Nutritional Strategies for Orthostatic Intolerance
Orthostatic intolerance (OI) is a condition where the body has difficulty regulating blood pressure and heart rate in response to standing up. When someone with OI stands, they may feel dizzy, lightheaded, or even faint. This happens because the blood doesn’t flow back to the heart and brain as effectively as it should. For some, these symptoms can become intense and severely debilitating.
Orthostatic intolerance (OI) is notably prevalent among individuals with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), fibromyalgia, and long-haul COVID. Prevalence in ME/CFS is estimated to be from 30 to 100% of patients (1). A multicenter study in long-haul COVID found that orthostatic intolerance was common to more than half of the study population (2).
I’ve recently been reading Dr. Peter Rowe’s new book on the topic (3). He is an expert in OI with years of clinical experience at Johns Hopkins University School of Medicine. Let’s outline the types of OI and then look at nutritional considerations.
💡 Looking for quick answers? Jump to the FAQ
Orthostatic Intolerance: Types & Symptoms
There are different types of orthostatic intolerance, each with unique features:
Postural Orthostatic Tachycardia Syndrome (POTS): POTS is a form of OI where the heart rate spikes significantly when standing, sometimes by over 30 beats per minute. This increase happens without a major drop in blood pressure, but people with POTS still experience symptoms like dizziness, fatigue, and even nausea. It’s more common in young adults and teenagers, especially females.
Classic Orthostatic Hypotension: In classic orthostatic hypotension, blood pressure drops sharply within three minutes of standing up. This drop in blood pressure can cause fainting, dizziness, and other uncomfortable symptoms. It’s often seen in older adults and can sometimes be a side effect of certain medications.
Delayed Orthostatic Hypotension: Unlike classic orthostatic hypotension, delayed orthostatic hypotension causes a drop in blood pressure after standing, but this happens more slowly, usually taking more than three minutes. While the symptoms are similar, people with this type may notice them later than those with classic orthostatic hypotension.
Neurally Mediated Hypotension (NMH): NMH is when blood pressure suddenly drops in response to standing for an extended period. This reaction happens because the nervous system misinterprets the signals from the body, resulting in a sudden drop in blood pressure and symptoms like dizziness, nausea, or fainting.
It’s important to highlight that those with orthostatic issues usually require medications and careful monitoring to manage symptoms. However, the below nutritional tips are also important. Check out Dr. Rowe’s new book Living Well With Orthostatic Intolerance: A Guide to Diagnosis and Treatment for more great information.
Top Nutrition Tips for Managing Orthostatic Intolerance, POTS, & Low Blood Pressure Symptoms
1. Increase Salt Intake
Salt can help the body retain fluids, which may improve blood volume and circulation, reducing symptoms of OI. It’s especially helpful for those with Postural Orthostatic Tachycardia Syndrome (POTS), where low blood volume can be an issue. Always check with a healthcare provider before making major changes to salt intake, as too much salt can lead to other health issues. Dr. Rowe recommends salt tablets such as Thermotabs or SaltStick Vitassium. The amount of salt you need will vary from person to person. Supplement with care.
2. Stay Hydrated
Drinking plenty of fluids is crucial. Water helps increase blood volume and supports healthy circulation, which can alleviate dizziness and fatigue associated with OI. Try to drink throughout the day rather than all at once. Some people with OI find that electrolyte-rich beverages, such as sports drinks or electrolyte solutions, are particularly helpful as they replenish salts and minerals lost through sweating. Dr. Rowe writes about TriOral, LMNT, or Ceralyte.
3. Eat Small, Frequent Meals
Large meals can divert blood flow to the digestive system, which may worsen symptoms like dizziness or fatigue in those with OI. Eating smaller, balanced meals more frequently can prevent this. Aim to include a combination of protein, healthy fats, and fiber-rich carbs to sustain energy and avoid blood sugar fluctuations.
4. Avoid High-Carb Meals
High-carb meals can cause a rapid spike and then drop in blood sugar, potentially worsening OI symptoms. Instead, choose high-fiber carbohydrates, legumes, proteins, and vegetables. These foods release energy more gradually, preventing sudden shifts in blood sugar levels that can exacerbate dizziness or lightheadedness.
5. Include Foods Rich in Potassium and Magnesium
Potassium and magnesium are essential minerals that support heart and muscle function. Foods like bananas, potatoes, avocados (for potassium), and leafy greens, nuts, and seeds (for magnesium) can be beneficial for overall cardiovascular health, which may support blood flow and reduce symptoms of OI.
6. Limit Caffeine and Alcohol
Both caffeine and alcohol can lead to dehydration, which can worsen OI symptoms. In some people, caffeine can also raise heart rate, which might not be ideal for those with conditions like POTS. If you enjoy caffeinated beverages, consider sticking to a minimal amount and monitor how it affects your symptoms.
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Orthostatic intolerance is difficulty maintaining stable blood pressure and heart rate when standing. It can cause dizziness, fatigue, nausea, and fainting. OI is common in ME/CFS, fibromyalgia, and long-haul COVID due to blood-volume and autonomic regulation issues.
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Proper nutrition supports blood volume, electrolyte balance, and vascular tone. Increasing salt and fluids, eating smaller meals, and ensuring adequate minerals can significantly reduce dizziness and fatigue.
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Most patients benefit from 3–10 g of sodium per day (roughly 1½–2 tsp of salt), but needs vary. Use physician-approved salt tablets like Thermotabs or SaltStick Vitassium, and combine with steady hydration or electrolyte solutions (LMNT, TriOral, Ceralyte).
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Yes. Electrolyte beverages replace sodium, potassium, and magnesium lost through sweat or low blood volume, improving circulation and energy. Choose low-sugar formulas to avoid glucose spikes.
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Large meals divert blood to the digestive tract and can drop blood pressure. High-carb meals also cause insulin surges and transient vasodilation, worsening dizziness. Small, balanced meals stabilize blood flow.
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Potassium: bananas, potatoes, avocados
Magnesium: nuts, seeds, leafy greens
Salt (sodium chloride): table salt or electrolyte products
These support cardiovascular and muscle function vital for OI management.
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Generally yes. Both increase dehydration and, in some, raise heart rate excessively. Limit or avoid them, especially on hot days or during flare-ups.
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Yes. Hypoglycemia can mimic or aggravate OI symptoms. Balanced macronutrient meals—protein, fats, and complex carbs—prevent rapid blood-sugar drops.
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Some clinicians recommend oral rehydration salts, magnesium glycinate, or potassium citrate when dietary intake is insufficient. These should be used under medical supervision, especially if on blood-pressure medications.
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Dr. Peter Rowe’s book Living Well With Orthostatic Intolerance provides detailed clinical insights. For a deeper dive into how potassium interacts with sodium balance and orthostatic symptoms in long COVID and ME/CFS, see my Low Potassium in Long COVID & CFS post.
References
1. Grach SL, Anderson MS, Bart CR, et al. Diagnosis and management of myalgic encephalomyelitis/chronic fatigue syndrome. Mayo Clin Proc. 2023;98(10):1544-1551.
2. Lee C, Greenwood DC, Master H, et al. Prevalence of orthostatic intolerance in long covid clinic patients and healthy volunteers: A multicenter study. J Med Virol. 2024;96(3):e29486. doi:10.1002/jmv.29486
3. Rowe PC. Living Well with Orthostatic Intolerance: A Guide to Diagnosis and Treatment. Baltimore, MD: Johns Hopkins University Press; 2024.
