Continuing Education Activity

Selenium is an essential trace mineral that is vital in maintaining human health. Selenium is predominantly found in the form of selenoproteins, which play a crucial role in the body's physiological processes and metabolism. This activity explores the multifaceted roles of selenium, facilitated by selenoproteins, encompassing antioxidant protection by glutathione peroxidase against oxidative stress, selenium-dependent thyroid hormone conversion, immune system modulation, and its impact on HIV progression.

This activity discusses the ramifications of selenium deficiency, including its links to cardiovascular disease, infertility, myodegenerative conditions, and cognitive decline, and the ongoing research on selenium's potential role in cancer treatment. This activity provides a comprehensive overview of the assessment and management of selenium deficiency, highlighting the significance of an interprofessional healthcare team in enhancing patient care.

Objectives:

• Identify the risk factors associated with selenium deficiency in patients, including dietary habits, geographical location, and underlying medical conditions.
• Screen individuals at risk for selenium deficiency by conducting thorough medical history assessments and ordering appropriate laboratory tests to measure selenium levels promptly.
• Select appropriate selenium supplementation options, such as selenomethionine or selenium-enriched foods, tailored to each patient's specific needs and preferences.
• Communicate effectively with patients about the diagnosis, treatment, and management of selenium deficiency, providing education on dietary sources and supplementation options.

Introduction

Selenium is an essential trace mineral that is vital in maintaining human health. Selenium primarily exists as selenoproteins, which have diverse roles in the body's regular physiological processes and metabolism.[1] In particular, glutathione peroxidase (G-Px), a selenoprotein, contributes to antioxidant defense, safeguarding the body against the damaging effects of reactive oxygen and nitrogen species. Another significant selenium-dependent function involves iodothyronine deiodinases, which facilitate the conversion of inactive thyroxine or tetraiodothyronine (T4) into the active thyroid hormone triiodothyronine (T3).[2]

Selenium's impact extends to the immune system, influencing its proper function and affecting the progression of HIV to AIDS. Research suggests that selenium deficiency is associated with an increased risk of various health conditions, including cardiovascular diseases, infertility, myodegenerative disorders, and cognitive decline.

Current research is investigating the potential role of selenium in cancer treatment. Our understanding of selenium's significance in human health has evolved over the past 200 years since its discovery in 1817. Previously considered a carcinogen, selenium is now recognized as a crucial nutrient with a narrow therapeutic-to-toxic range.[1][3] 

Historically, selenium deficiency was associated with a type of cardiomyopathy known as Keshan disease, which was initially documented in China in the 1930s.[4] The administration of selenium supplementation to individuals residing in areas where Keshan disease is endemic has demonstrated a significant reduction in the incidence of this condition, underscoring selenium's therapeutic potential.[3][5]

Etiology

Selenium occurs naturally in soil, affecting the selenium content in plant-based foods. Brazil nuts, green vegetables, shiitake and button mushrooms, and various kinds of seeds, such as young barley seedlings, are excellent organic sources of selenium in regions with adequate selenium levels in the soil.[6]

Selenium yeast is another significant source of this essential mineral and is even used in bread production. Animals that consume selenium-rich plant-based foods, especially fish, seafood, beef, and poultry, are valuable sources of selenium in regions with an adequate supply. In plant-based foods, selenium is present in an organic form called selenomethionine, which has 90% bioavailability. In supplemental forms, inorganic variations such as selenate and selenite are utilized, exhibiting high levels of bioavailability.[7]

Several factors can affect selenium content within various foods. The rate at which plants absorb selenium plays a pivotal role, and it is determined by factors such as plant type, pH levels, soil composition, rainfall patterns, microbial activity, and other biogeochemical elements.[8] Selenium deficiency results from inadequate dietary intake of selenium, typically due to a lack of selenium sources in a specific region. Interestingly, many selenium-deficiency diseases are associated with concurrent vitamin E deficiency.

