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.  

How is POTS diagnosed?

Because of the multiple symptoms, the diagnosis of POTS is not always easy to determine. 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: In adults sitting in an upright posture, an increase in heart rate of ≥ 30 beats per minute in ≤ 10 minutes   
• Lack of orthostatic hypotension  
• Complaints of intolerance to a change in position for ≥ 6 months  

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 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 to help alleviate these symptoms include soluble fiber intake through diet or supplementation and selection of prebiotics and probiotics. In some individuals, a low FODMAP diet has also demonstrated symptom improvement. Monitoring patient symptoms as they incorporate these different foods can help determine tolerance. Foods that should be limited or avoided to promote gut health are those that are heavily processed, high in fructose, refined carbohydrates, or sources of alcohol.   

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 2.5 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.   

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.  

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