Nutritional Anemia 2017

NUTRITIONAL
ANEMIA
A. Yasmin Syauki
Nutritional Department
School of Medicine Hasanuddin University
syaukiyasmin@gmail.com
IMUNOLOGY HEMATOLOGY
15/05/2019 1
SYSTEM
 Dua orang ibu hamil bercengkrama di ruang tamu.
Mereka mengeluh sering letih, lemes, lesu, mata
berkunang-kunang.
 Apa yang bisa menyebabkan hal tersebut?
15/05/2019 2
SYSTEM
ONE MINUTE PAPER
 Coba definisikan dengan pemahaman anda :
 anemia defisiensi besi
15/05/2019 3
SYSTEM
OBJECTIVE
 To identify and manage iron deficiency anemia
(level 4)
 To identify and refer nutritional anemia of

megaloblastic (level 3A)
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SYSTEM
OUTLINE
 Preface
 Iron deficiency anemia
 Anemia megaloblastic :
 Vitamin B12 deficiency
 Folate deficiency
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SYSTEM
PREFACE
15/05/2019 6
SYSTEM
NUTRITIONAL ANEMIA
(ANEMIA GIZI )
 Anemia is :
 not a disease
 an expression of an underlying
disorder
 the functional inability to supply
tissues with adequate oxygen,
usually due to decreased
hemoglobin level.
15/05/2019 IMUNOLOGY HEMATOLOGY SYSTEM 7

HEMOGLOBIN,
HEMATOCRIT/PCV AND
MCHCVALUE
Age of Group Hb Ht /PVC (%) MCHC
g/100ML
Children 6 mos -6 11 33 34
yrs
Children 6 – 14 yrs 12 36 34
Adult male 13 39 34
Adult female 12 36 34
Pregnant woman 11 33 34
15/05/2019 8
SYSTEM
Nutritional Non
anemia’s nutritional
anemia’s
Diet related due to Due to varied causes such
deficient intake or as abnormal bleeding
faulty absorption of (from a serious injury),
heavy menstrual periods,
nutriens such as iron, hemorrhoids, stomach
folic acid, vitamin ulcers, or cancer of
B12, vitamin B6, stomach or colon or
vitamin C, Cu and because inherrited
Co, protein condition
Often corrected by intake Kidney or bone

of foods or supplements marrow disease,
that reverse the Aplastic anemia
deficiency
15/05/2019 IMUNOLOGY HEMATOLOGY SYSTEM
9
CLASSIFICATION OF ANEMIA BASED
ON RED BLOOD CELL PROFILE
Microcytic (<80 fl) & Macrocytic (>100 fl) & Normocytic (80-100 fl)
hypochromic (< 30%) normochromic (32- & normochromic (32-
36%) 36%)
thallasemia, Vitamin B12 Iron deficiency (early)
sideroblastic deficiency, folate Chronic disease
anemia,chronic Iron deficiency, vitamin C
deficiency leading deficiency,
poisoning,anemia of chemotherapy
chronic illness (megaloblastic
marrow), aplastic
anemia,
hypothyroidism
(normoblastic )
15/05/2019 10
SYSTEM
 Nutritional anemia arises :
 Inadequate intake (Primary)
 Inadequate absorption (GI
disease)
 Inadequate utilization (cancer,
infection)
 Increase requirement (pregnancy,
infancy, childhood)
 Increase excretion (liver disease)
15/05/2019 11
SYSTEM
IRON DEFICIENCY ANEMIA
(IDA)
15/05/2019 IMUNOLOGY HEMATOLOGY SYSTEM 12

INTRODUCTION
 Iron deficiency (ID) is one of the most

frequent nutrition deficiency all round the
world.
 Its prevalence is higher in children and

