Management of Low Omega-3 Index, Low Ferritin, and Elevated Folate
You need immediate oral iron supplementation to correct your depleted iron stores, and you should increase dietary omega-3 fatty acids or consider supplementation to raise your omega-3 index to the optimal range of ≥8%.
Iron Deficiency: Immediate Priority
Diagnosis and Clinical Significance
Your ferritin of 23 µg/L falls in the borderline-to-low range that indicates depleted iron stores requiring treatment. 1 While a ferritin <15 µg/L has 99% specificity for absolute iron deficiency, values between 15–30 µg/L generally indicate low body iron stores that warrant intervention. 1, 2 Your level of 23 µg/L sits squarely in this treatment zone.
The most critical step is to calculate your transferrin saturation (TSAT) to confirm iron deficiency and assess iron availability for red blood cell production. 3 TSAT = (serum iron × 100) ÷ total iron-binding capacity. 3 A TSAT <20% confirms iron deficiency regardless of ferritin level. 1, 3
Immediate Treatment
Start oral iron supplementation immediately with ferrous sulfate 65 mg elemental iron daily, or consider alternate-day dosing (60–65 mg every other day) to improve absorption by 30–50% and reduce gastrointestinal side effects. 2 Do not wait for additional testing to begin treatment. 2
- Take iron on an empty stomach for optimal absorption, or with meals if gastrointestinal symptoms occur. 2
- Expected side effects include constipation, nausea, or diarrhea, which can be minimized by taking with food or switching to alternate-day dosing. 2
- Continue supplementation for at least 3 months after hemoglobin normalizes to fully replenish iron stores and achieve a target ferritin >100 ng/mL. 2
Investigation of Underlying Causes
Screen for celiac disease with tissue transglutaminase (tTG) IgA antibodies, as celiac disease accounts for 3–5% of iron deficiency cases and can cause treatment failure if missed. 2 Also perform non-invasive testing for Helicobacter pylori (stool antigen or urea-breath test), as this organism impairs iron absorption. 2
If you are a premenopausal woman with heavy menstrual bleeding and no gastrointestinal symptoms, empiric iron supplementation without immediate endoscopy is appropriate. 2 However, reserve bidirectional endoscopy (upper and lower GI) if you are ≥50 years old, have GI symptoms (abdominal pain, altered bowel habits, visible blood), positive celiac or H. pylori testing, lack of response to oral iron after 8–10 weeks, or a strong family history of colorectal cancer. 2
If you are an adult male or post-menopausal woman, urgent bidirectional endoscopy is required because iron deficiency may be the sole manifestation of gastrointestinal malignancy. 1
Monitoring and Follow-Up
- Repeat complete blood count (CBC) and ferritin at 8–10 weeks to assess response to treatment. 2
- Expected response: hemoglobin should rise by ≥10 g/L within 2 weeks of starting therapy. 2
- Target ferritin >100 ng/mL to restore iron stores and prevent recurrence. 2
- If no improvement occurs, consider malabsorption, non-compliance, ongoing blood loss, or need for IV iron. 2
When to Consider Intravenous Iron
Switch to intravenous ferric carboxymaltose (15 mg/kg, maximum 1000 mg per dose) if you have: 2
- Oral iron intolerance (marked nausea, constipation, diarrhea)
- Confirmed malabsorption (celiac disease, inflammatory bowel disease, post-bariatric surgery)
- Ongoing blood loss exceeding oral replacement capacity
- Chronic inflammatory conditions (chronic kidney disease, heart failure, cancer)
- Lack of hemoglobin response after 8–10 weeks of adequate oral iron
Omega-3 Index: Cardiovascular Risk Optimization
Current Status and Target
Your omega-3 index of 4% is well below the optimal level of ≥8%, which is associated with the lowest risk for sudden cardiac death and coronary heart disease. 4 The omega-3 index reflects red blood cell levels of EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid), which are a reliable marker of tissue omega-3 status. 4
Treatment Strategy
Increase dietary intake of omega-3 fatty acids by consuming fatty fish (salmon, mackerel, sardines, herring) at least 2–3 times per week. If dietary intake is insufficient or you prefer supplementation, consider omega-3 supplements providing 1800–2000 mg of combined EPA+DHA daily to raise your index toward the optimal ≥8% range. 5, 4
While one study in hemodialysis patients showed that omega-3 supplementation (1800 mg/day for 4 months) did not significantly improve anemia parameters, it did show relative improvement in systemic inflammation. 5 However, this study was in a specific population (hemodialysis patients) and may not directly apply to your situation. 5
The primary benefit of raising your omega-3 index is cardiovascular risk reduction, not anemia correction. 4 Optimal omega-3 levels (≥8%) are associated with decreased risk for sudden cardiac death and may play a pathophysiologic role in preventing coronary heart disease. 4
Folate: No Action Needed
Your serum folate of 1040 µg/L is markedly elevated and well above normal ranges. 1, 2 This level is not concerning and does not require intervention. Folate is water-soluble, and excess is typically excreted in urine. 1
However, be aware that high folate levels can mask vitamin B12 deficiency-related megaloblastic anemia. 1 If you develop macrocytic anemia (elevated MCV) in the future, ensure vitamin B12 levels are checked, as folic acid supplementation can correct the anemia of B12 deficiency while allowing neurologic damage to progress. 1
Critical Pitfalls to Avoid
- Do not assume your ferritin of 23 µg/L is "normal enough" to ignore—this level indicates depleted iron stores requiring treatment. 1, 2
- Do not discontinue iron therapy once hemoglobin normalizes—continue for an additional 3 months to achieve ferritin >100 ng/mL. 2
- Do not overlook celiac disease screening, as its 3–5% prevalence among iron-deficiency cases can lead to treatment failure if missed. 2
- Do not delay endoscopic evaluation if you are ≥50 years old, have GI symptoms, or fail to respond to oral iron, as gastrointestinal malignancy can present solely with iron deficiency. 2
- Do not rely on omega-3 supplementation to correct your iron deficiency—the evidence does not support this, and iron supplementation is the definitive treatment. 5