As per the April 2000 recommendations, the Recommended Dietary Allowance (RDA) for selenium is set at 70 µg/d for men and 55 µg/d for women to support optimal biological functioning. However, this level is considered low based on alternative studies, with some literature suggesting a minimum requirement of 90 µg/d per adult. The World Health Organization specifies a tolerable upper intake level for selenium in adults aged 19 and older, established at 400 µg/d or 5.1 µmol/d. Consuming amounts beyond this limit is considered potentially toxic.[9]

Epidemiology

Selenium deficiency impacts a significant global population, ranging from 500 million to 1 billion individuals, primarily due to insufficient dietary intake. In the United States, regions with the lowest selenium levels in soil and plant sources include the Northwest, Northeast, Southeast, and areas of the Midwest adjacent to the Great Lakes. The Great Plains and the Southwest generally possess adequate selenium content.[10]

Notably, individuals with conditions such as phenylketonuria or other diet-related diseases are especially vulnerable to selenium deficiency. This susceptibility arises from their dietary restrictions, frequently resulting in insufficient consumption of products rich in this vital element. 

Selenium levels in many parts of Europe are notably lower than those in the United States, with Eastern Europe having a lower average selenium intake than Western Europe.[11] Finland initially had the most insufficient selenium intake, but they took measures to address this issue by fortifying their fertilizers with selenium, resulting in a positive shift. Brazil nuts are the primary source of selenium in these countries, while crab, liver, other shellfish, and fish serve as moderate sources. However, the utility of these sources is limited by the existence of various selenium compounds within fish and the occurrence of known contaminants such as arsenic and mercury.

Selenium deficiency has been extensively documented in countries such as China and New Zealand.[12][13] In the Middle East, selenium intake varies significantly based on socioeconomic status—a pattern substantiated by the limited available data.

Pathophysiology

Selenium deficiency can lead to various systemic issues, some of which are listed below.

Cardiovascular System

Keshan disease is a type of congestive cardiomyopathy characterized by symptoms like heart failure, cardiac enlargement, electrocardiogram (ECG) irregularities, gallop rhythm, and cardiogenic shock. This condition predominantly impacts children and women of reproductive age. Initially discovered in areas of China plagued by selenium deficiency, Keshan disease was associated with a significant morbidity rate of 50%, often accompanied by occurrences of mortality. Additional factors such as chemical exposure or the presence of Coxsackievirus frequently compounded the severity of the disease.[14][15] 

Notably, selenium supplementation has shown promise in combating this ailment. The use of fortified salt enriched with selenium has been associated with a reduced incidence of Keshan disease, offering a potential approach for prevention and management.

Endocrine System

Among the 35 identified selenoproteins, 3 hold a significant role and are recognized as iodothyronine deiodinases—pivotal contributors in thyroid hormone metabolism. Notably, the thyroid gland contains the highest selenium concentration among all organs in the human body. The initial iodothyronine deiodinase converts inactive T4 into its active form, T3. The second enzyme is abundant within the central nervous system, brown fat, and skeletal muscles, contributing to the activation of thyroid hormones. The third enzyme is involved in deactivating thyroid hormones, serving as a crucial regulatory element in thyroid function.[16][17]

Immune System and Host Defense

G-Px is a selenium-dependent enzyme that protects cell membranes and organelles containing lipids from peroxidative damage through inhibition and neutralization processes. This enzymatic action, combined with vitamin E, preserves the structural integrity of the cell membranes and counteracts the effects of hydrogen peroxide through redox reactions with glutathione. Selenium deficiency exacerbates redox byproduct toxicity and leads to oxidative damage to cell membranes.

Furthermore, selenium deficiency has been observed to transform otherwise benign viruses within hosts into highly virulent pathogens, potentially playing a role in developing conditions such as Keshan disease. The recurring emergence of novel influenza virus strains within China with its selenium-deficient belt has new implications, highlighting the link between immune response and selenium deficiency.

