Eating for POTS: What to Eat (and Avoid) - Ask a Nutritionist

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Transcript

Teresa: Welcome to “Ask a Nutritionist”, our weekly mini episode of Dishing Up Nutrition. I am Teresa Wagner, a Registered and Licensed Dietitian with Nutritional Weight & Wellness. Now, have you ever sit up and suddenly felt your heart racing? Maybe you get lightheaded, shaky, weak, nauseated, or feel like you might faint.

Maybe simple things, standing in a shower, walking through the grocery store, or eating a big meal leave you completely wiped out. For people with POTS, or postural orthostatic tachycardia syndrome, those symptoms can be a part of everyday life.

And if you've been searching online for answers, you've probably come across all kinds of dietary recommendations. So what actually helps? Today we're talking about eating for POTS and what POTS is, why food can affect symptoms, and what you may want to eat more of, what you may want to limit, and which nutrient deficiencies are worth investigating.

One important point before we get started, POTS is a medical condition, and nutrition is not a substitute for medical evaluation or treatment. There also isn't one universal POTS diet. The goal is to figure out which particular nutrition strategies support your physiology.

What is POTS?

So what is POTS? POTS stands for postural orthostatic tachycardia syndrome. It's a disorder of the autonomic nervous system, the part of your nervous system that you don't have to think about to control. It automatically regulates things like heart rate, blood pressure, digestion, sweating, and blood vessel constriction.

One of the hallmark features is an excessive increase in heart rate, tachycardia, when someone moves from lying down to standing. But POTS is much more than simply having a fast heart rate. People may experience dizziness, weakness, fatigue, exercise intolerance, brain fog, headaches, nausea, digestive symptoms, heart palpitations, shakiness, and sometimes fainting.

Not all POTS is disruptive to life. It exists on a wide spectrum where severity varies greatly from person to person, with severe cases being debilitating and life-altering, while mild cases have more minimal symptoms. POTS isn't necessarily caused by one single thing. Researchers believe that several mechanisms may contribute to this condition, including low blood volume, abnormal narrowing of the blood vessels, excessive activity of the sympathetic nervous system, autonomic neuropathy, and other physiological changes.

Let me break that down just a little bit. The sympathetic nervous system is a part of the autonomic nervous system responsible for the body's fight or flight response. It automatically increases heart rate, raises blood pressure, and constricts blood vessels when the body perceives stress or needs to respond quickly.

Autonomic neuropathy refers to damage to the nerves that control these automatic functions, which can disrupt normal regulation of heart rate, blood pressure, and circulation.

What can cause POTS?

When framing from a nutrition perspective, the reduced plasma or blood volume that is common with POTS helps explain why fluids and sodium are such an important part of conventional and nutritional POTS management.

POTS can also develop or become apparent following illnesses and other physiological stressors. There has been particular interest in POTS following viral infections, including COVID-19. So from a dietitian's perspective, I like to think about what factors could be contributing to this person's symptoms.

We might look at hydration, electrolyte intake, nutrient status, blood sugar, overall food intake, digestive health, sleep, physical conditioning, and coexisting medical conditions. But it's equally important not to assume that finding one abnormality means that we've discovered the root cause. POTS is complicated, and our understanding is still evolving.

Avoid dehydration

So can POTS be triggered by diet? Food usually isn't considered the underlying cause of POTS, but what you eat and how you eat can absolutely influence symptoms. One of the biggest examples is dehydration. If you're not drinking enough fluid, your circulating blood volume can decrease.

If maintaining adequate blood volume is already difficult for your body, dehydration may make dizziness, rapid heart rate, and weakness worse. The same concept applies to sodium. Most of us have heard for years that we need to eat less salt, but POTS is one of those situations where we may actually recommend significantly more sodium because sodium helps the body retain fluid and expand blood volume.

Avoid larger meals, especially a diet high in refined carbohydrates

Another common trigger is a large meal, particularly a meal containing a lot of refined carbohydrate. After you eat, more blood is directed towards the digestive tract. That's normal. But for someone already struggling to regulate blood flow while upright, that shift can make symptoms worse.

That's why some POTS nutrition recommendations include smaller, more frequent meals, and limiting refined carbohydrates. Think about a breakfast of pancakes or waffles with syrup, fruit, fruit juice, and a coffee with sugar and cream compared to a breakfast with eggs cooked in butter and a few vegetables with some berries.

Or compare a big bowl of pasta with garlic bread at dinner to chicken with green beans and a small serving of potatoes and some butter to pull it all together to make it taste great. The second type of meal provides animal protein, natural fats, real food carbohydrates to produce a more gradual blood sugar response while avoiding an enormous carbohydrate load at one sitting.

There's no scientifically established POTS diet. Instead, I would think about building meals around several fundamentals: protein plus vegetables plus a natural fat plus a small portion of a whole food carbohydrate while getting adequate fluids and electrolytes throughout the day.

