Nutritional Strategies to Help Manage POTS

Trial and error with your diet is important to see what foods might trigger you and in what conditions you feel a little better. These tips and tricks work for many with POTS, but you will have to try to see which might work best for your unique situation.

• Increase fluid and sodium/salt intake.  The 2021 POTS Expert Consensus Review (Vernino et al., 2021) endorses patients consuming at least 2-3 Liters of water per day along with 3-10 grams of sodium from ordinary table salt, salt tablets or electrolyte solutions.  Other expert guidelines recommend up to 10-12g salt/day (Kichloo et al., 2021).  One teaspoon salt contains about 2300mg sodium.  Salt tabs work great for some patients but can cause stomachaches for others, as they pull water into the stomach.  Drinking plain water is adequate for many patients, and others feel better getting up to half their fluids from drinks with natural or added electrolytes.  Drinking the first 2 cups of fluids before getting out of bed helps some patients.
• Try eating smaller, more frequent meals.  It is common for large meals to exacerbate POTS because digestion sends more blood to the GI organs and away from the brain and heart (Mehr et al, 2021). For patients with gastroparesis, eating smaller, more frequent meals that are lower in fat and fiber (which can further slow digestion) may help, but has not been formally studied (Tu et al., 2020).  Liquid or pureed meals may also help.
• Try to include plenty of variety in your diet; for enjoyment, nutrition and a healthy gut microbiome (Heiman & Greenway, 2016). 
• Reduce intake of high-glycemic and high-carbohydrate foods, such as sweets, baked goods, pretzels, chips, bread, potatoes and pasta.  High-carbohydrate foods are found to exacerbate POTS symptoms, and send more blood to the GI organs, meaning there is less blood in circulation to the head and heart (Mehr et al., 2018).  These foods can be replaced with foods higher in protein, healthy fats and fiber.  This strategy may also help because POTS patients may be at increased risk of glucose intolerance, which increases risk to develop type 2 diabetes (Breier et al., 2022).
• For patients with dumping syndrome, meals that are higher in fat and fiber may help slow transit, and complex carbohydrates are recommended over sweets or processed carbs.  In addition, a pectin supplement to increase viscosity of diet can be considered.  Delaying any drinking of water for 30 minutes after meals may also help.  It should be noted, however, that these recommendations come from patients with dumping syndrome who did not also have POTS (Tu et al., 2020).
• Try to correct any nutrient imbalances.  If you have a restricted diet or digestive issues that impair nutrient absorption, consider speaking with your healthcare practitioner about whether you should be tested for nutrient imbalances.  This page discusses nutrient imbalances associated with POTS.
• If, despite best efforts, patients are not able to get adequate nutrition orally, there may be need for non-oral nutrition support, in the form of IV fluids, enteral nutrition or parenteral nutrition (Tseng et al., 2021).

Try to identify any other food allergies/intolerances that may be causing symptoms.  The most common allergens are wheat, cow’s milk, eggs, peanuts, soy, sesame, tree nuts, fish and shellfish, but individuals can be allergic/intolerant to any food (AAAAI.org).  Working with an allergist or dietician may be advised if you suspect significant allergies or intolerances.  Elimination diets can be useful tools for identifying offending foods, but should be done under the supervision of a healthcare professional who can make sure you get adequate nutrition.

• Consider a 1-month trial gluten-free, to see if it helps.  POTS patients were found to have higher prevalence of Celiac Disease (4% vs 1% background rate) and gluten intolerance (42% vs 19% background rate; Penny et al, 2016).  In a survey of 20 POTS patients who had, on their own,  decided to be gluten-free for >4 weeks, the self-reported reduction in POTS symptoms was a whopping 45% (Zha et al., 2022).
• If you have comorbid MCAS, you might consider speaking to your healthcare provider about a trial of a low-histamine diet.
• If you have comorbid autoimmune disease, you might consider speaking to your healthcare provider about a trial of an autoimmune protocol diet.

Nutritionist and SUTP Board member Jill Brook created a page called What the Bleep Can I Eat? to help patients navigate which foods can be consumed on a variety of diet options.

• Be careful with alcohol.  Anecdotally, drinking alcohol exacerbates POTS, possibly because it is a diuretic, vasodilator and potential mast cell trigger.
• Observe your response to caffeine.  Anecdotally, some POTS patients enjoy the energy and vasoconstriction effects whereas others get jitters, insomnia, diarrhea or other negative side effects.
• Be careful with energy drinks.  One case study describes a patient whose POTS was caused by inadvertent overuse of Red Bull (Terlizzi et al., 2008).

• This 1-hour presentation about nutrition for POTS was created by Nutritionist Jill Brook for the Johns Hopkins POTS group
• The POTScast episode #3:  Occupational Therapy Tips for Cooking and More with Dr. Joanna Behm
• The POTScast episode #13:  Small Intestinal Bacterial Overgrowth with Dr. Leonard Weinstock
• The POTScast episode #27:  POTS & Blood Volume with Nutritionist Jill Brook
• The POTScast episode #43:  Carbohydrates and Glucose Intolerance in POTS with Nutritionist Jill Brook
• The POTScast episode #58:  Improving Gut Health with Nutritionist Jill Brook
• The POTScast episode #82:  Choline Issues in POTS with Dr. Leila Schenkel
• The POTScast episode #91:  Vitamin D and Autoimmunity with Dr. Eduardo Beltran
• The POTScast episode #120: Autoimmune Diet with Nutritionist Jill Brook
• The POTScast episode #129:  Health Willpower Strategies with Nutritionist Jill Brook