MCR Diabetes & Eye Care · Kannur, Kerala
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Anaemia is so common among Indian women that it has become normalised — fatigue is attributed to housework, breathlessness to being unfit, hair fall to the weather. National survey data has consistently found more than half of Indian women of reproductive age to be anaemic. What makes this frustrating is that iron deficiency is straightforward to diagnose and treat, yet most cases are managed poorly: the wrong test, the wrong dose, too short a course, and no search for the underlying cause. Our specialist team at MCR Diabetes & Eye Care, Kannur, sets out what proper care looks like.
Evidence update: The WHO 2024 guideline defines anaemia using haemoglobin, but haemoglobin alone does not establish iron deficiency. Ferritin and the clinical context matter, particularly when inflammation can raise ferritin. Oral iron may be prescribed daily or on alternate days; a systematic review found similar haemoglobin improvement with fewer gastrointestinal adverse effects on alternate-day schedules. The dose and schedule should therefore be individualized rather than self-prescribed.
Over 50%
of Indian women of reproductive age are anaemic
Ferritin
the test most often missed
3-6 months
extra treatment needed after Hb normalises
Alternate-day
dosing may reduce side effects for some people
Iron deficiency progresses in stages. Stores deplete first — detectable only by ferritin — then red cell production suffers, and only at the final stage does haemoglobin fall enough to be called anaemia. This is why a “normal haemoglobin” report does not exclude iron deficiency, and why symptomatic women are frequently reassured incorrectly. For an overview of the full blood panel, see our complete blood count guide.
Symptoms — Including the Ones Nobody Connects
Common
- Persistent fatigue and low energy
- Breathlessness climbing stairs or on light exertion
- Pallor — most reliably seen in the lower eyelid, tongue, and nail beds
- Palpitations
- Dizziness or light-headedness
- Headaches
- Poor concentration and low mood
Frequently Missed
- Hair fall — one of the most common presentations in young Indian women
- Brittle, spoon-shaped nails
- Restless legs at night — an urge to move the legs that disturbs sleep
- Cracks at the corners of the mouth
- Sore, smooth tongue
- Pica — craving ice, clay, or chalk
- Reduced exercise tolerance attributed to being “out of shape”
- Recurrent infections
Key fact: Iron stores deplete long before haemoglobin falls. A ‘normal haemoglobin’ does not exclude iron deficiency — which is why symptomatic women with hair fall, restless legs, and fatigue are so often incorrectly reassured. Ferritin is the test that finds it.
The Right Tests
| Test | What It Shows | Deficiency Pattern |
|---|---|---|
| Haemoglobin | Presence of anaemia | Low (last to fall) |
| Ferritin | Iron stores — the key test | Below 30 ng/mL (below 15 = definite) |
| MCV | Red cell size | Low (microcytic) |
| RDW | Size variation | Raised — helps separate from thalassaemia |
| Serum iron / TIBC | Circulating iron and capacity | Low iron, high TIBC |
| Transferrin saturation | Iron availability | Below 20% |
| CRP | Inflammation | Raised CRP can falsely normalise ferritin |
| Hb electrophoresis | Thalassaemia trait | Ordered if RDW normal with low MCV |
The single most important addition to a haemoglobin test is ferritin, which reflects iron stores. One trap to know: ferritin is an acute-phase protein and rises with any inflammation, infection, obesity, or liver disease. In these settings a “normal” ferritin can mask true deficiency — checking CRP alongside, or using transferrin saturation, clarifies the picture.
Finding the Cause — Not Just Treating the Number
Iron deficiency is a symptom, not a diagnosis. Common causes in Indian women:
- Heavy or prolonged menstrual bleeding — by far the most common, and frequently under-reported because women assume their own pattern is normal. Fibroids, adenomyosis, and hormonal causes should be evaluated.
- Repeated pregnancies with short gaps and breastfeeding without repletion
- Dietary insufficiency — vegetarian diets provide non-haem iron, absorbed at roughly 2-10% versus 15-35% for haem iron from meat and fish
- Absorption inhibitors — tea and coffee with meals, calcium supplements, antacids and proton pump inhibitors
- Coeliac disease — under-diagnosed in India; consider with unexplained refractory deficiency
- Hookworm and other parasitic infestation — still relevant in some settings
- Gastrointestinal bleeding — ulcers, gastritis, and in older women or any man, colorectal disease. Iron deficiency in a post-menopausal woman or an adult man always requires GI evaluation.
- Chronic kidney disease — a different mechanism, relevant in diabetics; see our diabetic nephropathy guide
⚠ Important: Iron deficiency in a post-menopausal woman or in any adult man is never simply dietary — it requires gastrointestinal evaluation to exclude bleeding from ulcers, gastritis, or colorectal disease. Do not accept iron tablets alone as the whole answer in these groups.
Treatment: Where Most Cases Go Wrong
Dose and Frequency
Conventional practice has been 100-200 mg of elemental iron daily in divided doses. Newer evidence shows this is often counterproductive: each dose raises hepcidin, a hormone that blocks further absorption for the next day or so. Consequently:
- Alternate-day dosing of a single 60-120 mg elemental iron dose often achieves equal or better absorption with far fewer side effects
- Single daily doses on an empty stomach are preferable to multiple divided doses
- Discuss the regimen with your doctor rather than assuming more is better
Improving Absorption
- Take on an empty stomach where tolerated — about an hour before food
- Take with vitamin C (a lime, an orange, or an ascorbic acid tablet)
- Avoid tea and coffee for at least an hour either side — the single most impactful habit change for Indian households, where tea accompanies most meals
- Separate from calcium supplements, dairy, and antacids by at least two hours
Duration
This is the most common failure. Haemoglobin usually normalises within 6-8 weeks — and that is precisely when most people stop. But stores are still empty. Iron must be continued for a further 3-6 months after haemoglobin normalises to refill ferritin, otherwise the anaemia simply returns.
