Dr. Justin Marchegiani and Evan Brand explore POTS (postural orthostatic tachycardia syndrome) and how dysautonomia, adrenal function, electrolyte balance, and blood flow may contribute to dizziness when standing. They discuss common upstream contributors like tick-borne infections, mold exposure, inflammation, and thyroid issues, plus the functional lab testing they use to look for root causes.
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Quote 1: “There could be 20 different cases of POTS that have 20 different ways that we got there.” Speaker: Evan Brand Use for: Audiogram, Instagram graphic, or social media clip
Quote 2: “Eventually your budget, your sanity, or your compliance, one of those levers is going to break.” Speaker: Evan Brand Use for: Audiogram, Instagram graphic, or social media clip
Quote 3: “Make sure whatever you’re doing, your body has enough ability to adapt from it.” Speaker: Dr. Justin Marchegiani Use for: Audiogram, Instagram graphic, or social media clip
Dr. Justin Marchegiani: Hey guys, it’s Dr. Justin Marchegiani [transcription artifact: “Marcian”]. Welcome to the Beyond Wellness Radio podcast. Feel free and head over to justinhealth.com. We have all of our podcast transcriptions there, as well as video series on different health topics ranging from thyroid to hormones, ketogenic diets, and gluten. While you’re there, you can also schedule a consult with myself, Dr. J, and/or our colleagues and staff to help dive into any pressing health issues you really want to get to the root cause on. Again, if you enjoy the podcast, feel free and share the information with friends or family. And enjoy the show.
Dr. Justin Marchegiani: And we are live. It’s Dr. J in the house with Evan Brand. Today we’re going to be talking about POTS, postural orthostatic tachycardia syndrome. We’ll be talking about that and how it connects to your adrenals, to dysautonomia, to electrolytes, and to your hormones. Again, this is not going to be medical advice. We’re talking about upstream physiological imbalances and how they may connect downstream to different symptom manifestation. Again, if you think you have a POTS issue, please get analyzed by your conventional medical doctor first. We’re just trying to give you a little bit more info on the hormonal, biochemical, endocrinological root causes behind this. Evan, how we doing, my man?
Evan Brand: I’m doing good. In the last five years we’ve seen a huge rise in POTS. So we hope to unpack some of this for you and then give you some root cause strategies, things that you could be looking into from a root cause perspective that, truthfully, some of them can be quite simple. And I’ve had POTS. I remember years ago, I was at my grandma’s house helping to pick some weeds, and I remember standing up and falling back. This was many years ago, but just that level of faintness from standing, that huge decrease in blood pressure. You literally can lose the oxygen to your brain, so this can be a bad situation, especially if you’re in the bathroom. You stand up out of the tub, the hot water plus the low blood pressure, you stand up, you hit your head on a toilet. I’ve heard that story before, and it’s not pretty.
Dr. Justin Marchegiani: Yeah, the biggest thing we look at with POTS is, where’s your blood pressure at? So you can always do what’s called an orthostatic hypotension test. You can get your blood pressure laying down, stand up, and see where the blood pressure goes. It should actually go up, right? So when you’re laying down, think about it, you’re horizontal. Your heart does not have to pump as much because gravity’s kind of evenly spreading out blood flow. When you stand up, now your heart rate has to go up, so blood pressure should go up to be able to perfuse to your brain. And so when you change that body position, if you get dizzy, that’s a sign that your heart and your nervous system are not compensating fast enough to get the blood up to the brain, so you get dizzy. And so you can test your blood pressure, right? Put it on your arm, lay down, get your blood pressure, and then when you stand up, test it again right away. You should have a five or 10 point increase. If you have a decrease overall, that’s a sign of dysautonomia, that your nervous system is not adequately responding.
Now, a couple things we can do is we can look at electrolytes. That’s a big deal: your potassium, your sodium, and your magnesium. We can also look at hydration. These are all important things. And then we can also look deeper at some of the hormones that control those things, like the adrenal glands, especially the outer part, the glomerulus fascicularis [flag: anatomical misstatement; aldosterone is made in the zona glomerulosa], which is the outer part of the adrenal gland that helps regulate your mineralocorticoids and helps make the hormone that helps hold onto your electrolytes, called aldosterone.