At Nutritional Weight & Wellness, we are biased towards animal proteins as the best source of protein: eggs, chicken, turkey, beef, fish, cottage cheese, Greek yogurt, or whatever protein works well for you. Add colorful vegetables and perhaps some fruit for vitamins, minerals, and antioxidants, some extra fiber.

Include natural fats, olive oil, avocado, nuts, seeds, or butter. Then add smaller amounts of whole food carbohydrates. Whole food carbohydrates, foods that look like how they grew in the field or in the orchard. Add these according to your individual tolerance, fruit, beans, lentils, squash, potatoes, sweet potatoes, quinoa, or other real food carbohydrate sources.

The goal isn't necessarily low carb, it's more about avoiding huge doses of digesting carbohydrate, especially if you notice that they trigger symptoms.

Instead of having a bagel or cereal for breakfast, for example, you could have eggs, avocado, and berries. Instead of crackers or pretzels for a snack, try some nitrate-free summer sausage, cubed cheddar, and cucumber slices or carrot sticks.

Or if you prefer sweet over savory, Greek yogurt with raspberry and some raw or dried roasted nuts. That combination of protein, fat, and carbohydrate helps create a more balanced meal or snack.

Adequate sodium is important

Let's talk about salt. This is one of the areas where POTS nutrition looks very different from general nutrition advice. Expert recommendations commonly include two to three liters of water per day for a person with POTS.

So that's roughly seventy to one hundred ounces of water or nine to twelve cups, along with substantially increased sodium or salt intake. Although the appropriate amount needs to be individualized. Research has found that a high sodium diet can increase plasma volume and reduce the increase in heart rate that occurs upon standing with people with POTS.

Some POTS guidelines have suggested around ten grams of salt per day, which provides roughly four grams of sodium. Notice we're talking about salt versus sodium, and these are not necessarily interchangeable numbers And this also, it doesn't mean that everyone listening should start eating that much salt.

If you have high blood pressure, kidney disease, heart disease, or another medical condition affecting fluid or electrolyte balance, increasing sodium substantially could be inappropriate or potentially harmful. This is something to discuss with the clinician managing your POTS.

If increased sodium has been recommended for you, you can still do this by eating mostly real food, minimally processed foods. It doesn't mean starting to eat lots of ultra-processed salty foods like chips or canned soup. Think about adding salt on eggs, meat or fish, and on your vegetables, or choosing real foods that naturally contain higher amounts of sodium like olives, pickles, cheese, cottage cheese, bone broth, or homemade soups with added salt.

We can add electrolyte drinks when appropriate, and no, I'm not talking about the red, blue, and fluorescent yellow-colored sports drinks. Options like LMNT, Re-Lyte by Redmond, and ZeroLyte by Trace. These are zero-sugar powders that you add to water that have significant amounts of sodium and electrolytes.

Then spread those fluids and sodium out throughout the day. We are better hydrated when fluids and electrolytes are taken in slowly and consistently rather than all at once.

What foods or dietary patterns can make POTS worse?

Now let's answer the question, what foods or dietary patterns can make POTS worse? There are a few common culprits. Number one, not eating enough. This one often gets overlooked. Someone with POTS might feel nauseated or not well after eating, so they may start eating less.

Eventually, they're consuming too few calories, too little protein, too little fluid, and possibly too little sodium. That can create an unfortunate cycle of weakness and poor nutrition.

Number two, too large of meals. This is because blood moves to your stomach and intestines to help with digestion. In POTS, the body has trouble tightening the blood vessels to make up for that movement, so too much blood pools in the digestive system and less returns to the heart and brain. With less blood coming back, your heart speeds up to try to keep up.

If you feel noticeably worse after big meals, experiment with smaller meals more frequently throughout the day to find the right amount of food that works for you.

Number three, very high carbohydrate meals. We're especially talking about refined carbohydrates, cereal, pastries, and other bread products, big bowls of pasta, pancakes, granola, and cereal bars, and other foods that deliver a lot of carbohydrate very quickly.

Because of that quick sugar absorption in the gut, a surge of insulin and other gut hormones widen the blood vessels, pulling even more blood away from your heart. The result? Thirty to sixty minutes later, dizziness, weakness, brain fog, heart palpitations, and fatigue. Pairing real food carbohydrates with protein, fat, and fiber can be helpful.

Number four, alcohol. Alcohol can dilate blood vessels and contribute to dehydration, both of which may aggravate those orthostatic symptoms. POTS nutrition recommendations advise avoiding alcohol altogether.

And lastly, number five, possibly eliminating caffeine. This is individual. Some people tolerate coffee and caffeine just fine. Others notice more palpitations, rapid heart rate, or shakiness. If you suspect that caffeine is making you feel worse, try reducing it and observe your symptoms rather than assuming you just need it for fatigue.

What helps POTS immediately?