Managing Side Effects
Constipation, nausea, dark stools, and a metallic taste are common. Dark stools are harmless and expected. If side effects are limiting: switch to alternate-day dosing, try a different salt (ferrous ascorbate and iron bisglycinate are generally better tolerated than ferrous sulphate), or take with a small amount of food, accepting slightly reduced absorption.
Intravenous Iron
Appropriate when oral iron is not tolerated or not absorbed, when deficiency is severe, when ongoing losses outpace oral replacement, in advanced kidney disease, or when rapid correction is needed. Modern preparations allow large doses in a single sitting and are widely available.
Dietary Iron for Indian Kitchens
- Haem iron (best absorbed): fish, chicken, mutton, liver, prawns — a genuine advantage in coastal Kerala
- Non-haem iron: ragi, bajra, jaggery, sesame, dates, green leafy vegetables (cheera, muringa leaves), pulses, beetroot
- Pair with vitamin C: lime over dal, tomato in curries, guava or amla as fruit — this can double or triple non-haem absorption
- Cook in iron vessels — a traditional iron kadai measurably increases the iron content of acidic dishes
- Shift tea timing away from meals
Diet alone corrects mild deficiency and maintains levels, but rarely corrects established anaemia. Both are needed.
Complete Anaemia Panel at MCR
Ferritin, iron studies, and investigation of the underlying cause — not just a prescription for tablets.
Special Considerations
In Pregnancy
Requirements roughly double. Screening and supplementation are routine, and untreated anaemia raises risks for both mother and baby. Anaemia also complicates gestational diabetes management — see our gestational diabetes guide.
In Diabetics
Anaemia distorts HbA1c results, sometimes substantially — iron deficiency can falsely raise HbA1c, while treatment can lower it without any change in actual glucose. Interpret HbA1c cautiously in anaemic patients; see our HbA1c guide.
Thalassaemia Trait
Common in parts of Kerala and easily mistaken for iron deficiency — both produce small red cells. The distinction matters, since giving iron to someone with thalassaemia trait and normal stores is useless and potentially harmful. Ferritin and haemoglobin electrophoresis clarify.
Iron Deficiency at a Glance
| Aspect | Key Point |
|---|---|
| Key test | Ferritin — not haemoglobin alone |
| Most common cause in women | Heavy menstrual bleeding |
| Dosing | 60-120 mg elemental iron, often alternate-day |
| Take with | Vitamin C, on an empty stomach |
| Avoid within 1 hour | Tea, coffee, calcium, antacids |
| Duration | 3-6 months beyond haemoglobin normalising |
| Better-tolerated salts | Ferrous ascorbate, iron bisglycinate |
| IV iron | Intolerance, malabsorption, severe or urgent cases |
| In diabetics | Anaemia distorts HbA1c — interpret with caution |
Frequently Asked Questions
Below are the questions our patients ask most often. If you have additional questions, our specialist team at MCR Diabetes & Eye Care, Kannur, is always available to help.
My haemoglobin is normal but I am always tired. Could it still be iron?
Yes. Iron stores deplete well before haemoglobin falls, and symptoms including fatigue, hair fall, and restless legs can occur at that stage. Ask specifically for a ferritin test.
Why do my iron tablets upset my stomach?
Ferrous sulphate commonly causes nausea and constipation. Alternate-day dosing, a gentler salt such as ferrous ascorbate or iron bisglycinate, or taking with a little food usually resolves it. Dark stools are expected and harmless.
Is alternate-day dosing really as good as daily?
Often better. Each dose raises hepcidin, which blocks absorption for the following day or so. Alternate-day single doses frequently achieve equal or greater total absorption with markedly fewer side effects.
How long do I need to take iron?
Until three to six months after your haemoglobin normalises. Stopping when haemoglobin recovers is the single most common reason anaemia returns — stores are still empty at that point.
Can I fix this with diet alone?
Diet corrects mild deficiency and maintains levels, but rarely corrects established anaemia. Combining both works best: supplements to correct, diet to maintain — with tea moved away from mealtimes.
Why did my doctor order a thalassaemia test?
Thalassaemia trait also produces small red cells and is not uncommon in Kerala. Distinguishing it from iron deficiency matters, because giving iron to someone with normal stores is useless and potentially harmful.
Does anaemia affect my diabetes reports?
Yes — meaningfully. Iron deficiency can falsely raise HbA1c, and correcting it can lower the reading without any real change in glucose control. Always interpret HbA1c alongside a blood count.
Final Takeaway: Test Properly, Treat Fully, Find the Cause
Three changes would transform anaemia care for Indian women: measure ferritin rather than haemoglobin alone, continue iron for three to six months after haemoglobin normalises, and always ask why the deficiency happened. Fatigue endured for years frequently resolves entirely once this is done properly.
At MCR Diabetes & Eye Care, Kannur, we offer complete anaemia panels including ferritin and iron studies, investigate the underlying cause, and prescribe regimens designed for absorption and tolerability. If you are persistently tired, or have been on iron tablets on and off for years, book a proper assessment today.
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- HbA1c Test: Normal Range and What It Means
Sources and Further Reading
Clinical recommendations and key claims in this article were checked against the following guidance and research. Individual care should be discussed with your clinician.
- World Health Organization: Guideline on haemoglobin cutoffs to define anaemia (2024)
- ICMR–National Institute of Nutrition: Dietary Guidelines for Indians (2024)
- Daily versus alternate-day oral iron therapy in iron-deficiency anaemia: systematic review
- Cochrane Review: Daily iron supplementation for menstruating women
