Nutrition in a Time of POTS: 6 Reasons to See an RDN

Nutrition in a Time of POTS: 6 Reasons to See an RDN

Published on Friday, January 13, 2023 by Elyse Krawtz

Postural orthostatic tachycardia syndrome (POTS), a disorder that a viral infection may trigger, is in the spotlight because of the recent pandemic.

We need more and better research to truly understand POTS, its incidence, and how to treat it, however, according to a 2022 Heart Rhythm review, POTS might affect up to an estimated 2-14% of COVID-19 survivors.

Experts convened at NIH for a 2019 meeting about POTS  and described it in their report as: “…a complex, multi-system, chronic disorder of the autonomic nervous system characterized by orthostatic intolerance with excessive heart rate increase and symptoms on standing while blood pressure is maintained.”

They noted that symptoms improve after lying back down and that POTS can develop slowly or rapidly after a trigger. Triggers include viral upper respiratory or gastrointestinal infections, menarche, pregnancy, surgery, or physical trauma such as a concussion. 

Experts in a 2019 issue of Practical Gastroenterology reviewing hydration and nutrition in POTS report that it is more common in individuals with chronic fatigue syndrome, fibromyalgia, interstitial cystitis, migraines, autoimmunity, Ehlers-Danlos syndrome, and mast cell activation disorder and could occur with a wide variety of symptoms: 

  • Psychological: panic disorder, anxiety, depression, attention deficit, behavioral amplification, somatization, and hypervigilance 
  • Gastrointestinal: nausea, irregular bowel movements, abdominal pain, constipation, heartburn, bloating, motility changes, dysmotility-induced small intestinal bacterial overgrowth, celiac artery compression syndrome 
  • Neurological: visceral hypersensitivity, central sensitization, and tremors
  • Nutrition: loss of appetite or difficulty eating, weight loss, dehydration, nutrient malabsorption, or increased nutrient needs
  • Other: difficulty breathing, lightheadedness, palpitations 

POTS diagnosis by a knowledgeable physician is relatively simple, but it requires ruling out other possible causes for the symptoms. POTS is easy to miss because many conditions can cause at least some of these symptoms. In the 2019 NIH expert summary, experts noted that 75% of individuals eventually diagnosed with POTS suffer from misdiagnoses for over 4 years. 

POTS has no one-size-fits-all treatment because of the breadth of possible symptoms, triggers, and co-occurring conditions. A multidisciplinary, integrated healthcare team must design a personalized plan which might include medications, medical nutrition therapy, medical foods, supplements, and psychological therapy as suited to the individual. 

Those suffering from POTS should include a nutrition professional such as an RDN on their healthcare team to help with their individual case and coordinate their nutrition care.


RDNs help people with POTS navigate: 


1. Staying hydrated.

People with POTS may benefit from additional fluid, and electrolytes such as sodium, as well as strategies to hydrate while coping with nausea and dysmotility. A promising small, short-term 2021 randomized controlled trial published in the Journal of the American College of Cardiology showed some benefit to a higher sodium diet in people with POTS, but the authors noted it was not a sufficient treatment to fully manage the condition. 

2. Staying nourished.

People with POTS may benefit from strategies to get enough calories to prevent malnutrition and unintentional weight loss using well-tolerated foods, and even nutrient-dense liquid sources of energy when symptoms are severe. 

3. Maintaining vitamin and mineral sufficiency.

Eating a restricted diet and suffering from malabsorption can lead to vitamin and mineral deficiencies. RDNs may recommend lab work, supplements, and specific foods to promote vitamin and mineral sufficiency. 

4. Strategic fiber intake.

People with POTS could experience improved or worsened symptoms after different fiber sources depending on their unique case and symptoms. 

5. Identifying food triggers.

Patients with POTS and co-occurring celiac disease require a gluten-free diet and people with IBS and POTS may benefit from a Low FODMAP diet. However, people with POTS should consult a professional to help safely implement restrictions. Improperly restricting can worsen their already increased risk of deficiencies, dehydration, and malnutrition. 

6. Selecting and trying appropriate supplements.

There is no evidence-based standard supplement regimen for people with POTS. However, there is some evidence for specific supplements for certain symptoms and conditions associated with POTS. An RDN can help someone with POTS strategically and safely select high-quality dietary supplements with low risk and with potential benefit in his or her unique case. 

    1. Vernino, S., Bourne, K. M., Stiles, L. E., Grubb, B. P., Fedorowski, A., Stewart, J. M., Arnold, A. C., Pace, L. A., Axelsson, J., Boris, J. R., Moak, J. P., Goodman, B. P., Chémali, K. R., Chung, T. H., Goldstein, D. S., Diedrich, A., Miglis, M. G., Cortez, M. M., Miller, A. J., Freeman, R., … Raj, S. R. (2021). Postural orthostatic tachycardia syndrome (POTS): State of the science and clinical care from a 2019 National Institutes of Health Expert Consensus Meeting - Part 1. Autonomic neuroscience : basic & clinical, 235, 102828.
    2. Ormiston, C. K., Świątkiewicz, I., & Taub, P. R. (2022). Postural orthostatic tachycardia syndrome as a sequela of COVID-19. Heart rhythm, 19(11), 1880–1889. Advance online publication.
    3. DiBaise, J. K., Lunsford, T. N., & Harris, L. A. (2019). The POTS (Postural Tachycardia Syndrome) Epidemic: Hydration and Nutrition Issues. Practical Gastroenterology, 14–26. 
    4. Garland, E. M., Gamboa, A., Nwazue, V. C., Celedonio, J. E., Paranjape, S. Y., Black, B. K., Okamoto, L. E., Shibao, C. A., Biaggioni, I., Robertson, D., Diedrich, A., Dupont, W. D., & Raj, S. R. (2021). Effect of High Dietary Sodium Intake in Patients With Postural Tachycardia Syndrome. Journal of the American College of Cardiology, 77(17), 2174–2184.
    5. Raj, S. R., Bourne, K. M., Stiles, L. E., Miglis, M. G., Cortez, M. M., Miller, A. J., Freeman, R., Biaggioni, I., Rowe, P. C., Sheldon, R. S., Shibao, C. A., Diedrich, A., Systrom, D. M., Cook, G. A., Doherty, T. A., Abdallah, H. I., Grubb, B. P., Fedorowski, A., Stewart, J. M., Arnold, A. C., … Vernino, S. (2021). Postural orthostatic tachycardia syndrome (POTS): Priorities for POTS care and research from a 2019 National Institutes of Health Expert Consensus Meeting - Part 2. Autonomic neuroscience : basic & clinical, 235, 102836. 

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