#1: fluids & sodium

Now, what helps POTS immediately? If someone is having severe symptoms, faints, develops chest pain, has difficulty breathing, experiences new or concerning symptoms, that's not something to treat with food at home. Seek appropriate medical care. But for someone's usual POTS symptoms, fluids and sodium are among the most commonly used first-line strategies.

One interesting strategy is drinking water earlier in the day, even before getting out of bed for people whose symptoms are particularly difficult in the morning. If your healthcare provider has advised increased sodium, an electrolyte drink containing meaningful sodium may also be useful.

Maybe try an unsweetened coconut water with a high-quality salt, like Redmond's Celtic Sea Salt. Another idea to consider when looking through the lens of nutrition and POTS is if there are nutrient deficiencies that contribute to POTS.

I want to make an important distinction. There isn't one vitamin or mineral deficiency known to cause POTS. If someone tells you POTS is just a deficiency in this nutrient, that's an oversimplification of what we currently know.

#2: rule out low iron

However, nutrient deficiencies can produce symptoms that overlap with POTS or potentially make someone feel significantly worse. For example, iron is one nutrient worth investigating. Iron deficiency and anemia can contribute to weakness, fatigue, shortness of breath, and rapid heart rate.

One small study of adolescents with POTS found a relatively high prevalence of low iron stores and mild anemia, although that doesn't establish that iron deficiency as the cause of POTS.

#3: rule out vitamin B12 deficiency

Vitamin B12 is another consideration. B12 is important for neurological function, brain function, and it's important for red blood cell production. Low red blood cell count decreases blood volume and decreases the oxygen-carrying capacity of the cells, leading to low oxygen to the brain.

And you guessed it, this leads to a feeling of being lightheaded, dizzy, tired, and possibly even fainting. Research in adolescents has also reported an association between lower B12 levels and POTS, although, again, an association does not prove that B12 deficiency causes POTS.

#4: additional lab markers to have tested

Before starting a new supplement, let's test for deficiencies that might actually be contributing to symptoms. Depending on someone's medical history, we may evaluate things such as a complete blood count, ferritin and iron status, B12, folate, vitamin D, thyroid function, and other markers. Then you can address the actual deficiency rather than guessing.

Sample day of eating

So in making this practical, what should you eat if you have POTS? Let's put everything together in a sample day. When you wake up, start hydrating, maybe even while still in bed. If your doctor has recommended increased sodium, this might include water with an electrolyte product.

Try all smaller meals more often. For example, for breakfast, have a couple of eggs with a small amount of sautéed vegetables, a quarter of an avocado, all sprinkled with salt, and a half a cup of melon.

Two to three hours later, another balanced mini meal, Greek yogurt with a half a cup of blueberries and a few dry roasted and salted pepitas. Two to three hours later for lunch, make an avocado oil mayo-based chicken salad with celery and onions and a few sliced red grapes.

Put it over a bed of mixed greens. For an after-lunch mini meal, try a couple of nitrate-free beef sticks, some red bell pepper slices, and an olive oil hummus. For maybe a dinner on the smaller side, have some iron and B12-rich roast beef with broccoli and cauliflower tossed in olive oil or butter and a side of some baby red potatoes.

And since dinner is small, and if it's early, a small after-dinner mini meal may be needed. If you like something a little sweet and cold after dinner, try blending a scoop of our Wellness Whey vanilla protein powder with a quarter cup of canned coconut milk and a half a cup of frozen mango for a healthy tropical treat.

And of course, continue drinking water throughout the day. Notice what's happening here. We're not eliminating every carbohydrate, we're not fasting all day, we're not eating giant meals, and we're not surviving on electrolyte drinks while forgetting about actual food.

We're giving the body adequate protein, natural fats, fiber-rich carbohydrates, vitamins, minerals, and a steady supply of nourishment while intentionally addressing fluid and sodium needs. If you have POTS, food isn't necessarily a magic cure, but nutrition is a meaningful part of symptom management.

Start with the fundamentals. Stay adequately hydrated. Work with your healthcare provider to determine the appropriate amount of sodium for you. Eat enough food, and especially enough protein. Build balanced meals rather than relying on refined carbohydrates.

Consider smaller, more frequent meals if larger meals trigger symptoms. Avoid alcohol, and pay attention to your personal response to caffeine. And work with a dietitian on knowing which supplements might help and how to take them, like iron, B12, or any other suspected nutrient deficiencies.

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And most importantly, remember that POTS is a complex disorder of autonomic regulation, and the best plan usually combines nutrition with appropriate medical care, movement, sleep, stress support, and other individualized strategies. But what you eat and drink and how you structure your meals can make a meaningful difference in how you feel throughout the day.

That's all for today's episode of “Ask a Nutritionist”. If you know someone with a POTS diagnosis, please send this episode their way. The best way you can support our podcast is by sharing it with others.

Thanks for spending a part of your day with me. If today's podcast sparked something for you, come back for more episodes of “Ask a Nutritionist” or Dishing Up Nutrition, brought to you by Nutritional Weight & Wellness, where our mission is to help each and every person experience real health through eating real food.