childbearing age women.
 Iron deficiency anemia (IDA) mainly affects

child behavior and development, work
performance and immunity.
15/05/2019 13
SYSTEM
ETIOLOGY
1. Increase requirement
 infancy/childhood
 pregnancy/lactation
 preterm/SDF babies
2. Defective absorption
 malabsorption
 low levels of enhancers/increased levels of inhibitors
 achlorhydria/gastrectomy
15/05/2019 14
SYSTEM
ETIOLOGY
3. Increase losses
 occult bleeding/hookworm infestation
 uterine causes
4. Diminished strores
 preterm/SDF babies/ante partum hage
5. Decreased intake
 poor diet
 no breast feeding
 babies in cows milk
 anorexia of pregnancy
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SYSTEM
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SYSTEM
DIAGNOSIS
 Clinical and laboratory indices
 Clinical features :
 ↓ production of Hb : less oxygen reaches the
tissues especially the brain and heart muscle
causing pallor, tiredness, shortness of breath,
giddines, palpitations
Symptoms usually occur when Hb < 8 g/dl
- Epithelial abnormalities
angular stomatitis (cracked corners of mouth)
glossitis (sore tongue)
koilonychia (spoon-shaped nails)
15/05/2019 17
SYSTEM
DIAGNOSIS
 Laboratory indices is the most common methods to

assess iron nutritional status
 low hemoglobin
 low hematocrit
 low MCV, MCH, MCHC
 normal or low reticulocyt count
 serum iron 2.5 -10 umol/l
 serum ferritin < 10 ng/ml
 transferrin saturation <15%
 TIBC > 350 ug/l
 increased free erythrocyte protoporphyrin (100-
600 ugm/l)
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SYSTEM
 Transferrin saturation (%) :
= serum iron (μmol/L)/ TIBC (μmol/L) x 100%
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SYSTEM
Fe Def Anemia
 In severe cases may
have additional
physical exam
findings:
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SYSTEM
BLOOD SMEAR
TEST
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SYSTEM
Prelatent Latent IDA
Hemoglobin Normal Normal Decreased
MCV (80-100 fl) Normal Normal Decreased
MCHC (32-36%) Normal Normal Decreased or

normal
Iron absorption(10%) Increased Increased Increased
% saturation (30-50) Normal Decreased (<20) Decreased
Serum ferritin (50- Decreased (<20) Decreased Decreased

200 ug/l)
Iron stores (1-3+) Decreased (0-1) Absent Absent
TIBC (300-360ug/dl) Increased (>360) Increased (>380) Increased

(>400)
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SYSTEM
MANAGEMENT
 History and physical examination is sufficient to exclude
serious disease (e.g pregnant or lactating women,
adolescents)
- CURE ANEMIA
 History and/or physical examination is insufficient (e.g

old men, postmenopausal women)
- FIND ETIOLOGY OF ANEMIA AND CURE (CAUSAL

TREATMENT)
 Benzidine test
 Gastroscopy
 Colonoscopy
 Gynaecological examination
15/05/2019 23
SYSTEM
MANAGEMENT
 ORAL
 200 mg of iron daily 1 hour before meal (e.g.
100 mg twice daily)
 How long?
 14 days + (Hg required level – Hg current
level) x 4
 half of the dose - 6 – 9 months to restore iron
reserve
 Absorption
 is enhanced: vitamin C, meat, orange juice,
fish
 is inhibited: cereals, tea, milk
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SYSTEM
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SYSTEM
MANAGEMENT
 PARENTERAL IRON SUBSTITUTION
 Bad oral iron tolerance (nausea, diarrhoea)
 Negative oral iron absorption test
 Necessity of quick management (CHD, CHF)
 50 - 100 mg daily
 I.v only in hospital (risk of anaphilactic shock)
 I.m in outpatient department
 iron to be injected (mg) = (15 - Hb/g%/) x body weight
(kg) x 3
15/05/2019 26
SYSTEM
MANAGEMENT
Iron supplementation
 Menstrual woman -> lost 30 mg -> need 1 mg Fe / day
 Pregnant woman -> 900 mg for foetus, labour and lactation-> need 2 mg
Fe / day
Prevention :
1. Fe prophylaxis
2. Adequate intake of food sources of iron
3. Well planned family
4. Food fortification
5. Infestation eradication
15/05/2019 27
SYSTEM
THINK, PAIR, SHARE
 Seorang ibu hamil, 27 tahun datang ke puskesmas
dengan keluhan sering lemes, mata berkunang-
kunang. Ibu sudah diperiksa darahnya dan diperoleh
hasil anemia mikrositik hipokrom
 Bagaimana penatalaksanaan nutrisinya?
15/05/2019 28
SYSTEM
IRON
15/05/2019 29
SYSTEM
INTRODUCTION
 Iron -> a metal, exist in several oxidation states varying from
Fe6+ to Fe2+, depending on its chemichal environment.
 The only states that are stable in the aqueos environment of

