SALT SCIENCE

If you’ve been diagnosed with postural orthostatic tachycardia syndrome (POTS), your doctor probably advised you to dramatically increase your fluid and salt intake.

There are several reasons for this, and because each POTS patient is slightly different, individual salt intake needs can vary widely, with some physicians recommending 3,000 mg of sodium, and others recommending up to 10,000 mg.

Changes in Blood Pressure and Blood Distribution


When a person goes from a lying to sitting position, or from a sitting to standing position, her body’s head position relative to her feet suddenly becomes much higher. Gravity pulls the blood down towards the feet. To continue to deliver optimal amounts of blood and oxygen to the brain, her body must quickly adjust blood pressure to “pull” blood away from her feet and “push” it to her heart and head. In a person without POTS, the blood vessels in the legs will constrict and the heart rate will increase slightly during this process, but only for a few seconds.

There is a problem with this process in people who have POTS. POTS is caused by a problem with the autonomic nervous system — the system that controls the “automatic” functions of the body, such as heart rate, breathing, digestion and blood pressure. With this system hampered, the POTS patient’s body has a harder time redistributing the blood from the lower extremities to the heart and brain. Therefore, when she changes positions, the blood doesn’t reach her head in an efficient manner, leading to lightheadedness, a racing heartbeat, and, in some cases, fainting. (Learn more about changes in blood pressure and blood distribution.)

Low Blood Volume


Additionally, many POTS patients have hypovolemia, or low blood volume. The exact causes for this are not known, but low blood volume contributes to lowered blood pressure or difficulties distributing blood throughout the body even when the blood pressure is normal. Rapid changes in blood pressure and blood distribution must occur to keep oxygen flowing to the brain as a person changes position. A person with hypovolemia must fight an uphill battle when she changes position, because there is less blood to “pull” from her feet and “push” to her head than in a person without POTS. (Learn more about low blood volume.)

Low Aldosterone Levels


Sodium, along with water and potassium, is critical to the body’s ability to manage blood pressure. Sodium levels are regulated by the hormone aldosterone, which is released when concentrations become too low, promoting the reabsorption of sodium back into the bloodstream in the kidneys. This restores an appropriate balance of electrolytes.

In some instances, POTS patients experience low levels of aldosterone, which inhibits their bodies’ ability to reabsorb enough sodium to adequately manage blood volume and blood pressure. (Learn more about low aldosterone levels.)

The Solution: Add Salt


In POTS patients, increasing sodium intake can assist with low blood pressure, low blood volume and an overall improvement in distribution of blood throughout the body. In addition to salt, patients are also advised to consume at least two liters of water per day, and to drink water at least once every two hours. The increased fluid intake should also help expand blood volume and reduce POTS symptoms. (Learn more about adding salt.)

The exact amount of sodium will vary from patient to patient. The best approach is to consult with your physician to explore the right level for you. Some Vitassium consumers take as low as two capsules per day, which translates to 500 mg of extra sodium. Others take more than eight per day, which equates to more than 2,000 mg of extra sodium. Keep in mind, these patients are also getting extra salt through their diet, which is usually high in salty foods such as salted potatoes, eggs or drinks such as V-8.

SUMMARIES OF RESEARCH ARTICLES


If you want to dive more into these topics, below is a selection of research articles related to sodium supplementation in POTS, EDS and elderly orthostatic intolerance: 

Healthy, free-living individuals can achieve sodium balance through normal diet alone. It is recognized that, on average, people with Western-style diets already consume sufficient (or excess) sodium. Vitassium can help supply additional dietary sodium to specific populations who may benefit from higher sodium intake than average. In many cases, consumers seek to increase sodium intake as a first-line attempt to resolve certain underlying symptoms relating to high sodium excretion or poor sodium retention that is characteristic of conditions such as Postural Orthostatic Tachycardia Syndrome (POTS) and Ehlers-Danlos syndrome (EDS), often under the recommendation and guidance of their physician as a first line non-drug treatment along with additional fluid intake, exercise and other lifestyle changes.

Additional sodium intake can also be of benefit for certain people to assist with proper hydration. In the absence of sodium replacement, intake of fluid is associated with a decrease in thirst and an increased diuresis despite the continued presence of a significant fluid deficit. In combination with increased salt intake, proper hydration is key to preventable and treatable fluid imbalance.

