You have been tired for months. Not the kind of tired that one good night’s sleep fixes – the kind that settles in and stays. You get breathless doing things that did not used to require effort. You feel cold in rooms other people find comfortable. You have had two illnesses in four months when you would normally have one in a year, and each one took longer to shake. Your doctor ran a blood test, noted that your haemoglobin was low, and prescribed iron tablets. The tablets caused constipation so severe that you stopped taking them after three weeks. You are now back where you started, except you now know the number: 10.1 g/dL.
The tiredness is real. The low haemoglobin is real. But the treatment conversation may have stopped too early – because iron deficiency anaemia and the habits that prevent iron absorption from working are almost never explained together. This article does both.
What the Numbers Actually Mean – Before Anything Else
The World Health Organisation defines anaemia in non-pregnant women as haemoglobin below 12 g/dL. The Indian Council of Medical Research uses the same threshold in its dietary guidelines at icmr.gov.in. Mild anaemia is 11 to 11.9 g/dL. Moderate anaemia – the range where most of the fatigue, breathlessness, and reduced immunity symptoms become noticeable – is 8 to 10.9 g/dL. Severe anaemia is below 8 g/dL and requires medical intervention beyond dietary management.
A haemoglobin of 10.1 g/dL is moderate anaemia. The symptoms you are feeling are proportional to that level. They will not fully resolve until haemoglobin rises above 12 g/dL – which, at the typical rate of improvement with correct treatment, takes three to four months minimum. There is no supplement or food that corrects haemoglobin in days or weeks. Anyone claiming otherwise is selling something.
According to the National Family Health Survey (NFHS-5, 2019-21), 57 percent of women aged 15 to 49 in India are anaemic. This is not a statistic from a developing-country context – it applies to urban, educated, salaried Indian women in exactly the demographic that Preethi represents. The causes are not poverty or food scarcity. They are dietary composition, absorption-blocking habits, and in a significant proportion of cases, B12 deficiency that is entirely separate from iron.
The Symptoms That Are Easy to Misread
Fatigue and pallor are the textbook symptoms and most people know them. The ones that go unrecognised – and that often appear before the more obvious signs – are worth naming specifically.
Cold hands and feet in a warm environment. Anaemia reduces red blood cell count, which reduces the oxygen-carrying capacity of blood. The body responds by prioritising blood flow to vital organs – brain, heart, lungs – and reducing circulation to the extremities. The result is hands and feet that feel cold even in a Chennai May, even indoors with the ceiling fan off. This symptom is commonly attributed to “poor circulation” or dismissed as a personal tendency. In a woman of reproductive age in India, it warrants a blood test.
Unusual food cravings. Pica – craving for and sometimes consuming non-food substances – is a documented symptom of severe iron deficiency. In the Indian context, the most common forms are craving for ice (pagophagia), raw rice, or in some cases chalk or clay. Many women with this symptom feel ashamed of it and do not mention it to a doctor. It is a clinical symptom, not a character deficiency, and its presence strongly suggests iron deficiency severe enough to warrant medical evaluation rather than dietary management alone.
Smooth or sore tongue. A tongue that has lost its normal texture – appearing unusually smooth, red, and sometimes painful – is a symptom of B12 or folate deficiency anaemia, not iron deficiency. If this is present alongside fatigue and low haemoglobin, it changes the diagnostic picture significantly. Iron tablets will not help this.
Restless legs at night. An uncomfortable, crawling, or aching sensation in the legs that occurs specifically at night and is relieved by moving around is associated with iron deficiency. It is commonly attributed to stress, poor sleep habits, or dismissed as minor joint pain. In someone already flagged for low haemoglobin, it is worth mentioning to a doctor explicitly.
Brittle nails with vertical ridges, or nails that have developed a spoon shape (concave rather than convex) – koilonychia in clinical terminology – are a sign of longstanding iron deficiency. Most women notice the nail changes and attribute them to calcium deficiency or nail product use.
Why Your Tea Habit May Be Defeating Every Effort to Raise Your Iron
This is the India-specific fact that changes the outcome for many women who are eating iron-rich food and taking supplements but not improving.
Iron from plant sources – spinach, dal, rajma, ragi, garden cress seeds – is non-heme iron. The body absorbs non-heme iron at a rate of 2 to 10 percent under ideal conditions. Under non-ideal conditions, that absorption rate drops further. The single most powerful inhibitor of non-heme iron absorption is tannins – the same compounds that give tea and coffee their distinctive taste and colour.