Evan Brand: Yeah, I got really messed up with this years ago when I had mold exposure and three tick bites in one summer. Just getting to the top of a flight of stairs, standing up out of bed, getting out of the car, getting up out of the bathtub, getting out of the sauna, I would just have these different triggering events that I knew I had to be careful with. Luckily, I never fully went to the ground or anything like that, but there were definitely times where I was like, “Wow, this is not good.” I could imagine being elderly and this really turning into a bad issue where you fall, break a hip, something crazy. So I really think the biggest thing for me was the sauna and improving my blood flow. Because when I had POTS the worst, and I think this is somewhat of a vascular issue as well, you’re mentioning adrenals, but when I had POTS the worst, my hands and feet were freezing. And now that I’ve used some things to help boost circulation, my hands and feet are no longer cold, and my POTS is also significantly decreased, so I think I’m onto something with this blood flow piece. And if you look at Lyme and Babesia, you and I have covered this before, and also the virus that went around, it all creates hypercoagulation. It creates a thickening of the blood. And so when I used natto or Lumbro to help thin the blood a little bit, everything got better.
Dr. Justin Marchegiani: Yeah, so anytime we have excess inflammation in the body, that can cause cells to kind of agglutinate and stick and get more clotty. And so we can run blood testing looking at fibrinogen, and we can look at D-dimer to assess the clotting of your blood. The more inflamed you are, that’s going to be a problem. So if you have elevated hs-CRP, high sensitivity C-reactive protein, elevated ESR, erythrocyte sedimentation rate, elevated homocysteine, like 10 or higher, these are all signs of inflammation in the body. And so when we see higher levels of inflammation, we know that’s going to make our blood cells more prone to stick. So that’s a big thing out of the gate. So you could take systemic enzymes like Evan talked about: the nattokinase, serrapeptidase, lumbrokinase. These are good things. But we want to also add this in with the root cause.
And so fish oil is also very good. Making sure we’re eating good fatty acids, so grass-fed meat, egg yolks, making sure they’re pasture-fed, because you’re going to get more omega-3s in that type of thing, plus less seed oils, less processed fats, which are going to be more prone to oxidation. The more oxidation we have in our body, the more that lipid membrane, that outer part of our cell, becomes inflexible, because the fats that encompass it start to become more prone to oxidation, right? These are going to be either trans fats or our processed vegetables [flag: likely “processed vegetable oils”]. We want good, healthy fats so our cell membranes become healthier and more fluid.
Evan Brand: Yeah. If you look in the literature, Lyme and co-infections, including Bartonella and Babesia, can also trigger POTS. There’s been discussion, I haven’t personally seen any boxes of ticks, but there’s been discussions this year about farmers finding these random boxes of ticks. I don’t know if that part is true, but here’s the deal. Even if that’s not true, trust me, there’s plenty of ticks east of the Mississippi, all throughout the Midwest. Kentucky, where I’m from, the ticks were so bad. I told you before we hit record, I’d go on this 30 acre property and I’d walk for 10 minutes and I’d have 20 ticks, and some of them were so small they were a speck of pepper. I never had an issue with POTS pre-tick bite. So yes, there are other root causes that we have to factor in, but that was a huge one for me. And the CDC estimates there’s 470…
Dr. Justin Marchegiani: 470,000 cases of Lyme per year? Is that what you’re saying? Was it 470,000 cases per year? Is that what you were highlighting?
Evan Brand: Yeah, 470,000 estimate. [flag: verify statistic against CDC source]
Dr. Justin Marchegiani: Wow.
Evan Brand: Yeah, it’s pretty nuts.
Dr. Justin Marchegiani: You were talking about how Sawyer makes a product, was it the picaridin one? The piperine extract, and then there’s the permethrin, right?
Evan Brand: Yeah.
Dr. Justin Marchegiani: They make both, but there’s permethrin and then there’s picaridin, right?
Evan Brand: Yes.
Dr. Justin Marchegiani: And the picaridin…
Evan Brand: One’s the piperine, the pepper one.
Dr. Justin Marchegiani: The pepper. Yeah, that’s the one you want. And then permethrin’s more of a synthetic kind of thing, but it’s supposedly less toxic, right?
Evan Brand: If it’s in your clothing, it’s supposed to be a non-issue for your health, but I personally don’t use it. I just do crazy tick checks, especially behind the kids’ ears and the neck and stuff like that. So obviously the prevention of POTS is better than having to go pursue it and fix it. So if you can avoid mold and avoid tick bites, that would be my recommendation.