the body and in food are the ferric (Fe3+) and the ferrous
(Fe2+) forms.
 Highly reactive element that can interact with oxygen to form

intermediates able to damage cell membrane or degrade
DNA.
 Iron must be tightly bound to proteins to prevent

destructive effects.
15/05/2019 30
SYSTEM
THE DISTRIBUTION AND FUNCTION
OF TOTAL BODY IRON
Site Function Amount of Percentage of
iron (mg) total body iron
Total body iron 3500 – 5000 100
Haemoglobin Oxygen transport 2500 60-70
Ferritin (2/3) and Iron storage: mainly liver , 1000 27

haemosiderin (1/3) spleen and bone marrow
Myoglobin Oxygen transporter in muscle 130 3.5
Uncharacterized iron- Storage 80 2.2

binding molecules
Cytochromes and Electron transport chain 8 0.2

other iron-containing cytochrome P450 (drug
enzymes metabolism),catalase
Transferrin Transport iron from intestines 3 0.08
to tissues
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SYSTEM
IRON METABOLISM
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SYSTEM
TRANSFER OF IRON TO THE
CIRCULATION AND TRANSPORT
 Transferrin is the major protein responsible

for transporting Iron in the body.
 Transferrin receptors, located on the
surface of nearly all cells in the body, can
bind two molecules of transferrin.
 Transferrin saturation is important in
assessing ID.
15/05/2019 33
SYSTEM
TRANSFER OF IRON TO THE
CIRCULATION AND TRANSPORT
 Tissues with higher requirements of Iron (erythroid

precursors, placenta and liver) contain higher
concentration of transferrin receptors.
 Once in tissues, Iron is stored as ferritin and

hemosiderin compounds, which are present
primarily in the liver, RE cells and bone marrow.
 The amount of ferritin in storage compartment

depends on Iron status which ranges from
depleted to replete iron status
 Ferritin concentration expresses Body Iron Stores

when assessing ID.
15/05/2019 34
SYSTEM
REGULATORY MECHANISMS OF IRON
ABSORPTION AND CELLULAR UPTAKE
Dietary Factors
•Physico –chemical form (ferrous form
better absorbed),
•other dietary constituents (phosphates,
phytates, calcium, tannic acid, etc.),
•Iron dose
Host-related conditions
15/05/2019 35
SYSTEM
DIETARY FACTORS
 Dietary sources of Iron can be classified as food
sources and fortified foods.
 The amount of iron varies widely between foods.
 Iron exists in food under two forms,

 Heme : in animal products (hemoglobin &
myoglobin), well absorbed, about 10% of iron
consumed
 non heme : mainly in plants, main source of diet
(90%), absorption variable, affected by other
factors
 They are not only different in terms of their sources,
but also in terms of bioavailability.
15/05/2019 36
SYSTEM
BIOAVAILABILITY
 Heme iron, is readily absorbed.
 Inorganic (non-heme) iron, is mostly in the oxidized

(Fe3+) state and must be reduced for absorption.
 Factors affecting bioavailability :

 Absorption is favoured in the ferrous as opposed to
the ferric form
 Stomach hydrochloric acid and ascorbic acid both
favour absorption by reducing iron to the ferrous form
 Increased erythropoetic activity (e.g due to bleeding)
increases absorption
 Alcohol increases absorption
 Phospates and phytates
IMUNOLOGY (from plants) form insoluble
HEMATOLOGY
15/05/2019 37
complexes with ironSYSTEM
and prevent absorption
FORMS OF DIETARY
SOURCES OF IRON
15/05/2019 38
SYSTEM
IRON ABSORPTION
 Healthy Individuals: 5-10% absorbed
 Iron deficiency : Up to 40% absorbed
 Factors that affect absorption:
Enhancing factors /facilitators :
acid in the stomach
heme iron
high body demand
low body stores
meat protein factor
vitamin C
15/05/2019 39
SYSTEM
IRON ABSORPTION
Inhibiting factors/inhibitors :
 low acidity in stomach
 dietary fiber (phytate)
 tannin in tea
 oksalat
 polifenol
 calcium and phosphorus (food)
 inadequate protein intake