Research published in the American Journal of Clinical Nutrition by Hallberg and Rossander in 1982 – one of the most cited studies on dietary iron absorption – found that tea consumed with a meal reduces non-heme iron absorption by 60 to 70 percent. Coffee reduces it by approximately 39 percent. The critical detail: the inhibition occurs when tea or coffee is consumed within one hour of the meal, not just during the meal itself.
The standard Indian eating pattern – breakfast followed immediately by a cup of chai, or lunch ending with a cup of tea, or an evening chai within 30 minutes of a snack – places tannin consumption precisely in the window that blocks iron absorption. A woman eating a dal-and-spinach lunch and then drinking chai ten minutes later has absorbed a fraction of the iron from that meal. She does the same at breakfast. She does the same at dinner if she has evening tea.
The dietary change that makes the largest single difference for iron absorption – and it costs nothing – is to wait at least 90 minutes after any meal before drinking tea or coffee. This one habit change, sustained for three months, can meaningfully improve the iron absorbed from an unchanged diet.
The complementary change: consume a source of vitamin C with or immediately after iron-rich meals. Vitamin C (ascorbic acid) increases non-heme iron absorption by a factor of three to six. A small glass of lemon juice, a raw tomato, or a piece of guava eaten at the same time as iron-rich food significantly improves absorption. The combination of removing the tannin inhibitor and adding the vitamin C enhancer has been shown in multiple ICMR-cited studies to double and sometimes triple the effective iron absorbed from an ordinary Indian vegetarian meal.
Iron Deficiency vs B12 Deficiency – Why This Distinction Changes the Treatment
Both cause anaemia. Both cause fatigue. Both are extremely common in India. They are not the same condition and they do not respond to the same treatment.
Iron deficiency anaemia occurs when the body cannot make enough haemoglobin because it lacks sufficient iron. The red blood cells produced are small and pale – microcytic, hypochromic in clinical terminology. The treatment is iron supplementation and dietary iron improvement.
Vitamin B12 deficiency anaemia occurs when the body cannot produce red blood cells properly because of insufficient B12. The cells produced are large and abnormal – megaloblastic anaemia. The haemoglobin count falls even though iron may be adequate. The treatment is B12 supplementation, not iron.
B12 exists almost exclusively in animal products: meat, fish, eggs, dairy. Strict vegetarians and vegans who do not supplement have no reliable dietary source of B12. The Indian vegetarian diet – particularly in South India where dairy is consumed but meat and eggs are not – can be adequate in B12 through dairy alone, but this depends on the quantity and type of dairy consumed and varies significantly by household.
A standard haemoglobin test does not distinguish between the two types. A complete blood count (CBC) report includes parameters called MCV (Mean Corpuscular Volume) and MCH (Mean Corpuscular Haemoglobin) that do distinguish them. Low MCV suggests iron deficiency. High MCV suggests B12 or folate deficiency. If you have a recent CBC report, look at these values. If you have only a haemoglobin reading, ask your doctor specifically for a CBC with B12 and folate levels before beginning iron supplementation. Treating iron deficiency when the actual deficiency is B12 – or when both are present – means months of taking the wrong supplement with no improvement and no understanding of why.
The Iron Tablet Problem – and What to Ask Your Doctor About
Ferrous sulphate is the most commonly prescribed iron supplement in India. It is on the government’s National List of Essential Medicines, it is inexpensive, and it is effective when tolerated. The problem is that a significant proportion of people – in some studies, up to 50 percent – experience gastrointestinal side effects severe enough to cause them to stop taking it. Nausea, constipation, dark stools, and stomach cramping are the most common.
The side effects occur because ferrous sulphate releases free iron in the gut, which interacts with the intestinal lining. The dose typically prescribed – 100 to 200 mg of elemental iron per day – is higher than absorption capacity, which means a large portion remains unabsorbed in the gut and causes the irritation.
Ferrous bisglycinate is a chelated form of iron where the iron is bound to the amino acid glycine, allowing it to pass through the intestinal lining more efficiently at a lower dose. Because less unabsorbed iron remains in the gut, gastrointestinal side effects are significantly less common and less severe. Multiple comparative studies published on PubMed confirm equivalent or superior efficacy with lower GI side effects compared to ferrous sulphate.