Dr. Justin Marchegiani: Correct. Do you use the Sawyer picaridin around your kids, like on their socks or their shoes or on their ankles, if they’re going to be out walking?
Evan Brand: I haven’t yet this year because I haven’t seen any ticks. But if we do go further north where it’s more grassy and there’s more ticks up there, I probably will, like if we’re in a state forest or something up there. But so far this year, no ticks.
Dr. Justin Marchegiani: Yeah. My kids go out to certain camps, and we’ll spray at least their feet and their ankles and that area, and we’ll use some of the cedar oil on their clothes or on their skin, because cedar oil is also one of those things they hate as well. So there’s a lot of things you can do. But yeah, tick checks are key.
Evan Brand: It’s hard because when your kids get out of school, you’re like, “Yay, summer camp. Let’s put them out in the wilderness so they can have a blast.” But then if they’re not checking and the camp staff is not checking, especially if it’s a week-long camp, these are the stories where you hear parents bring their kid home and there’s a tick behind the ear or a tick in the scalp. So just try to educate your kids. You don’t necessarily need to fearmonger them, but just educate them like, “Hey, if you feel something weird…” Sometimes you can’t even feel them crawling, because they have a numbing agent in their saliva, and it actually numbs you from feeling the bite. So that’s the tricky part. But if you can, just get used to your body and just know when something’s not right.
Dr. Justin Marchegiani: Yeah. No, that makes sense. That’s really good. So when we look at the adrenals and we look at some of the upstream hormones that can impact dysautonomia, that just means your nervous system, right, your autonomic nervous system, which is the automatic part. Autonomic equals automatic, meaning you’re controlling parasympathetic: rest, digest, relaxation, secreting your hormones to help your body be healthy, thyroid, testosterone, estrogen, progesterone. You’re not thinking about your thyroid gland pinching off a bit of T4, right? It just happens. And then you have your sympathetic that’s regulating heart rate, heart rhythm, breathing. All these things are automatic. And so the more stressed you are, the autonomic, the automatic, converts more to sympathetic. And so when that happens, you’re also more prone to depleting certain B vitamins. You’re more prone to depleting a lot of your electrolytes: magnesium, potassium, your sodium, et cetera.
And so when this starts to happen, over time that can create problems with your heart and your mitochondria not having the nutrients they need to function optimally. And then if you add in some crummy food and some inflammatory food, and let’s say maybe you have Hashimoto’s, let’s say you have some thyroid antibodies, maybe your T3 is starting to drop. Maybe you have a T4 to T3 conversion problem. Symptoms can start to go up, up, up, up. And again, female patients are five times more likely to have an autoimmune thyroid issue. And so this is why when you think there’s an issue, “Oh, it’s got to be adrenals,” it could be adrenals plus thyroid plus hypercoagulability. Maybe you’re hypocoagulable [flag: context indicates “hypercoagulable” was intended], right? Blood’s not flowing well, and then you also have some mitochondrial dysfunction. So it could be a lot of things that just kind of stack up in your corner, so just be aware of that.
Evan Brand: Yeah. It’s always a puzzle, and that’s why we’re here and that’s why we do the labs that we do, because if you go and follow some trending video you saw on social media about five ways to fix POTS, you’re going to see things that are pretty generic. You mentioned maybe some adaptogenic herbs for the adrenals. We love using those. You could see magnesium, you could see fish oil or something for blood flow. Maybe you see just a mineral blend. Maybe it’s an electrolyte powder or something like that. But you’re really not going to get the root cause stuff, and it’s not going to be “do these five things.” There could be 20 different cases of POTS that have 20 different ways that we got there, and so it’s very rare for us to just go, “Yep, that’s it for everyone. Here’s the protocol.” So I just encourage you, when you’re looking at the noise of social media, I mean, it’s amazing. You have so many people now that are spitting out AI content as well, where it’s not even their personal vet [flag: likely “personally vetted”]. If you’re going to do AI and you vet it and you know that it’s legit and you have clinical experience to back that up, I’d say post it. But I’ve seen even in the last six months a slurry of accounts that don’t even look like they’re from a person, but yet they’re…
Dr. Justin Marchegiani: I agree. You get a lot of AI slop that’s put out there. Also, the problem with AI is it’s very agreeable. So if you’re going down a conventional path or a natural path, it tends to be very agreeable depending on what path you go down. And so with the information we use, I use AI to sift through the literature and get more information about what’s out there in the literature, but we’re also talking with each other and other clinicians about what’s working. Because how most scientific studies happen is people have experienced something that’s beneficial and they’re like, “We should probably study that, because there’s something happening mechanistically. Let’s go deeper.” And then studies start to happen. So it almost always starts clinically, and then it goes into these different studies that are more double-blind, placebo controlled.