Individuals living with HIV infection require selenium as a crucial nutrient. Over 20 studies have reported the correlation between declining plasma selenium levels and diminishing CD4 counts. Notably, selenium has been demonstrated to facilitate the differentiation of CD4+ T cells into T-helper-1 (Th1) cells. This phenomenon has been associated with decreased hospital admissions, especially for co-infections, such as mycobacterial infections, in individuals with HIV. Thus, it appears that selenium's influence is related to impeding the progression of HIV to AIDS.[18]

In addition to its effects on HIV, selenium protects individuals with hepatitis B or C, impeding the transition to malignancy. This multifaceted role underscores the broader significance of selenium in immune function and disease progression.

Although selenium has been associated with an improved immune response, its role in cancer prevention is somewhat restricted. Selenium has been known to augment the cytotoxic effect of natural killer cells and increase the activity of T cells and macrophages. In addition, selenium stimulates antibody production and exhibits a synergistic relationship with vitamin E regarding the cellular aging process.

In addition to its immunological functions, selenium extends its protective effects to mitigate the toxicity of heavy metals, including lead, cadmium, arsenic, mercury, and organic compounds such as paraquat herbicides. These attributes underline selenium's diverse and significant role in safeguarding the body from a spectrum of potentially harmful substances.

Musculoskeletal System

Kashin-Beck disease is a debilitating condition known for causing deformities in bones, cartilage, and joints, leading to joint enlargement and restricted mobility. This ailment is particularly prevalent in Tibet, China, Siberia, and North Korea. The origin of this disease is multifaceted, among which selenium deficiency is an implicating cause.[19]

Keshan disease and muscular syndrome have been reported in individuals receiving total parenteral nutrition without selenium supplementation. In these cases, symptoms described include intermittent myalgias, tenderness, and the eventual development of white fingernail beds.

Neurological and Psychiatric Systems

Research has indicated that inadequate selenium intake can contribute to depressed mood and increased hostile behavior. Notably, during a selenium deprivation state, the brain receives prioritized supplies of selenium, indicating the importance of selenium in maintaining brain health. Furthermore, selenium deficiency has been observed to affect the turnover rate of certain neurotransmitters.

Reproductive System

Selenium plays a pivotal role in various aspects of male reproductive health. It is essential for testosterone biosynthesis and contributes to the formation and development of normal spermatozoa. Moreover, testicular tissue contains significant selenium concentrations responsible for maintaining sperm quality and male fertility health. 

Although the connection between selenium and male reproductive health is well-established, there is relatively limited information regarding the relationship between selenium and female fertility. Additional research is required to gain a comprehensive understanding of the potential role of selenium in supporting female reproductive processes and fertility.

History and Physical

The assessment of selenium deficiency involves a comprehensive approach, which includes taking the patient's medical history and performing physical examinations, to gather relevant information and identify potential symptoms. Severe selenium deficiency primarily manifests with symptoms affecting the heart muscles and joints. A moderate deficiency is notably associated with increased male infertility, heightened risk of prostate cancer, and susceptibility to neurological disorders.[15] Therefore, a comprehensive evaluation is essential due to the broad spectrum of symptoms linked to selenium deficiency. 

Patient History

Medical history: The healthcare provider gathers information about the patient's medical history, including any preexisting conditions, current medications, and family history of selenium-related disorders.

Dietary history: The healthcare provider seeks information about the patient's diet, focusing on selenium-rich foods such as nuts, seeds, seafood, and vegetables. Particular attention is given to any dietary restrictions or significant changes in eating habits.

Geographical location: The healthcare provider determines the patient's geographical location or travel history, as regions with selenium-deficient soil may increase the risk of deficiency.

Symptom assessment: The healthcare provider investigates any symptoms associated with heart health, joint discomfort, male infertility, neurological issues, growth disorders in children, or any other relevant complaints of patients.

Physical Examinations

Cardiovascular examination: The healthcare provider evaluates the heart's function, including heart rate, rhythm, and any signs of cardiac enlargement or irregularities.

Musculoskeletal examination: The healthcare provider examines the patient's joints for tenderness, swelling, and restricted movement. The presence of specific symptoms such as rheumatoid arthritis, abnormally shortened fingers and toes, or growth disorders in areas characterized by selenium-deficient soil should raise heightened suspicion of selenium deficiency. This is particularly relevant when evaluating children between the ages of 5 and 13.