The following references are available as hyperlinks below, and major bullet points relating to the implementation of sodium supplementation are outlined for each article.

Orthostatic Intolerance  


Claydon VE, Hainsworth R. Salt supplementation improves orthostatic cerebral and peripheral vascular control in patients with syncope. Hypertension. 2004 Apr;43(4):809-13. doi: 10.1161/01.HYP.0000122269.05049.e7. Epub 2004 Feb 23. PMID: 14981050.  

  • Highlights: Patients receive 6 g slow-release sodium chloride tablets (HK Pharma) and were reassessed after 2 months. Salt loading in posturally related syncope patients increases orthostatic tolerance and improves cerebrovascular and peripheral vascular control without affecting blood pressures. These changes are likely to contribute to the beneficial effects of salt loading in these patients. 

Mtinangi BL, Hainsworth R. Early effects of oral salt on plasma volume, orthostatic tolerance, and baroreceptor sensitivity in patients with syncope. Clin Auton Res. 1998 Aug;8(4):231-5. doi: 10.1007/BF02267786. PMID: 9791744. (abstract only) 

  • Highlights: Tests were carried out in patients with poor orthostatic tolerance and low initial urinary salt excretion, before and after 7 or 3 days of salt loading (120 mmol/d). Implications consist of beneficial effects of salt in some patients and show that all these changes occur within 3 days.  

Vasovagal or Neurocardiogenic Syncope 


Williams EL, Raj SR, Schondorf R, Shen WK, Wieling W, Claydon VE. Salt supplementation in the management of orthostatic intolerance: Vasovagal syncope and postural orthostatic tachycardia syndrome. Auton Neurosci. 2022 Jan;237:102906. doi: 10.1016/j.autneu.2021.102906. Epub 2021 Nov 11. PMID: 34823150. 

  • Highlights: short-term (~3 months) salt supplementation improves susceptibility to Vasovagal Syncope (VVS) and associated symptoms, with little effect on supine blood pressure. In patients with VVS, salt supplementation is associated with increases in plasma volume, and an increase in the time taken to provoke a syncopal. Salt supplementation also improved symptoms, plasma volume, and orthostatic responses in patients with POTS. 

El-Sayed H, Hainsworth R. Salt supplement increases plasma volume and orthostatic tolerance in patients with unexplained syncope. Heart. 1996;75(2):134-140. doi:10.1136/hrt.75.2.134 

  • Highlights: Participants took capsules containing 10 mmol sodium chloride or placebo (12 per day). In the open study, they took slow sodium (Ciba) (10 mmol, 12 per day). In patients with unexplained syncope who had a relatively low salt intake administration of salt increased plasma volume and orthostatic tolerance, and in the absence of contraindications, salt is suggested as a first line of treatment. 

  • Highlights: In patients with recurrent vasovagal syncope (VVS) and no clear contraindication, such as a history of hypertension, renal disease, HF, or cardiac dysfunction, it may be reasonable to encourage ingestion of 2 to 3 L of fluid per day and a total of 6 to 9 g (100 to 150 mmol) of salt per day, or about 1 to 2 heaping teaspoonfuls. Salt supplementation increases plasma volume, with limited benefit in patients with already high salt intake.  

Guzman JC, Armaganijan LV, Morillo CA. Treatment of neurally mediated reflex syncope. Cardiol Clin. 2013 Feb;31(1):123-9. doi: 10.1016/j.ccl.2012.10.007. PMID: 23217693. 

  • Highlights: Non-pharmacological measures (such as salt and fluid intake) are simple and usually safe and should be tried as first-line therapy in patients with frequent syncope and no obvious contradictions (abstract only) 

Postural Orthostatic Tachycardia Syndrome (POTS) 


Vernino S, Bourne KM, Stiles LE, Grubb BP, Fedorowski A, Stewart JM, Arnold AC, Pace LA, Axelsson J, Boris JR, Moak JP, Goodman BP, Chémali KR, Chung TH, Goldstein DS, Diedrich A, Miglis MG, Cortez MM, Miller AJ, Freeman R, Biaggioni I, Rowe PC, Sheldon RS, Shibao CA, Systrom DM, Cook GA, Doherty TA, Abdallah HI, Darbari A, Raj SR. Postural orthostatic tachycardia syndrome (POTS): State of the science and clinical care from a 2019 National Institutes of Health Expert Consensus Meeting - Part 1. Auton Neurosci. 2021 Nov;235:102828. doi: 10.1016/j.autneu.2021.102828. Epub 2021 Jun 5. PMID: 34144933; PMCID: PMC8455420. 

