Iron Deficiency Anaemia: Why It Is So Common in India
Iron deficiency is the most common nutritional deficiency in the world and is strikingly prevalent in India, particularly among women of reproductive age, adolescents and young children. It develops slowly, and because the body adapts, people often function for months while progressively more tired than they realise.
What iron deficiency feels like
- Fatigue and reduced exercise tolerance
- Breathlessness on stairs or mild exertion
- Pale skin, inner eyelids and nail beds
- Palpitations
- Headache and poor concentration
- Hair fall
- Brittle or spoon-shaped nails
- Restless legs at night
- Craving for ice, clay or raw rice, a symptom called pica that is quite specific to iron deficiency
- Cracks at the corners of the mouth, sore tongue
Symptoms of iron deficiency can appear before haemoglobin falls, which is why a normal haemoglobin does not rule it out.
Why it is so common here
Dietary form of iron
Iron from plant foods, called non-haem iron, is absorbed far less efficiently than iron from meat, fish and poultry. In predominantly vegetarian diets, absorption may be only 2-5% of intake compared with 15-35% from haem sources.
Absorption inhibitors at every meal
Tea and coffee taken with or immediately after meals reduce iron absorption substantially through polyphenols. Phytates in whole grains and legumes, and calcium from milk and dairy, also compete.
Menstrual and obstetric losses
Heavy periods are the single commonest cause in women of reproductive age and are frequently normalised rather than investigated. Closely spaced pregnancies deplete stores further.
Hookworm and chronic blood loss
Intestinal parasites remain a meaningful cause in some regions. In men and in women past menopause, unexplained iron deficiency should always prompt a search for gastrointestinal blood loss.
Diagnosing it properly
A haemoglobin test alone is not enough. The key tests are:
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- Haemoglobin – defines anaemia but not its cause
- Ferritin – the best single marker of iron stores; low ferritin confirms deficiency
- Mean corpuscular volume (MCV) – typically low in iron deficiency
- Transferrin saturation – falls in deficiency
One important caveat: ferritin rises with infection, inflammation and liver disease, so a normal ferritin in someone who is unwell does not exclude deficiency. In that setting, transferrin saturation and CRP help.
In India, thalassaemia trait is common and also produces a low MCV. Treating it as iron deficiency with long-term iron is both ineffective and potentially harmful, which is why ferritin matters before starting supplements.
Correcting it
Oral iron, taken correctly
Most people can be treated with oral iron. What has changed in recent years is the dosing:
- Alternate-day dosing is now preferred over multiple daily doses. Frequent dosing raises hepcidin, which blocks absorption of the next dose, so one tablet every other day often delivers more absorbed iron with fewer side effects.
- Take it with vitamin C – a glass of citrus juice or a 100 mg tablet – which improves absorption of non-haem iron.
- Take it away from tea, coffee, milk, calcium supplements and antacids.
- Expect a rise in haemoglobin within two to four weeks, but continue for three months after haemoglobin normalises to refill stores.
Nausea, constipation and dark stools are common. Dark stools are expected and harmless.
Diet
Diet alone rarely corrects established deficiency, but it prevents recurrence.
- Iron-rich vegetarian sources: bajra, ragi, amaranth, soy, rajma, chana, green leafy vegetables, sesame, jaggery
- Pair them with lemon, amla, guava, tomato or citrus
- Move tea and coffee to between meals rather than with them
- Cooking in iron utensils genuinely increases iron content of food
Intravenous iron
Used where oral iron is not tolerated or not absorbed, in malabsorption, chronic kidney disease, inflammatory bowel disease, or where correction is needed quickly such as late pregnancy.
When to investigate further
- Iron deficiency in any man, or in a woman after menopause – this needs evaluation for gastrointestinal bleeding
- Anaemia that does not respond to three months of appropriate iron
- Weight loss, change in bowel habit, or blood in stool alongside anaemia
- Very heavy menstrual bleeding, which has treatable causes of its own
This article is general health information. Do not take long-term iron supplements without a confirmed diagnosis, since iron overload carries its own risks.