Neurological examination: The healthcare provider evaluates the patient's neurological function, including sensory perception, reflexes, and coordination, while looking for any signs of neurological disorders.

Skin and nails: The healthcare provider inspects the patient's skin for any symptoms of selenium deficiency, such as skin texture or pigmentation changes. They also examine the patient's nails for signs of white spots or brittleness.

Reproductive health assessment: The healthcare provider inquires about fertility concerns, conducts relevant examinations for male patients, and gathers information about menstrual irregularities or other reproductive issues for female patients.

Growth assessment: The healthcare provider monitors growth patterns and assesses for any growth disorders in children.

General physical health: The healthcare provider conducts a comprehensive physical examination to assess the patient's overall health status, paying attention to any signs that could indicate selenium deficiency.

Evaluation

Evaluating selenium deficiency involves laboratory tests, radiographic assessments, and other clinical measures. However, it is important to note that although some guidelines exist, standardized protocols for selenium deficiency evaluation may not be universal.

Selenium Deficiency Evaluation Tests and Imaging

Tests commonly used to assess selenium deficiency in individuals are mentioned below.

Serum selenium levels: Evaluating serum selenium concentration is a standard method to assess selenium deficiency. National and international guidelines often provide reference ranges. For example, the U.S. Institute of Medicine recommends a reference range of 70 to 155 μg/L for selenium in serum.

Plasma G-Px activity: This test measures the activity of the selenium-dependent enzyme G-Px and can offer valuable insights into selenium status.

Urinary selenium levels: The urinary selenium levels can reflect recent selenium intake, although their interpretation can be complex due to variations in urinary excretion.

X-ray imaging: In cases of suspected Kashin-Beck disease or other skeletal abnormalities related to selenium deficiency, x-rays can assist in identifying bone and joint deformities.

Magnetic resonance imaging (MRI): MRI can be used to assess joint and tissue health, especially when symptoms such as joint pain or restricted movement are present.

Bone density scans: Bone density scans or dual-energy x-ray absorptiometry (DEXA) scans assess bone health and density and can identify selenium deficiency, which may affect bone structure and increase the risk of fractures.

Selenium deficiency can present with a wide range of symptoms and is often more prevalent within a community rather than occurring sporadically. When suspicion arises, serum selenium levels or selenium levels in scalp hair or nails can be assessed, as a strong correlation exists between serum and hair or nail selenium levels.

In regions where deficiency is endemic, scalp hair samples are preferred over blood samples due to ease of collection by unskilled workers. Additional parameters for assessment include measuring G-Px activity in various blood components, including plasma (G-Px3), erythrocytes (G-Px1), thrombocytes (G-Px1), or whole blood (G-Px1 and G-Px3). Another effective laboratory indicator of selenium status in patients is the selenoprotein P (SePP) concentration.[20]

Treatment / Management

Selenium deficiency is typically a concern that affects entire communities at the population level rather than being an isolated individual issue. Biofortification strategies have been implemented to address this challenge, which involves soil enrichment through agricultural practices. Another approach involves increasing the selenium content of food sources, which is achieved by supplementing animal fodder with selenium compounds. This method can lead to selenium-enriched eggs or egg yolks, which are more effective in boosting nutritional selenium intake.

Selenium-fortified eggs, meat, and milk have been successfully introduced in many countries. Harnessing microorganisms to produce functional foods, such as selenium yeast, is an innovative method. This approach highlights efforts to combat selenium deficiency and improve public health and nutrition.[21]

Organic selenium sources typically have a slower accumulation of toxic levels than the more rapid potential of selenite and selenate supplementation, which are inorganic salt forms of selenium supplements. However, using inorganic salts offers a swift means to address selenium deficiency in cases of acute and immediate deficiency. The recommended supplementation level to target is approximately 90 mcg/d for adults.