But again, the only problem with functional medicine is that it’s hard to control variables, because a good functional medicine doctor is controlling 20 or 30 variables every time they’re with a patient, right? Everything from electrolytes to different nutrients. Every nutrient you’re working on is a variable. When you’re giving someone a multivitamin that’s high quality, well, that’s 50 different variables, right? You’re working on sleep, vitamin D, movement. You’re working on different nutrients. You’re working on the hormones. There’s too many variables, and conventional medicine hates that. They want one variable at a time. That’s the whole double-blind, placebo controlled study. You’re controlling one variable at a time so you know. Conventional is not like functional medicine testing. And not to mention, most conventional studies can’t even be repeated. We talked about this before: the gold standard for any study should actually be whether or not it can be repeated, and over half of all the studies that are out there cannot be repeated. And so we want the gold standard to be, “Hey, this thing, vitamin C and, let’s say, immunity, we see this repeat over and over again,” right? That’s a good study. Most studies are not that way. And so functional medicine will never be the double-blind placebo control, because there’s too many variables that we’re moving, and that’s why it doesn’t fit into that nice little box there.
Evan Brand: Yeah. And you could see one single ingredient, B1 or B2, B3, B6, B12. Even that alone, just dialing that in could change your life. So to put it on one sticky note about what to do, I don’t want to say it’s impossible, but it’s a little bit tricky, which is why we lean on organic acids testing, so we can see exactly what’s happening with mitochondria. We’ll look at nutrient levels.
Dr. Justin Marchegiani: There you go.
Evan Brand: If you guys don’t have this stuff, reach out to us. Let us help you. Justinhealth.com, reach out to Dr. J, or me at evanbrand.com. Reach out and let us just show you what the heck is going on, because it’s the data that allows you to be laser-focused. We see a lot of people that are taking 20 and 30 supplements as they come in, and we get the list way down to five or six, and it’s because we’re actually laser-focused based on data. We’re not giving you the “might help, can’t hurt” stuff. Sure, everyone could do vitamin D, magnesium, CoQ10, vitamin C, adaptogenic herbs. These are things that all may help improve POTS, but eventually your budget, your sanity, or your compliance, one of those levers is going to break. And so what we try to do is balance everything all at the same time while looking at your unique issues. And like I said, I wish it was black and white for POTS, but it’s not, and it wasn’t for me personally either, 100%.
Dr. Justin Marchegiani: So the big testing we’re going to do: we’re going to do DUTCH testing. We’re going to look at the adrenals. We’re going to look at cortisol. We’re going to look at the cortisol rhythm. The more dysregulated that cortisol rhythm is, the more sign of adrenal dysfunction we have. We can also look at AM cortisol in a blood test. If it’s on the lower side, that could be a sign, too. Or if it’s too high, that could also be a sign, right? Because high and low cortisol can disrupt your electrolytes. We may also run a metabolic panel to look at your protein, your creatinine, your serum protein, to look at your potassium, your magnesium, your sodium, chloride, your anion gap. We may look at all those things. Your serum magnesium. We may also look at your red blood cell magnesium. These are all good things to look at that give us a window under the hood.
Also, Evan talked about going in a sauna. I can’t tell you enough: if you do a sauna, make sure you’re hydrating and doing electrolyte support before you go in. Hydrate while you’re in, and also leave the sauna while you’re still feeling good. You should not be lightheaded and tired when you leave. So just try to always get on top of that. People do sauna, but then they can also create electrolyte problems, and that can actually be a stressor on their body. So make sure whatever you’re doing, your body has enough ability to adapt from it.
And last but not least is exercise. Make sure you answer these three questions positively. Number one, you feel better after the workout than when you started. You can emotionally repeat it; you don’t feel so depleted you couldn’t do it again. And later that day or that next morning, you don’t feel like you’re hit by a bus. Obviously, if it’s a new movement, you haven’t done lunges in a while, okay, you may feel a little bit sore, but you shouldn’t feel overly hit by a bus. So make sure you’re answering positively to all those, so what you’re putting into your life isn’t a stressor that your body cannot adapt and come back from.