  • Highlights: To expand blood volume, patients should have a minimum intake of 2 to 3 L of water per day along with increased sodium intake. Most clinicians recommend oral sodium intake to avoid potential complications of intravenous access. Sodium intake can be increased to 3 to 10 g daily using ordinary table salt (1 tsp. is approximately 2.3 g sodium), salt tablets or electrolyte solutions. 

Garland EM, Gamboa A, Nwazue VC, Celedonio JE, Paranjape SY, Black BK, Okamoto LE, Shibao CA, Biaggioni I, Robertson D, Diedrich A, Dupont WD, Raj SR. Effect of High Dietary Sodium Intake in Patients With Postural Tachycardia Syndrome. J Am Coll Cardiol. 2021 May 4;77(17):2174-2184. doi: 10.1016/j.jacc.2021.03.005. PMID: 33926653; PMCID: PMC8103825. 

  • Highlights: Patients received 6 days of LS (10 mEq sodium/day) or HS (300 mEq sodium/day) diet. In POTS patients, high dietary sodium intake compared with low dietary sodium intake increases plasma volume, lowers standing plasma norepinephrine, and decreases changes in heart rate.  

Low PA, Sandroni P, Joyner M, Shen WK. Postural tachycardia syndrome (POTS). J Cardiovasc Electrophysiol. 2009;20(3):352-358. doi:10.1111/j.1540-8167.2008.01407.x 

  • Highlights: Management always involves expansion of plasma volume with high salt and high fluid intake. All patients with POTS require a high salt diet, copious fluids, and postural training. The hypovolemic patient will do well with expanding plasma volume with generous salt intake and fludrocortisone. The salt intake should be between 150–250 mEq of sodium (10–20 g of salt). The patient should have at least 1 glass or cup of fluids with their meals and at least 2 at other times each day to obtain 2–2.5 L/day. 

Abed H, Ball PA, Wang LX. Diagnosis and management of postural orthostatic tachycardia syndrome: A brief review. J Geriatr Cardiol. 2012;9(1):61-67. doi:10.3724/SP.J.1263.2012.00061 

  • Highlights: Increasing sodium intake by taking salt tablets or an electrolyte solution helps expand blood volume, which will alleviate the hypotension some POTS patients suffer. Some physicians suggest patients take ten to fifteen grams of sodium daily, which is equivalent to 5.85 g (approximate. 250 mmol, 250 mEq) of sodium. Sodium chloride 0.9% infusion has been reported very beneficial in decreasing symptoms in POTS patients and improving quality of life. 

Sheila Carew, Margaret O. Connor, John Cooke, Richard Conway, Christine Sheehy, Aine Costelloe, Declan Lyons, A review of postural orthostatic tachycardia syndrome, EP Europace, Volume 11, Issue 1, January 2009, Pages 18–25

  • Highlights: Salt supplements may be considered. Blood volume is low in many patients with POTS. The tachycardic response to upright posture correlates with the severity of hypovolemia.  

Raj SR. Postural tachycardia syndrome (POTS). Circulation. 2013;127(23):2336-2342. doi:10.1161/CIRCULATIONAHA.112.144501 

  • Highlights: Patients with POTS should avoid aggravating factors such as dehydration and extreme heat. To ensure adequate hydration, we ask our patients to consume 8 to 10 cups of water daily and to increase their sodium intake to up to 8 to 10 g/d. If this cannot be accomplished with dietary modification, supplemental NaCl tablets (with meals) can be used.

  • Highlights: Recommendation is sodium, fluid, exercise, compression garments, medication; Salt helps the body retain water, which in turn increases blood volume. Drinking more fluids, especially in combination with salt, helps expand blood volume and increase blood flow. Most doctors recommend two to three liters per day of hydrating fluids such as vegetable or tomato juice, coconut water, decaffeinated tea with salt, or chicken broth. 

Dysautonomia In Teens/Adolescents 


McLeod KA. Dizziness and syncope in adolescence. Heart. 2001;86(3):350-354. doi:10.1136/heart.86.3.350 

  • Highlights: Increase in dietary salt. Often with the simple measures of reassurance, fluid, posture and salt, symptoms will improve significantly. 