According to the World Health Organization, the upper limit for selenium intake in adults 19 and older is 400 µg or 5.1 µmol/d. Exceeding this limit is considered hazardous due to potential toxicity. Emphasizing a well-balanced diet is the most effective approach to preventing selenium deficiency, thereby ensuring optimal health and avoiding the need for excessive supplementation.[9]

Differential Diagnosis

Selenium is a mineral that can influence various systems of the body. The conditions that should be considered when suspecting a case of selenium deficiency include Addison disease, anemia, anovulation, autoimmune thyroid disease and pregnancy, cardiac tamponade, constipation, euthyroid sick syndrome, goiter, hypothyroidism, nutritional cardiomyopathy, pericardial effusion, pituitary macroadenomas, prolactin deficiency, thyroid lymphoma, and T4-binding globulin deficiency.

Prognosis

The prognosis for selenium deficiency varies based on factors such as the severity and duration of deficiency, the individual's overall health, and the effectiveness of intervention measures. If left untreated, selenium deficiency can cause various health issues, including impaired immune function, cardiovascular effects, reproductive and fertility problems, thyroid dysfunction, neurological symptoms, and musculoskeletal abnormalities.

The prognosis for selenium deficiency typically improves with timely recognition and appropriate intervention. Selenium deficiency can often be resolved through dietary modifications or supplementation. After correcting the deficiency, many associated symptoms and health risks can be reversed. However, the extent and recovery speed can vary among individuals depending on the severity of the deficiency and the individual's underlying health status.

Although mild-to-moderate selenium deficiency can be effectively managed, severe or prolonged deficiency can result in irreversible health complications. Notably, severe selenium deficiency is independently associated with reduced exercise tolerance, a 50% higher mortality rate, and mitochondrial dysfunction in vitro within human cardiomyocytes.[22]

Complications

Selenium deficiency can be associated with various complications, including thyroid disorders, cardiomyopathy, male and female infertility, heart failure [23], miscarriage, preeclampsia, fetal growth restriction, Keshan disease, Kashin-Beck disease, cognitive decline, preterm labor, and gestational diabetes.[24]

Deterrence and Patient Education

Educating patients about the significance of selenium as a vital micronutrient essential for human health is crucial. Selenium is widely available in various foods, further underscoring its significance. Notable dietary sources include meat, grain cereals, milk, egg yolk, Brazil nuts, garlic, mushrooms, and seafood.[25] Consuming a well-balanced diet comprising these selenium-rich foods can help maintain optimal selenium levels and promote overall well-being.

Pearls and Other Issues

Selenium is a multifaceted, critical trace element present in various foods and is crucial for maintaining overall human health. Additional information related to selenium is listed below.

• Selenium plays an active role in synthesizing active thyroid hormones, promoting the proper functioning of the immune system, contributing to cognitive well-being, and serving as an antioxidant by protecting cells from oxidative damage.

• Selenium has been found to be essential for human growth and reproduction.[26]

• Myodegenerative diseases, such as muscle weakness, are often linked with moderate selenium deficiency.

• An insufficient selenium status has been associated with adverse mental health outcomes, including symptoms of depressed mood, increased anxiety, and heightened confusion.

• Research on selenium's role in cancer treatment is an active area of investigation and study.

• Studies have shown that selenium can help prevent pre-eclampsia—a severe pregnancy complication.[27]

• Selenium has a narrow therapeutic window and can become toxic if doses are exceeded.

• Many diseases linked to selenium deficiency often coincide with concurrent vitamin E deficiency.

• Keshan disease is prevalent in some areas of China where there is a lack of selenium. This disease is characterized by congestive cardiomyopathy, heart failure, cardiomegaly, and ECG changes. Coxsackievirus or certain chemical factors often trigger Keshan disease.

• Kashin-Beck disease is a condition that affects bones, cartilage, and joints, causing deformities that lead to restricted movements due to enlarged joints. The disease is prevalent in Tibet, China, Siberia, and North Korea and has a multifactorial etiology, with selenium deficiency being one of the causes.

