Definition and Overview
Diet is a key non-pharmacological treatment that is equally important as drug treatment in the management of POTS (orthostatic tachycardia syndrome). In many POTS patients, intravascular volume is reported to be about 10-20% less than normal, and securing volume through sufficient water and salt intake is the basic strategy for alleviating symptoms when standing.
The 2015 Heart Rhythm Society expert consensus also recommends increasing water and salt intake and controlling diet as the first non-drug treatment for POTS.
hydration
recommended amount
Consumption of 2-3 L of water per day is recommended. This is water intake in the form of beverages, not the total amount including water in food.
Fluid intake during acute symptoms
When orthostatic symptoms are acutely worsened, drinking about 480 mL (about 2 cups) of water quickly (within 5 minutes) activates the sympathetic nerves through the osmopressor response and has the effect of increasing systolic blood pressure by about 20 mmHg. This effect lasts for about 20 to 30 minutes.
Hydration Strategy
- Drink 500 mL of water immediately after waking up in the morning to compensate for nighttime dehydration.
- Drink evenly throughout the day and do not consume excessive amounts at once.
- Caffeinated drinks (coffee, green tea) have a diuretic effect, so limit them to less than 200 mg (about 2 cups of coffee) per day.
- Alcohol causes vasodilation and dehydration, so avoid it as much as possible.
salt intake
recommended amount
POTS patients are recommended to consume 10 to 12 g of salt (NaCl) (approximately 4 to 5 g of sodium) per day. This is approximately 2 to 2.5 times the recommended amount for a general healthy person (sodium 2 g/day).
How to consume salt
- Sprinkle extra salt when eating.
- Take a salt tablet (1 g/tablet) with a meal.
- Foods high in sodium: miso soup, kimchi, pickles, olives, pretzels
- Oral rehydration solution (ORS): Replenishes sodium and water simultaneously.
Precautions
If you have kidney disease, heart failure, or high blood pressure, a high-salt diet may be contraindicated and you must consult your doctor. When salt intake increases, potassium intake also increases to maintain electrolyte balance.
eating strategy
small frequent meals
Instead of three large meals a day, it is recommended to eat five to six small meals a day. Large meals cause splanchnic vasodilation, which worsens symptoms when standing up.
Avoid eating large, high-carbohydrate meals
Consuming large amounts of refined carbohydrates (white bread, white rice, sugar) promotes insulin secretion, and insulin affects sodium reabsorption and vasodilation, which can worsen postprandial symptoms.
balanced nutrients
- Protein: Include adequate protein at every meal to help stabilize blood sugar.
- Complex carbohydrates: Choose foods with a low glycemic index (GI), such as brown rice, whole grains, and sweet potatoes.
- Healthy fats: olive oil, nuts, avocado
- Potassium: Supplement with bananas, potatoes, spinach, etc.
Special dietary considerations
low histamine diet
In POTS patients with MCAS, a low-histamine diet may help relieve symptoms.
High-histamine foods to avoid include: - Fermented foods: cheese (ripened), sausage, sauerkraut, kimchi (long-term fermentation) - Alcohol: especially red wine and beer - Processed meat: bacon, ham, salami - Certain seafood: tuna, mackerel (high histamine content) - Some fruits: strawberries, citrus fruits, tomatoes (promote histamine release)
gluten free diet
For POTS patients with celiac disease or non-celiac gluten sensitivity, eliminating gluten may help improve digestive and systemic symptoms. However, not all POTS patients need a gluten-free diet.
electrolyte supplementation
Oral rehydration solution (ORS)
According to the World Health Organization (WHO), ORS contains approximately 75 mEq of sodium per liter of water. You can efficiently replenish water and sodium by using commercially available oral rehydration solutions or electrolyte powders.
Limitations of Sports Drinks
Commercially available sports drinks are high in sugar (approximately 6-8%) and lower in sodium than ORS, so they are often not optimal for POTS management purposes. It is effective to choose products that are low in sugar and high in sodium, or to prepare your own electrolyte solution.
Summary of Practice
- Drink 500 mL of water immediately after waking up
- Aim for total water of 2-3 L and salt of 10-12 g per day.
- Small, frequent meals (5-6 times/day), avoidance of large, high-carbohydrate meals
- Limit alcohol and maintain an appropriate amount of caffeine
- Use of electrolyte supplements
- If MCAS is present, consider a low-histamine diet
- Do not stand up immediately after eating