Kizilbash SJ, Ahrens SP, Bruce BK, Chelimsky G, Driscoll SW, Harbeck-Weber C, Lloyd RM, Mack KJ, Nelson DE, Ninis N, Pianosi PT, Stewart JM, Weiss KE, Fischer PR. Adolescent fatigue, POTS, and recovery: a guide for clinicians. Curr Probl Pediatr Adolesc Health Care. 2014 May-Jun;44(5):108-33. doi: 10.1016/j.cppeds.2013.12.014. PMID: 24819031; PMCID: PMC5819886. 

  • Highlights: Adequate water and sodium intake are essential to maintain the intravascular blood volume. Patients are usually instructed to consume 64–80 oz of fluids (preferably caffeine free) and as much salt as their taste buds can tolerate. While some physicians use intravenous saline infusions in an effort to provide temporarily symptomatic relief, such treatment is costly and risks infection and blood clots, and is not advised. Oral intake of fluid and salt is preferred. 

Hypotension in Elderly and Aging Patients 


Gupta V, Lipsitz LA. Orthostatic hypotension in the elderly: diagnosis and treatment. Am J Med. 2007 Oct;120(10):841-7. doi: 10.1016/j.amjmed.2007.02.023. PMID: 17904451. 

  • Highlights: In most cases, treatment of orthostatic hypotension begins with nonpharmacological 
interventions, including withdrawal of offending medications (when feasible), physical maneuvers, compression stockings, increased intake of salt and water, and regular exercise. Liberal intake of salt and water to achieve a 24-hour urine volume of 1.5 to 2 liters may attenuate fluid loss commonly seen in autonomic insufficiency. In elderly patients with orthostatic hypotension related to deconditioning, an exercise regimen comprising swimming, recumbent biking, or rowing might lead to disappearance of symptoms.    

Myalgic Encephalomyelitis


Rowe PC, Underhill RA, Friedman KJ, Gurwitt A, Medow MS, Schwartz MS, Speight N, Stewart JM, Vallings R, Rowe KS. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Diagnosis and Management in Young People: A Primer. Front Pediatr. 2017 Jun 19;5:121. doi: 10.3389/fped.2017.00121. PMID: 28674681; PMCID: PMC5474682.  

  • Highlights: Low blood volume has also been found in some adult patients with ME/CFS. The initiation of treatments directed at OI can sometimes relieve ME/CFS symptoms in pediatric as well as adult patients. 

Bateman L, Bested AC, Bonilla HF, Chheda BV, Chu L, Curtin JM, Dempsey TT, Dimmock ME, Dowell TG, Felsenstein D, Kaufman DL, Klimas NG, Komaroff AL, Lapp CW, Levine SM, Montoya JG, Natelson BH, Peterson DL, Podell RN, Rey IR, Ruhoy IS, Vera-Nunez MA, Yellman BP. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Essentials of Diagnosis and Management. Mayo Clin Proc. 2021 Nov;96(11):2861-2878. doi: 10.1016/j.mayocp.2021.07.004. Epub 2021 Aug 25. PMID: 34454716.  

  • Highlights: Although there are no approved treatments specific to ME/CFS, clinicians can reduce the severity of symptoms with standard pharmacologic and nonpharmacologic treatments. Nonpharmacological approaches for orthostatic intolerance include salt and fluid loading. 

Ehlers Danlos Syndrome (EDS) As A Co-Morbidity to Dysautonomia 


Mehr SE, Barbul A, Shibao CA. Gastrointestinal symptoms in postural tachycardia syndrome: a systematic review. Clin Auton Res. 2018;28(4):411-421. 

  • Highlights: Between 60 and 80 percent of patients with HSD/hEDS have a disorder of orthostatic intolerance, such as POTS.   

Do T, Diamond S, Green C, Warren M. Nutritional Implications of Patients with Dysautonomia and Hypermobility Syndromes. Curr Nutr Rep. 2021 Sep 12:1–10. doi: 10.1007/s13668-021-00373-1. Epub ahead of print. PMID: 34510391; PMCID: PMC8435108. 

  • Highlights: Recommendations: Adequate salt and fluid intake may reduce orthostatic hypotension symptoms. Dietary supplements may help with osteoarticular, musculoskeletal, and fatigue symptoms. Individualized diet strategies and supplements can reduce the multiorgan system symptoms observed in dysautonomia and hypermobility syndrome.