Enhancing Healthcare Team Outcomes

Addressing selenium deficiency necessitates a collaborative approach involving an interprofessional healthcare team, including dietitians and nurses. Clinicians should be aware that selenium deficiency can manifest through a wide range of symptoms. Furthermore, the issue probably affects the entire community rather than just an isolated case. When suspicion arises, assessing selenium levels can be achieved through serum, scalp hair, or nail samples, with a notable correlation between them. In regions with endemic deficiency, the advantage of using hair samples lies in their ease of collection by unskilled workers compared to blood samples.

Public health nurses are crucial in identifying populations at risk of selenium deficiency. Dietitians should prioritize promoting a balanced diet over relying solely on supplements. Pharmacists are critical in reviewing supplement dosages, particularly in cases of severe deficiency. This collaborative and comprehensive approach, supported by an interprofessional healthcare team, ensures effective management of selenium deficiency and improves public health outcomes.

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References

1.

Kieliszek M, Błażejak S. Selenium: Significance, and outlook for supplementation. Nutrition. 2013 May;29(5):713-8. [PubMed: 23422539]

2.

Ambroziak U, Hybsier S, Shahnazaryan U, Krasnodębska-Kiljańska M, Rijntjes E, Bartoszewicz Z, Bednarczuk T, Schomburg L. Severe selenium deficits in pregnant women irrespective of autoimmune thyroid disease in an area with marginal selenium intake. J Trace Elem Med Biol. 2017 Dec;44:186-191. [PubMed: 28965575]

3.

Kieliszek M, Błażejak S. Current Knowledge on the Importance of Selenium in Food for Living Organisms: A Review. Molecules. 2016 May 10;21(5) [PMC free article: PMC6274134] [PubMed: 27171069]

4.

Oropeza-Moe M, Wisløff H, Bernhoft A. Selenium deficiency associated porcine and human cardiomyopathies. J Trace Elem Med Biol. 2015;31:148-56. [PubMed: 25456335]

5.

Zhou H, Wang T, Li Q, Li D. Prevention of Keshan Disease by Selenium Supplementation: a Systematic Review and Meta-analysis. Biol Trace Elem Res. 2018 Nov;186(1):98-105. [PubMed: 29627894]

6.

Schomburg L. Dietary Selenium and Human Health. Nutrients. 2016 Dec 30;9(1) [PMC free article: PMC5295066] [PubMed: 28042811]

7.

Reich HJ, Hondal RJ. Why Nature Chose Selenium. ACS Chem Biol. 2016 Apr 15;11(4):821-41. [PubMed: 26949981]

8.

Santos S, Ungureanu G, Boaventura R, Botelho C. Selenium contaminated waters: An overview of analytical methods, treatment options and recent advances in sorption methods. Sci Total Environ. 2015 Jul 15;521-522:246-60. [PubMed: 25847169]

9.

Kipp AP, Strohm D, Brigelius-Flohé R, Schomburg L, Bechthold A, Leschik-Bonnet E, Heseker H., German Nutrition Society (DGE). Revised reference values for selenium intake. J Trace Elem Med Biol. 2015 Oct;32:195-9. [PubMed: 26302929]

10.

Mistry HD, Broughton Pipkin F, Redman CW, Poston L. Selenium in reproductive health. Am J Obstet Gynecol. 2012 Jan;206(1):21-30. [PubMed: 21963101]

11.

Prabhu KS, Lei XG. Selenium. Adv Nutr. 2016 Mar;7(2):415-7. [PMC free article: PMC4785479] [PubMed: 26980826]

12.

Li Q, Liu M, Hou J, Jiang C, Li S, Wang T. The prevalence of Keshan disease in China. Int J Cardiol. 2013 Sep 30;168(2):1121-6. [PubMed: 23218571]

13.

Jia Y, Han S, Hou J, Wang R, Li G, Su S, Qi L, Wang Y, Du L, Sun H, Hao S, Feng C, Wang Y, Liu X, Zou Y, Zhang Y, Li D, Wang T. Spatial Epidemiological Analysis of Keshan Disease in China. Ann Glob Health. 2022;88(1):79. [PMC free article: PMC9479656] [PubMed: 36185998]

14.