Ferrous bisglycinate is available in India. Brand names include Feronia-XT (available in most pharmacy chains), Curfer, and Haem UP, among others. The price is higher than ferrous sulphate – typically ₹150 to ₹250 for a month’s supply versus ₹30 to ₹50 for ferrous sulphate. It requires a prescription. The correct approach: go back to your doctor, mention that ferrous sulphate caused severe constipation and you stopped taking it, and specifically ask whether ferrous bisglycinate is appropriate for your case. This is a legitimate clinical conversation and most doctors will accommodate the request.
Taking iron supplements with a source of vitamin C – a glass of lemon water, orange juice, or amla juice – at the same time improves absorption. Taking them on an empty stomach increases absorption but worsens GI side effects for most people; taking them with a small amount of food reduces side effects with a modest reduction in absorption. For someone who has already stopped a supplement due to side effects, taking it with food is the better practical choice even if slightly less efficient.
The Iron Kadai – the Traditional Indian Practice That Modern Nutrition Has Confirmed
Cooking in a cast iron kadai – the heavy iron cooking vessel used in traditional Indian kitchens – measurably increases the iron content of food. Research published in the Journal of the American Dietetic Association in 1986 (Brittin and Nossaman) demonstrated that cooking in iron cookware increases the iron content of food, with acidic foods showing the greatest benefit. In the Indian context, tomato-based curries, tamarind-based dishes, and preparations containing amchur or kokum – all acidic – cooked in an iron kadai show meaningful iron content increases.
The ICMR has acknowledged this in nutritional guidance for anaemia prevention at the population level. The iron that leaches from the kadai into food is in a form that the body can use. This is not a claim that cooking in iron replaces supplementation for severe anaemia – it does not. But as a dietary contribution to ongoing iron intake, the traditional iron kadai is a genuinely evidence-supported tool that has been abandoned in most Indian urban kitchens in favour of non-stick and stainless steel.
Maintaining an iron kadai requires seasoning it periodically with oil to prevent rust. A well-maintained iron kadai lasts decades. If iron deficiency is an ongoing concern, reintroducing it for curries, dal, and sabzi preparations is a low-effort, no-cost intervention that complements supplementation and diet improvement.
Two Women – What Changed and How Long It Took
Preethi Nair, 34, Chennai. Haemoglobin at 10.1 g/dL. Changed from ferrous sulphate to ferrous bisglycinate after requesting the switch from her doctor, explaining the constipation issue from the previous prescription. Shifted tea timing – waited 90 minutes after each meal before drinking chai, which required adjusting her routine significantly in the first two weeks. Added a small glass of lemon water with her daily dal at lunch. Her four-month follow-up blood test showed haemoglobin at 11.6 g/dL – still below normal but meaningfully improved. She noted that the breathlessness on stairs had resolved by month two and the cold hands by month three. Her doctor has scheduled a six-month test and expects haemoglobin to be above 12 g/dL by then.
Kavitha Desai, 38, homemaker, Pune. Strict vegetarian, dairy-consuming. Haemoglobin of 9.8 g/dL, fatigue for eight months. Her initial prescription was iron alone. At her three-month follow-up with no improvement in symptoms despite taking the supplement, her doctor ordered a complete CBC with B12 levels. B12 was 156 pg/mL – below the normal range of 200 to 900 pg/mL. She had both iron and B12 deficiency simultaneously. Her treatment was revised to include both iron supplementation and a weekly B12 injection for three months, followed by oral B12 maintenance. Symptoms began improving within six weeks of the combined treatment. The iron alone for three months had not moved her haemoglobin because B12 deficiency was preventing proper red blood cell production regardless of iron availability.
Frequently Asked Questions
How do I know whether my fatigue is anaemia or something else?
A blood test is the only reliable way to confirm. A complete blood count (CBC) measures haemoglobin, red blood cell size and colour, white blood cells, and platelets. It distinguishes between the types of anaemia and rules out other causes of low haemoglobin. Fatigue from anaemia typically improves with moderate rest but does not fully resolve, and is accompanied by at least one or two of the physical symptoms described in this article – breathlessness on mild exertion, cold extremities, pale inner eyelids or gums. Fatigue from sleep deprivation, thyroid issues, or depression has different accompanying patterns. A CBC plus thyroid function test covers the most common causes of persistent unexplained fatigue in Indian women and can be done at any diagnostic lab for ₹500 to ₹1,200 depending on the lab and city.
My spinach and dal intake is high. Why am I still anaemic?