Evan Brand: Yeah. If you got beat up by a trainer and you’re so out of breath and you can’t even turn the key, or I guess you’ve got a push button start. Or I guess if you’re in a Tesla, you don’t even push a button anymore, right? All these analogies are outdated with the Tesla. It has auto shift now. You don’t even shift, or you go on the screen. Okay, so you swipe into reverse and your arm can’t even be lifted, that workout was too much.
Dr. Justin Marchegiani: Too much. 100%. Always feel better. And again, always progress up. Progressive overload’s the best way to do it. Give your body a chance to adapt to whatever stressor is being put in.
Evan Brand: And what I’ll say personally, too, is when you have POTS, you actually get afraid of exercise, because you may get a little bit of trauma when you start to feel kind of gassed and tired. You may feel like…
Dr. Justin Marchegiani: Yeah, you may feel tired. You may feel like you don’t feel rested after you wake up. You may feel like you’re not recovering from the day in, day out stressors that are happening. No, I agree. Keep on going.
Evan Brand: Yeah. But for me, once I started to build that exercise tolerance, if you will, the POTS started to go away. When you go from sedentary to exercise, it may make the POTS a little bit worse, but as you get stronger, you build up the adrenals, and then all of a sudden you actually crave the exercise. So if you are fearful because of the POTS getting triggered, heart palpitations, something like that, reach out for a consult. Let us help you build a plan so you can get back to it.
Dr. Justin Marchegiani: Yes. 110%. Evanbrand.com to reach out to Evan. Dr. J here, myself, justinhealth.com. We see patients worldwide. There’ll be links down below where you can reach out. Also, one last thing. So, big tools, all right? Blood pressure cuff around the brachial artery or cephalic artery here, or vein, I should say. Laying down, standing up, we want that blood pressure to go up. Looking at your heart rate: is your heart rate too low? Sometimes too low of a heart rate, or bradycardia, can be a sign of lower potassium, and so looking at your electrolytes is important. Also, too high can be a sign of low sodium and chloride and other electrolytes. Next on top of that would be to get a pulse oximeter. How’s your pulse ox? Are you in the lower 90s? There could be some anemia going on. Maybe we have some estrogen dominance, some subclinical low red blood cell, hemoglobin, hematocrit. Maybe those are fine. Maybe it’s just a lower ferritin, lower iron saturation, right? Maybe there’s some estrogen dominance that’s causing heavy blood flow and you’re just menstruating a lot, or maybe your gut’s off and you’re not breaking down your minerals, your electrolytes, and your iron. So there could be deeper things to this. It may not be just a superficial, easy thing. There may be a lot of layers we have to peel back. Is there Hashimoto’s happening? Do you have elevated flares [flag: unclear audio; possibly “elevated TSH” or similar] and maybe low thyroid and elevated antibodies? These could all be root cause things that are in motion that we have to assess and get our arms wrapped around.
Evan Brand: Yeah. And this is one case where we actually love and utilize blood work, because we do talk a lot about functional labs, and for the case of parasites and digestive issues, blood work doesn’t help that much. But in POTS, blood work could be essential. It may be one of the top three most important things that we do. Except remember, this is going deeper than even Function Health. I know it’s gotten popular, there’s millions and millions of dollars of backing, but they’re still not looking deep enough. We may even need to add on to that. So sure, get some baseline stuff, a little bit more functional stuff, but we might even have to look deeper than that.
Dr. Justin Marchegiani: I agree. And again, the lab range is about two standard deviations, that’s 95%. And so most people may be at the ends and still be normal, so we want to use a functional range, not a pathological lab range. So how we’re looking at the labs is going to be different than, “Oh, your conventional doc ordered it, you’re fine.” That may mean you’re okay from a pathological standpoint, but it may not be optimal from a functional medicine standpoint. So just keep that in the back of your head if your doctor already told you you’re fine.
Evan Brand: Yeah, there’s that meme out there. It’s a lady laying in a casket and the doctor’s standing over her and it says, “Your labs are fine.”
Dr. Justin Marchegiani: Yeah, “Your labs are fine.” Exactly. No, that’s true. Well, evanbrand.com for Evan, justinhealth.com [flag: transcript reads “drjjustinhealth.com”], links below. You guys have an awesome day. Start to apply the info. If you need that extra level of support, we are here for you guys. Have an awesome one. Take care. Peace out.
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