Rayman MP. The importance of selenium to human health. Lancet. 2000 Jul 15;356(9225):233-41. [PubMed: 10963212]

15.

Rayman MP. Selenium and human health. Lancet. 2012 Mar 31;379(9822):1256-68. [PubMed: 22381456]

16.

Drutel A, Archambeaud F, Caron P. Selenium and the thyroid gland: more good news for clinicians. Clin Endocrinol (Oxf). 2013 Feb;78(2):155-64. [PubMed: 23046013]

17.

Lacka K, Szeliga A. Significance of selenium in thyroid physiology and pathology. Pol Merkur Lekarski. 2015 Jun;38(228):348-53. [PubMed: 26098657]

18.

Muzembo BA, Ngatu NR, Januka K, Huang HL, Nattadech C, Suzuki T, Wada K, Ikeda S. Selenium supplementation in HIV-infected individuals: A systematic review of randomized controlled trials. Clin Nutr ESPEN. 2019 Dec;34:1-7. [PubMed: 31677697]

19.

Yang L, Zhao GH, Yu FF, Zhang RQ, Guo X. Selenium and Iodine Levels in Subjects with Kashin-Beck Disease: a Meta-analysis. Biol Trace Elem Res. 2016 Mar;170(1):43-54. [PubMed: 26250430]

20.

Hill KE, Xia Y, Akesson B, Boeglin ME, Burk RF. Selenoprotein P concentration in plasma is an index of selenium status in selenium-deficient and selenium-supplemented Chinese subjects. J Nutr. 1996 Jan;126(1):138-45. [PubMed: 8558294]

21.

Rayman MP. The use of high-selenium yeast to raise selenium status: how does it measure up? Br J Nutr. 2004 Oct;92(4):557-73. [PubMed: 15522125]

22.

Bomer N, Grote Beverborg N, Hoes MF, Streng KW, Vermeer M, Dokter MM, IJmker J, Anker SD, Cleland JGF, Hillege HL, Lang CC, Ng LL, Samani NJ, Tromp J, van Veldhuisen DJ, Touw DJ, Voors AA, van der Meer P. Selenium and outcome in heart failure. Eur J Heart Fail. 2020 Aug;22(8):1415-1423. [PMC free article: PMC7540257] [PubMed: 31808274]

23.

Al-Mubarak AA, van der Meer P, Bomer N. Selenium, Selenoproteins, and Heart Failure: Current Knowledge and Future Perspective. Curr Heart Fail Rep. 2021 Jun;18(3):122-131. [PMC free article: PMC8163712] [PubMed: 33835398]

24.

Kong FJ, Ma LL, Chen SP, Li G, Zhou JQ. Serum selenium level and gestational diabetes mellitus: a systematic review and meta-analysis. Nutr J. 2016 Oct 28;15(1):94. [PMC free article: PMC5086076] [PubMed: 27793207]

25.

Brown KM, Arthur JR. Selenium, selenoproteins and human health: a review. Public Health Nutr. 2001 Apr;4(2B):593-9. [PubMed: 11683552]

26.

Boitani C, Puglisi R. Selenium, a key element in spermatogenesis and male fertility. Adv Exp Med Biol. 2008;636:65-73. [PubMed: 19856162]

27.

Rayman MP, Bath SC, Westaway J, Williams P, Mao J, Vanderlelie JJ, Perkins AV, Redman CW. Selenium status in U.K. pregnant women and its relationship with hypertensive conditions of pregnancy. Br J Nutr. 2015 Jan 28;113(2):249-58. [PMC free article: PMC4302388] [PubMed: 25571960]

Disclosure: Aparna Shreenath declares no relevant financial relationships with ineligible companies.

Disclosure: Muhammad Hashmi declares no relevant financial relationships with ineligible companies.

Disclosure: Jennifer Dooley declares no relevant financial relationships with ineligible companies.