Why India’s Anaemia Problem Is Worsening

“Laboratory tests showed she was anaemic, her haemoglobin was 8.3 g/dL, which is below 12.0 gm/dL, the lower limit of the normal range for women, but her serum iron level was normal as were her vitals, so we had to consider other causes of anaemia,” the treating doctor Bharesh Dedhia, head of Intensive Care at P.D. Hinduja Hospital & Medical Research Centre, Khar, Mumbai, told IndiaSpend.

For a long time, iron and folate deficiencies were thought to be the main causes of anaemia. However, recent studies show that vitamin B12 deficiency is also quite common, said Pankaj Malhotra, professor and head of Clinical Haematology & Medical Oncology at the Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh.

Chronic diseases, genetic conditions, bone marrow problems, the excessive breakdown of red blood cells, long-term blood loss, thyroid disorders, and certain medications can also cause anaemia. Infections like malaria and tuberculosis are major contributors to anaemia, especially in poorer communities, explained Malhotra.

In addition, exposure to polluted air could also trigger changes in the body that reduce the absorption, storage and distribution of iron, studies show.

This has policy implications for the elimination of anaemia, especially in the light of its rising national prevalence across population segments—women of reproductive age, children and men.

India’s Anaemia Mukt Bharat (Anaemia Free India) programme launched in 2018 focuses on iron and folic acid supplementation and making available rice fortified with micronutrients. But “merely ingesting more iron isn’t enough to ensure the iron is actually absorbed and lowers anaemia,” said Anura Kurpad, professor of physiology, St John’s Medical College, Bengaluru. “Anaemia due to other causes isn’t addressed through these measures, and there is the issue of potential side effects of universal fortification.”

Experts say India needs to focus more on finding out the cause of anaemia before treating it, encouraging dietary diversification, limiting the use of iron-fortified cereal, and ensuring iron supplements are absorbed into the body. The government should also create more awareness about the importance of an optimal level of haemoglobin and on combating the side-effects of iron supplementation, our reporting shows.

Anaemia is not only because of iron deficiency

India's nationwide survey of over 100,000 teenagers (10-19 years old) conducted between 2016 and 2018 found that iron deficiency was the main reason for anaemia. Other causes included a lack of folate, vitamin A, vitamin B12, vitamin D and zinc.

A January 2025 study published in the European Journal of Clinical Nutrition, conducted in eight Indian states, throws up new insights on anaemia. It concluded that “iron deficiency accounts for less than a third of the overall prevalence of anaemia." Further, the study found that "other" reasons were responsible for the major proportion of anaemia in all the age groups studied, albeit the prevalence of anaemia was lower than thought in adolescents, adults and the elderly, by testing venous blood instead of capillary blood.

Narrating these possible causes based on all the research available, co-author of the study, Kurpad, who is also professor of physiology, St John’s Medical College, Bengaluru, said besides iron deficiency, "a further third [of anaemia in India] is caused by a deficiency of vitamins B12 and folic acid, and the remainder of the prevalence may be caused by air pollution and other indeterminate reasons related to the environment".

Other causes of anaemia include chronic diseases such as chronic kidney disease, rheumatoid arthritis and cancer. It develops when chronic disease and inflammation cause a fall in the production of erythropoietin, a hormone produced by the kidneys to stimulate the production of red blood cells.

Dedhia’s patient had two chronic diseases—chronic kidney disease, for which she had been on dialysis for five years, as well as rheumatoid arthritis, for which she was on medication. Medicines to stimulate the production of red blood cells, iron supplementation, and vitamin B12 and folate supplementation to support red blood cell production, helped increase her haemoglobin level to a near normal level in about three months.

Since anaemia can have many causes, Dedhia underlined the need for thorough diagnosis and a treatment plan.

To effectively tackle anaemia, we must look at all possible causes besides nutrition, said Malhotra. “This includes checking for infections, particularly in rural areas, and managing chronic diseases.”

But what can be done to mitigate anaemia arising from air pollution?

Experts compared satellite images of fine particulate matter (PM 2.5) pollution in districts across India on the day prior to the National Family Health Survey IV, with the district-wise anaemia rates for children and women of reproductive age. What emerged was a clear relationship between the level of pollution and anaemia rates, according to studies published in Nature.

