POTS and nutrition interventions

Postural orthostatic tachycardia syndrome, more commonly known as POTS, is a condition in which a change in body position results in abnormal blood flow from the nerves and an increased heart rate. Specific symptoms triggered can vary depending on the individual, but persistent complaints are dizziness, syncope, fatigue, anxiety, an increased heart rate, headaches, nausea, impaired gastric motility, or abdominal bloating.

While a clear etiology for POTS is unknown, experts suggest that causes may stem from a neuropathic, hyperadrenergic, or hypovolemic trigger. In individuals struggling with POTS symptoms, consistent nutritional intake can be a challenge, and this is where collaborating with a registered dietitian nutritionist (RDN) can be critical.  

POTS is under the umbrella of dysautonomia, which includes other conditions that disrupt the normal function of the autonomic nervous system. The autonomic nervous system regulates involuntary bodily processes including breathing, digestion, heart rate, and blood pressure.  

How is POTS diagnosed?

Because of the multiple symptoms, the diagnosis of POTS is not always easy to determine. If available, a tilt table test is often ordered as part of a medical assessment. During this test, heart rate, heart rhythm, and blood pressure are tracked as the patient is positioned at different times at 30, 45, and 70 degrees. The onset of symptoms in these various positions can help determine if POTS is the issue, along with the criteria below.  

• Heart rate: An increase in heart rate of ≥ 30 beats per minute for adults (or ≥ 40 beats per minute for children) or a heart rate of 120 beats per minute or higher within 10 minutes of rising from a supine to an upright posture.    
• Absence of orthostatic hypotension (significant decline in blood pressure) 
• Persistent symptoms lasting at least 3 months  

In the absence of a table tilt test, one simple alternative is measuring blood pressure and heart rate in a patient transitioning from supine to upright at 2-, 5-, and 10-minute intervals. This easy method is called the Active Stand Test. The same diagnostic metrics above still apply. Some research is also investigating a very similar test called the NASA 10-Minute Lean Test. With this technique, a patient is supine for several minutes to establish a baseline, then quickly transitions to standing upright and leans against a wall for support while measurements are taken. 

Additional tests that you might also see with these patients during a work-up include blood or urine tests, tests of the autonomic nervous system, or cardiac testing, among others. While there is not yet a cure for POTS, diagnosis can better guide treatment, which involves a combination of lifestyle modifications, diet adjustments, exercise, and medication.  

Strategies for nutrition management

The nutritional status of an individual with POTS can vary due to a wide range of symptoms. Two specific barriers that often present are gastrointestinal symptoms and insufficient hydration. As with any other disease, lack of consistent nutritional intake can lead not only to deficits in macronutrient intake but also to micronutrient deficiencies. Guidance from the RDN should reflect goals for optimizing nutritional intake while considering the diet adjustments needed for specific POTS symptoms. 

GI health: With the common symptoms of abdominal pain, constipation or diarrhea, and impaired gastric motility, management of gut health is necessary for the patient with POTS. Diet modifications should be individualized and designed to minimize a patient’s symptoms. Fiber can be increased or decreased, depending on a patient’s needs and GI tolerance.

Sodium intake: Increased salt intake is needed to balance blood volume for symptom improvement. Compared to a standard healthy diet recommendation, salt intake should be much higher for POTS with sources recommending a range between 6 to 10 g per day. Intake of added salt and certain processed foods can help to reach this goal. Foods like broth, soups, or canned vegetables are preferred over cured meats. If supplemental sodium is needed, options include sodium chloride tabs or oral rehydration solutions. Physician guidance is encouraged when determining a specific sodium goal with POTS, particularly if other co-morbidities are a concern.  

Fluid goals: Adequate hydration can also help improve symptoms with POTS. Similar to higher sodium needs, fluid recommendations are above average and range from 2 to 3 liters per day.  While some caffeinated beverages can be included, most intake should come from water or non-caffeinated choices. To maintain hydration, some individuals may also require intravenous supplementation or the inclusion of oral rehydration solutions. In general, excessive alcohol or caffeine should be avoided, as these may cause a diuretic effect.  

Meal size and timing: With changes to gastric motility in more than half of individuals with POTS, adjustment from a diet with three main meals is likely needed. Instead, suggest a pattern of 4 to 6 smaller meals throughout the day. Some fluids may be taken with meals, but a larger amount should be encouraged between meals to limit early satiety. The RDN can be helpful in finding a balance of different foods that are well tolerated for these individuals.   

Vitamin and mineral supplementation: Severe symptoms that disrupt normal oral intake and digestion can result in the need for vitamin and mineral supplementation. Fat-soluble vitamins, iron, folate, vitamin B12, and thiamine should be routinely monitored by a physician and supplemented as needed.    

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References

Cleveland Clinic. Postural Orthostatic Tachycardia Syndrome (POTS). https://my.clevelandclinic.org/health/diseases/16560-postural-orthostatic-tachycardia-syndrome-pots. Accessed July 31, 2024.  

Ganesh R, Bonnes S, DiBaise J. Postural tachycardia syndrome: nutrition implications. Nutr Clin Pract. 2020;35(5):818-825.  

DiBaise J, Lunsford T, Harris L. The POTS (Postural Tachycardia Syndrome) epidemic: hydration and nutrition issues. Pract Gastroenterol. 2019;43(6):14-26.  

Cleveland Clinic. Tilt Table Test. https://my.clevelandclinic.org/health/diagnostics/17043-tilt-table-test. Accessed August 5, 2024.  

Postural Orthostatic Tachycardia Syndrome. Dysautonomia International website. https://dysautonomiainternational.org/page.php?ID=30. Accessed January 15, 2025.  

10-Minute NASA Lean Test. Bateman Horne Center website. https://batemanhornecenter.org/wp-content/uploads/filebase/providers/mecfs/10-Minute-NASA-Lean-Test-Clinician-Instructions-06_12_2022.pdf. Accessed January 15, 2025. 

Do T, Diamond S, Green C, Warren M. Nutritional implications of patients with dysautonomia and hypermobility syndromes. Curr Nutr Rep. 2021;10:324-333.