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Nonheme iron requires gastric acid for conversion to the ferrous form of iron for absorption.[196] 90% of dietary and 100% of oral iron supple-mentation is in the nonheme form.[197] So not surprisingly, several review studies in the literature conclude that PPI use leads to decreased iron absorption.[198,199] In one study, all markers of iron deficiency were decreased among patients on PPI therapy as compared to controls

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(Table 22b.6) showed markedly higher plasma methylmalonic acid concentrations in the infants on macrobiotic diets compared to the controls (Schneede et al., 1994)