Every 10 micrograms per cubic metre (µg m–3) increase in exposure to fine particulate matter (PM 2.5) increased the average anaemia prevalence by 10% among children, and by 7.23% among women of reproductive age.

Another study published last year in BMC Geriatrics showed an association between indoor air pollution, typically from the use of unclean fuel, with anaemia, which was more pronounced in elderly (above the age of 45 years) men than women.

Exposure to polluted air causes anaemia in two ways. First, “fine particulate matter triggers the production of cytokines, proteins that fight inflammation and signal the liver to secrete hepcidin, a hormone that reduces the absorption, storage and distribution of iron,” explained Kurpad, a co-author of the study on the relation between pollution and anaemia.

“Cytokines are also known to suppress the bone marrow, so fewer red blood cells are produced,” he added.

All of India’s population is exposed to unhealthy levels of ambient PM 2.5, according to the World Bank. In the study on air pollution and anaemia, industrial activity was seen to be the biggest contributor of such pollutants, followed by the unorganised, domestic, power, road dust, agricultural waste burning and transport sectors.

For reference, burning an incense stick for 15 minutes has been shown to push up the indoor PM 2.5 concentration to 197 µg m–3 , which is 13 times higher than the 15 µg m–3 maximum exposure advised by the World Health Organisation in 24 hours.

Kurpad pointed out that meeting India’s clean-air targets could theoretically reduce the overall prevalence of anaemia among women of reproductive age to 39.5%, and take 186 districts below the national target of 35%.

In other words, transitioning to clean energy would accelerate India’s progress towards the ‘anaemia-free’ mission target. The challenge is “state level initiatives to control pollution haven’t worked to any significant level as yet”, he said.

At the individual level, anaemia arising from air pollution can be mitigated by a diet rich in antioxidants but fruits containing these antioxidants, like vitamin C, are expensive.

“Guava is the best option as a seasonal fruit, papaya is useful but oranges are too expensive,” said Kurpad. “Banana is the most commonly eaten fruit by the poor; while it’s good to fill the stomach it has no antioxidants.”

Diet diversification could help reduce anaemia but is missing from India’s food policy

So far, India’s food policies have mainly focused on providing enough grain to prevent hunger.

To address anaemia, the government introduced fortified rice in 2021 as part of the subsidised food distribution programme, school meals and child nutrition programmes. By 2024, fortified rice was part of India’s Public Distribution System for foodgrains to the poor, in rice-eating states, and this will continue until 2028.

In Haryana, early research shows that fortified flour has shown positive results, but other states have yet to adopt it, Malhotra said.

In view of many people relying on cereals with a low-iron content and an increasing preference for fast food, anaemia is becoming more common. So, Malhotra suggested expanding the food fortification programme to include iron, folic acid and vitamin B12 in staples like rice, wheat, and salt.

However, “an excessive intake of iron has been associated with diabetes, and universal iron fortification could have serious implications in view of India’s diabetes epidemic,” said Kurpad.

One in 15 or 101 million Indians are diabetic, and millions more are pre-diabetic, a situation that has been fuelled by cereal-based diets, sedentary lifestyles and rising obesity, said Kurpad, and underscored the need to reconsider grain-centric nutritional policies.

“Policy and nutrition in India has progressed linearly rather than parallelly, solving first one problem and then another,” said Kurpad. “Instead, we need to consider the bigger picture, and opt for holistic solutions that could help solve multiple problems.”

Kurpad recommends fortifying diets through diet diversity that brings fruits and vegetables to an accessible level through intensive horticulture rather than solely agriculture.

Public policies that feed the masses the right type of diversified foods could help ensure that the poor eat more vegetables and fruits than just potatoes, green chillies and bananas, the least expensive options, especially iron-rich foods as well as those that help absorb iron.

Fortification alone does not work

A food may be iron-rich, either naturally or through fortification, but the nutrient must be absorbed by the body to be of use.

“Pushing nutrition through fortification has not had the spectacular effect we had thought it would possibly because iron is not absorbed as well from fortified foods,” said Kurpad.