Almost certainly absorption. Plant-based iron (non-heme iron) has baseline absorption of 2 to 10 percent. With tannin inhibition from tea or coffee within one hour of meals, absorption can fall to 1 to 4 percent. You may be eating adequate iron by weight but absorbing very little of it. Remove the tannin inhibitor (tea timing), add a vitamin C source with the meal, and retest haemoglobin at three months. If levels are still not rising with these changes and correct supplementation, a gastroenterology consultation is warranted to rule out malabsorption issues such as celiac disease, which has higher-than-recognised prevalence in India and directly impairs iron absorption.
Is it safe to take iron supplements during pregnancy without a doctor’s prescription?
No. Iron requirements increase significantly during pregnancy, and supplementation dose must be tailored to the specific deficiency level. Excess iron during pregnancy carries its own risks. All iron supplementation during pregnancy should be under medical supervision, with regular haemoglobin monitoring. The ICMR recommends 60 mg elemental iron daily for pregnant women as a minimum, but the appropriate dose for someone with existing moderate anaemia may be higher and must be assessed individually by an obstetrician or physician.
I have been taking iron tablets for three months with no improvement. What should I do?
Three possibilities. First, check whether you have been taking the tablets consistently with the tannin and vitamin C rules described in this article – many people do not, and absorption is dramatically affected. Second, get a CBC with B12 and folate levels if you have not already – co-existing B12 deficiency is common and would explain why iron alone is not working. Third, see a gastroenterologist to rule out conditions that impair iron absorption – celiac disease, Helicobacter pylori infection, and inflammatory bowel disease all reduce iron absorption and are more common in India than generally recognised. Non-response to iron supplementation over three months warrants investigation, not continuation of the same treatment.
Can men get iron deficiency anaemia?
Yes, though it is less common than in women of reproductive age because men do not have menstrual blood loss, which is the primary cause of iron deficiency in women. In men, iron deficiency anaemia is more often caused by internal bleeding – from peptic ulcers, gastritis, or in rare cases gastrointestinal cancers – or by severe dietary deficiency. A man with unexplained iron deficiency anaemia should always be investigated for a source of internal blood loss, which is more medically urgent than the same finding in a menstruating woman.
Does cooking in iron pots actually make a significant difference to iron intake?
For people with moderate deficiency who are already eating iron-rich foods and managing tea timing correctly, cooking in iron pots is a useful supplementary contribution, not a primary treatment. The iron leached per meal varies significantly by food type, cooking time, and the acidity of the preparation. A tomato-based curry cooked for 20 minutes in an iron kadai contributes more iron than a roti baked briefly on the same surface. Treat it as one supporting tool among several, not as a substitute for medical supplementation when haemoglobin is below 11 g/dL.
How often should I get my haemoglobin checked?
For women of reproductive age in India where anaemia prevalence is 57 percent, an annual blood test that includes haemoglobin and a basic CBC is reasonable practice. For women who have previously been diagnosed with anaemia, follow-up testing every three to four months during active treatment, and then every six months once haemoglobin has normalised. For pregnant women: at the first antenatal visit, at 28 weeks, and at 36 weeks as a minimum. Testing is inexpensive – a CBC at most Indian diagnostic labs costs ₹150 to ₹400.
Information last verified:
May 16, 2026. Primary sources: National Family Health Survey NFHS-5 (2019-21) on anaemia prevalence in Indian women, available at rchiips.org; Indian Council of Medical Research dietary guidelines at icmr.gov.in; WHO haemoglobin thresholds for anaemia at who.int; Hallberg L and Rossander L, “Effect of different drinks on the absorption of non-heme iron from composite meals,” American Journal of Clinical Nutrition, 1982 (PubMed ID 7081564); Brittin HC and Nossaman CE, “Iron content of food cooked in iron utensils,” Journal of the American Dietetic Association, 1986; PubMed review on oral iron tolerance and ferrous bisglycinate comparative efficacy (search term “ferrous bisglycinate gastrointestinal tolerance” at pubmed.ncbi.nlm.nih.gov); ICMR guidelines on anaemia prevention and dietary iron at icmr.gov.in.
If you are experiencing symptoms described in this article, consult a qualified physician before beginning any supplementation. This article is for educational purposes and does not replace medical advice. Anaemia has multiple causes and a blood test is required for accurate diagnosis and appropriate treatment.
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Chinnagounder Thiruvenkatam is the Founder and Publisher of dailyhindnews.in/ and Tips Clear Media LLP, Chennai. A 25-year veteran of the Central Reserve Police Force (CRPF) and full-time digital publisher since 2016. Full author profile
