The following nutrient imbalances may be worth investigation, as they have been associated with POTS, exacerbation of POTS-like symptoms, or common POTS comorbidities, such as small fiber neuropathy. In some cases, improvement in POTS has been documented upon correcting the nutrient imbalance. It should be noted, however, that research is extremely limited at this point.
Dr. Svetlana Blitshteyn, Founder of the Dysautonomia Clinic, typically runs the following vitamin and mineral tests for her dysautonomia patients:
- Vitamins: vitamin B1 whole blood, pyridoxine (vitamin B6), folate (vitamin B9), vitamin B12, vitamin D 25-OH, vitamin E, and homocysteine
- Minerals: copper, ferritin and magnesium
Note: we are grateful to Dr. Blitshteyn, a leading POTS physician and member of the SUTP Medical Advisory Board, for reviewing this page and sharing her testing insights with practitioners interested in learning more about POTS.
Nutritional imbalances to be checked:
- Sodium chloride: A 24-hour urine sodium can be ordered to assess whether there is adequate sodium-fluid balance.
- Iron: High rates of iron insufficiency, deficiency and anemia have been reported in children and adolescents with POTS (Anti
- el et al., 2011 ; Jarjour and Jarjour, 2013). ClinicalTrials.gov lists a proposed Mayo Clinic study investigating iron sucrose infusions for adolescents with iron deficiency and POTS, however the study is listed as terminated due to difficulty recruiting patients. This is best tested with serum ferritin.
- Choline: Schenkel and colleagues (2015) report a case of POTS where choline deficiency was identified through molecular analysis of skin cells, and where the patient improved with choline supplementation. Dr. Schenkel explained the study and findings in POTScast episode #82.
- Blood glucose: If diabetes or pre-diabetes is suspected, a fasting blood glucose level and a 3 hour glucose tolerance test is recommended.
- Gluten: POTS patients have elevated rates of Celiac disease (4% vs 1% background rate) and gluten intolerance (42% vs 19% background rate; Penny et al., 2016). One survey showed a 45% drop in self-reported POTS symptom severity in patients who had — on their own — decided to remain gluten-free for at least 4 weeks (Zha et al., 2022). There is no reliable test for gluten sensitivity, but there are tests for Celiac with the tissue transglutaminase antibodies and anti-gliadin antibodies.
Vitamin Imbalances
- Vitamin B1 (thiamin): Thiamin deficiency is rare, but the symptoms mimic POTS. In a retrospective study of 65 patients (Blitshteyn, 2017), 4 were found to have low (but not truly deficient) thiamin. When they supplemented with 100 mg/day, 1 patient saw quick and dramatic improvement in POTS. The conclusion states: “A small subset of patients with POTS may have vitamin B1 deficiency. Testing for vitamin B1 deficiency and correcting the deficiency is recommended.” Testing whole blood vitamin B1 is recommended.
- Vitamin B6 (peroxidine): Excessive supplemental vitamin B6 intake can cause peripheral neuropathy (Hemminger and Wills, 2022), which can be associated with, or an underlying cause of, POTS. Fatigued patients may be attracted to “energy drinks”, which sometimes contain high levels of vitamin B6. Testing serum vitamin B6 is recommended.
- Vitamin B12 (cobalamine): In one study (Oner et al., 2014), a much higher prevalence of vitamin B12 deficiency was found in adolescents with fainting disorders vs. healthy controls (47% vs. 18%). The authors hypothesized that B12 deficiency could lead to sympathetic nervous system baroreceptor dysfunction. Vegans are at high risk for B12 deficiency and must supplement. Testing serum vitamin B12 and serum methylmalonic acid if vitamin B12 is low normal or below normal is recommended.
- Vitamin D: In studies of children, low vitamin D was associated with orthostatic intolerance (Antiel et al., 2011) and cardiac autonomic dysfunction (Qingyou et al., 2021). Chaudhari et al. (2012) describes a POTS patient with adequate vitamin D3, and a genetic incapacity to convert it into calcitriol, the activated form of vitamin D3. Supplementing with calcitriol put this patient’s POTS in remission. Dr. Beltran explained the role of Vitamin D in autoimmunity in POTScast episode #91. Testing serum vitamin D25-OH is recommended.