15/05/2019 40
SYSTEM
IRON ABSORPTION
Facilitators Inhibitors
Beef, lamb, pork, liver, +++ Wheat bran +++

chicken, fish
Tea +++
Orange, pear, apple,
pineapple juices +++/++ Nuts +++
Plum, banana, mango ++/+ Legumes +++
Carrot, potato, pumpkin, Leafy vegetables +++

broccoli, cauliflower, ++/+ Coffee +++/++
tomato
Maize +++/++
Salad (lettuce, tomato,
green pepper, cucumber) + Rice ++/+
Eggs +
Spinach +
15/05/2019 41
SYSTEM
DIETARY NEED
 Only 10% of dietary iron is absorbed, therefore
the amount of digested daily is equal to the daily
requirement x 10.
 The daily iron requirement
Group Requirement
Adult male 1.0 mg
Child 1.5 mg
Menstruating woman 2.0 mg
Pregnant woman 3,0 mg
15/05/2019 42
SYSTEM
HOST RELATED FACTORS
The main factors regulating iron

absorption :
 Iron stores
 The amount of iron to which

intestinal cells have been exposed
15/05/2019 43
SYSTEM
OTHER FACTORS INFLUENCING
IRON ABSORPTION
 Rate of erythropoiesis
 Physiological state
 Gastric juice
15/05/2019 44
SYSTEM
VITAMIN C
15/05/2019 45
SYSTEM
VITAMIN C
 Powerful reducing agent :
 Reduces dietary Fe 3+
to Fe 2+ in the
gut, allowing its absorption (therefore
deficiency can lead to anaemia)
15/05/2019 46
SYSTEM
Source of Vitamin C
 AKG : 75-90 mg/day (adult)
 Sources
 Citrus fruits
 Tomatoes
 Berries
 Green vegetables
15/05/2019 47
SYSTEM
COPPER
15/05/2019 48
SYSTEM
COPPER
 COMPONENT OF MANY ENZYMES
 OXIDIZING IRON BEFORE IT IS TRANSPORTED

( ceruloplasmin, copper containing protein,
required for normal mobilization of iron from its
storage site to the plasma)
 PLAYS ROLE IN MITOCHONDRIAL ENERGY

PRODUCTION, PROTECTION FROM OXIDANTS,
AND SYNTHESIS PF MELANINE AND
CATHECOLAMINE
15/05/2019 49
SYSTEM
Source of Copper
 Most diet provide 2mg/day
 RDA 1.5 - 3mg/day
 Food high in copper

 Oysters, shellfish
 Liver, Kidneys
 Chocolate
 Nuts
 Dried legumes, Dried foods
 Cereals
 Poultry
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SYSTEM
COBALT
15/05/2019 51
SYSTEM
Cobalt
 A component of vitamin B12 (cobalamin)
 This vitamin is essential for maturation of red blood cells

and normal functioning of all cells
 Requirement expressed in terms of Vit B12 : 1.4-2 ug daily
 Toxicity : intake of 10 to 20 ug/kg Body weight : high

intake cobalt in animal diet produce polycytemia, bone
marrow hyperplasia, reticulocytosis, and increased blood
volume
 Deficiency: related to Vit B12 deficiency ---
macrocytic anemia
15/05/2019 52
SYSTEM
Source of Cobalt
 RDA 1.4 - 2.0 ug/day
 Liver, kidney,
 Oysters, clams
 Poultry
 Milk
15/05/2019 53
SYSTEM
ONE MINUTE PAPER
 Bagaimana pemahaman anda mengenai
 anemia defisiensi besi
 zat-zat gizi yang berperan serta sebutkan peranannya
15/05/2019 54
SYSTEM
ANEMIA MEGALOBLASTIC
15/05/2019 55
SYSTEM
INTRODUCTION
 Anemia’s characterized by distinctive
cytological and functional abnormalities in
peripheral blood film and bone marrow
cytology that is large cells of erythroid and
myeloid series due to impaired synthesis of
DNA
 Etiological types :
 vitamin B12 deficiency
 folic acid deficiency
15/05/2019 56
SYSTEM
BUZZ GROUP
 Coba diskusikan :
 seorang wanita, 32 tahun datang ke puskesmas dengan
keluhan sering lemas, pucat. Dalam pemeriksaan darah
diperoleh anemia makrositik.
 Sebutkan zat gizi yang dapat menjadi penyebab
terjadinya anemia pada pasien ini?
 Bagaimana penatalaksanaan nutrisinya?
15/05/2019 57
SYSTEM
VITAMIN B12 DEFICIENCY
15/05/2019 58
SYSTEM
ETIOLOGY
1. Impaired absorption
 Gastric causes
 Pernicious anemia
 Gastrectomy
 Intestinal causes
 H.pylori infection
 Blinloop syndrome
 Celiac disease
 Ileal resection
 Chron’s disease
 Pancreatic insufficiency
 TC II deficiency
2. Decreased intake
15/05/2019 59
SYSTEM
DIAGNOSIS