Instead, Kurpad said, “we need to add nutrients to pull fortified iron into the body”.

For instance, vitamin C helps improve the absorption of iron but it needs to be consumed in a greater quantity than iron. An intake of vitamin C in a meal, which is about five times more than iron (weight for weight), can increase iron absorption from less than 5% to anywhere up to 25%.

What’s important is that the “vitamin C-rich foods like citrus fruits should be eaten along with the iron-rich meals,” said Malhotra.

Simultaneously, the consumption of phytates (a form of phosphorus in plants such as tea leaves), tannins (tea and coffee), and calcium should be avoided during iron-rich meals because they block the absorption of iron.

In rural Haryana, adding guava, a vitamin C rich fruit, to a mung bean-based meal served to 6 to 10-year-olds reduced the prevalence of anaemia by half, over a period of seven months, according to a study published in the Journal of Nutrition in December 2024.

“Adding guava to students’ mung bean-based (green gram) mid-day meal, which contains a moderate amount of iron, helped improve the bioavailability of iron, and hence, the concentration of haemoglobin,” Varsha Rani, a study co-author and assistant professor, Foods & Nutrition, Chaudhary Charan Singh Haryana Agricultural University, told IndiaSpend.

“We chose guava because it is the richest source of vitamin C after Indian gooseberry (amla),” continued Rani. “Since amla can’t be eaten without processing, guava becomes a vitamin C hero. In our study, the combined nutrients reduced iron-deficiency anaemia but could not increase the iron stores in the body, possibly because the iron content in mung beans was not high enough.”

Mass awareness campaign vital to make community part of the anaemia solution

Anaemia isn’t just a nutritional problem, it’s also an awareness problem, according to Rahul Bhargava, principal director & chief of haematology at Fortis Hospital, Gurgaon, who also said that “door-to-door screening and delivering an iron (and any other) capsule will not solve anaemia.”

We’ll be fighting a losing battle until the community is part of the solution,” said Bhargava. “People must understand what a normal haemoglobin level can do for their health, and be motivated to achieve that.”

Without understanding, an anaemic person is likely to stop taking supplementation in the eventuality of experiencing constipation or any other side effect. Essentially, “people adjust to a suboptimal haemoglobin level, and then find it difficult to take supplementation,” said Bhargava. “But someone who has experienced the productivity that follows a normal haemoglobin level will make an effort to get back on track if it falls.”

Politicians must take the lead in publicising this message through mass media like Mann Ki Baat, the radio show, according to Bhargava. “It isn’t the government’s job to continuously screen for anaemia but it is the job of those in government to inspire people to ask why their haemoglobin level is less than normal,” he said.

“We need large-scale awareness campaigns to encourage healthy eating, promote iron supplements, and reduce the stigma around anaemia,” emphasised Malhotra.

High-risk groups like adolescent girls and women of reproductive age with menstruation-related problems are most in need of comprehensive nutrition and healthcare services, including information to manage anaemia.

We reached out to joint secretary in the Ministry of Health and Family Welfare, Meera Srivastava, Zoya Ali Rizvi, deputy commissioner (Nutrition); and Manisha Verma, additional director general (Media & Communications) for their comments on the varied causes of anaemia in India, and on the government’s plan to tackle these, on a holistic programme and community involvement to tackle anaemia but have not heard back. We will update the story when we receive a response.

Sufia Khatoon, age 38, a resident of Kolkata, has struggled with anaemia, experiencing menstruation-related issues, weakness, intense muscular pain around bones and weight loss, for which she has seen multiple doctors to try to understand how to manage her condition.

“I was told to take Hemfer XT for 6 months to get over the anaemia, but no one had any suggestions on overcoming the constipation that occurs nor on anaemia recurring, so what is an ideal maintenance dose to keep your body active and hormones in check,” said Khatoon. “The right information is hard to come by.”

Anaemia is as much a national health emergency as Covid was, said Bhargava. “We need to prioritise creating anaemia awareness just as we prioritised creating awareness of Covid, PCR testing and so on among the masses. Else, malnourished human resources will stall India’s progress towards becoming a developed nation by 2047. Let’s hear politicians say: ‘Ab ki baar, haemoglobin 12 ke paar’.”

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.