 
 
 
 
 
 
Practice placebo (optional) 
X 
 
 
 
 
 
 
 
 
Screening bloods1  
X 
 
 
 
 
 
 
 
 
Blood for DNA 
 
X 
 
 
 
 
 
 
 
Serum selenium  
 
X 
 
 
X 
 
 
X 
 
Height and weight 
 
X 
 
 
X 
 
 
X 
 
Pulse and blood pressure 
 
X 
 
 
X 
 
 
X 
 
Bloods for end-of-study analysis2 
 
X 
 
 
X 
 
 
X 
 
Urine for end-of-study analysis3 
 
X 
 
 
X 
 
 
X 
 
Physical function tests 
 
X 
 
 
X 
 
 
X 
 
Diet diary 
 
X 
 
 
 
 
 
X 
 
Concomitant medications  
 
X 
X 
X 
X 
X 
X 
X 
 
Randomisation 
 
X 
 
 
 
 
 
 
 
Dispensing of study drug 
 
X 
 
 
X 
 
 
 
 
Safety bloods4 
 
 
 
 
X 
 
 
X 
 
Compliance check 
 
 
X 
X 
X 
X 
X 
X 
 
Adverse events 
 
X 
X 
X 
X 
X 
X 
X 
X