 Glossitis
 Anorexia/diarrhea
 Neurological involvement (peripheral
neurophaty and subacute combined
degeneration of spinal cord)
15/05/2019 60
SYSTEM
DIAGNOSIS
 Laboratory indices is the most common methods to

assess iron nutritional status
 low hemoglobin
 low RBC count
 high MCV, MCH,
 normal or low MCHC
 high serum bilirubin
 high serum iron
 low serum vitamin B12
 serum folate normal
 Ig antibodies present (anemia pernicious)
 high LDH
15/05/2019 61
SYSTEM
BLOOD SMEAR
TEST
15/05/2019 62
SYSTEM
VITAMIN B12
15/05/2019 63
SYSTEM
15/05/2019 64
SYSTEM
an intermediate of the citric
Important for DNA synthesis,
acid cycle, porphyrin synthesis
nervous tissue and fat metabolism
in the liver (Heme synthesis)
15/05/2019 65
SYSTEM
15/05/2019 66
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15/05/2019 67
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15/05/2019 68
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Absorption and
transport of vitamin
B12
15/05/2019 69
SYSTEM
ANEMIA PERNICIOUS
15/05/2019 70
SYSTEM
INTRODUCTION
 Auto immune destruction of parietal cells
 Antibodies vs parietal cells, intrinsic factor
 Achlorhydria is universal
 Increased incidence of gastric cancer
 Often associated with autoimmune diseases e.g

Hashimoto’s thyroiditis
15/05/2019 71
SYSTEM
Pernicious
Anemia (PA)
 Early graying of hair
 Blue eyes
15/05/2019 72
SYSTEM
Pernicious Anemia
 Red beefy tongue
15/05/2019 73
SYSTEM
Pernicious Anemia
 Vitiligo
15/05/2019 74
SYSTEM
PA
Normal Gastric atrophy

15/05/2019 75
SYSTEM
15/05/2019 Atrophic Gastritis
SYSTEM
76
15/05/2019 77
SYSTEM
15/05/2019 78
SYSTEM
15/05/2019 79
SYSTEM
FOLATE DEFICIENCY
15/05/2019 80
SYSTEM
ETIOLOGY
1. Decreased intake
 Decreased intake of raw/fresh vegetables by young
childre
 Chronic alcoholics
2. Impaired absorption
 Celiac disease
15/05/2019 81
SYSTEM
ETIOLOGY
3. Increased demand
 pregnancy
 lactation
 infancy
 hemolysis
 myeloproliferative disorders/malignancy
4. effect of drugs
 folate antagonist (methotheraxate)
 phenytoin/oral conceptive
15/05/2019 82
SYSTEM
DIAGNOSIS

 Glossitis
 Anorexia/diarrhea
15/05/2019 83
SYSTEM
DIAGNOSIS
 Laboratory indices is the most common methods

to assess iron nutritional status
 serum folate (<3 ng/ml)
 RBC folate (<140 ng/ml)
 rest all features similiar to vitamin B12
deficiency
15/05/2019 84
SYSTEM
FOLATE
15/05/2019 85
SYSTEM
15/05/2019 86
SYSTEM
15/05/2019 87
SYSTEM
15/05/2019 88
SYSTEM
DIETARY FOLATE AND ITS
ABSORPTION
 Degraded by prolonged boiling
 Daily requirement roughly 100 mcg
 Folate free diet causes deficiency in a few

weeks
 Absorption is largely through the jejenum
15/05/2019 89
SYSTEM
15/05/2019 90
SYSTEM
COMPARISON OF VITAMIN B12 AND FOLATE
DEFICIENCY, MAIN DIFFERENCES
Characteristics Vitamin B12 Folate

Most common Pernicious ↓ dietary intake
cause anemia
Onset Slow, 20-30 years Develops over weeks
Neurological Frequent (+), Never
symptoms severe
Drug-related No : vitamin B12 Yes, anticonvulsants,
deficiency usually dihydrofolate reductase
causes inhibitors
secondary folate Folate deficiency occurs
deficiency frequently on its own
because↓ intake or ↑
demand
15/05/2019 91
SYSTEM
15/05/2019 92
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MANAGEMENT
 Vitamin B12 deficiency :
 Intramuskular injections of hydroxycobalamin for lif
 To fill the stores
 Folate deficiency
 Daily oral folate supplementation
 Folic acid 5-10 mg/day
 Cyanocobalamine 1000 ug 2 x
seminggu – 250 ug/mgg-normal
 Beware hypkalemia in severe cases
15/05/2019 93
SYSTEM
MANAGEMENT
 In pregnancy :
1. Folic acid 10 mg/day
2. severe anemia ---- transfusion
3. Fe tablet
 Prevention in pregnant woman:
1. 300-500 ug folic acid with
2. 60 mg elemental Fe / day in last trimester

15/05/2019 94
SYSTEM
ONE MINUTE PAPER
 Seorang wanita dewasa, 38 tahun datang dengan
keluhan sering lemes dan pucat. Pola kebiasaan
makannya adalah hanya mengkonsumsi lauk nabati.
 Apakah penyebab anemia dari nutrisi? Sebutkan ?
 Bagaimanan penatalaksanaannya?
15/05/2019 95
SYSTEM
15/05/2019 96
SYSTEM

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NUTRITIONAL

 Apa yang bisa menyebabkan hal tersebut?

 To identify and refer nutritional anemia of

 Iron deficiency anemia

15/05/2019 IMUNOLOGY HEMATOLOGY SYSTEM 7

Often corrected by intake Kidney or bone

15/05/2019 IMUNOLOGY HEMATOLOGY SYSTEM 12

 Iron deficiency (ID) is one of the most

 Its prevalence is higher in children and

 Iron deficiency anemia (IDA) mainly affects

 Laboratory indices is the most common methods to

= serum iron (μmol/L)/ TIBC (μmol/L) x 100%

Hemoglobin Normal Normal Decreased

MCV (80-100 fl) Normal Normal Decreased

MCHC (32-36%) Normal Normal Decreased or

% saturation (30-50) Normal Decreased (<20) Decreased

Serum ferritin (50- Decreased (<20) Decreased Decreased

TIBC (300-360ug/dl) Increased (>360) Increased (>380) Increased

 History and/or physical examination is insufficient (e.g

- FIND ETIOLOGY OF ANEMIA AND CURE (CAUSAL

 Menstrual woman -> lost 30 mg -> need 1 mg Fe / day

2. Adequate intake of food sources of iron

3. Well planned family

 Bagaimana penatalaksanaan nutrisinya?

 The only states that are stable in the aqueos environment of

 Highly reactive element that can interact with oxygen to form

 Iron must be tightly bound to proteins to prevent

Total body iron 3500 – 5000 100

Haemoglobin Oxygen transport 2500 60-70

Ferritin (2/3) and Iron storage: mainly liver , 1000 27

Myoglobin Oxygen transporter in muscle 130 3.5

Uncharacterized iron- Storage 80 2.2

Cytochromes and Electron transport chain 8 0.2

 Transferrin is the major protein responsible

 Tissues with higher requirements of Iron (erythroid

 Once in tissues, Iron is stored as ferritin and

 The amount of ferritin in storage compartment

 Ferritin concentration expresses Body Iron Stores

 Iron exists in food under two forms,

 Inorganic (non-heme) iron, is mostly in the oxidized

 Factors affecting bioavailability :

 Iron deficiency : Up to 40% absorbed

 Factors that affect absorption:

Enhancing factors /facilitators :

acid in the stomach

high body demand

low body stores

meat protein factor

 low acidity in stomach

 dietary fiber (phytate)

 calcium and phosphorus (food)

 inadequate protein intake

Beef, lamb, pork, liver, +++ Wheat bran +++

Plum, banana, mango ++/+ Legumes +++

Carrot, potato, pumpkin, Leafy vegetables +++

Adult male 1.0 mg

Menstruating woman 2.0 mg

Pregnant woman 3,0 mg

The main factors regulating iron

 The amount of iron to which

 AKG : 75-90 mg/day (adult)

 OXIDIZING IRON BEFORE IT IS TRANSPORTED

 PLAYS ROLE IN MITOCHONDRIAL ENERGY