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The Hidden Drug, Dietary Phosphate: Cause of Behaviour Problems, Learning Difficulties and Juvenile Delinquency by Hertha Hafer
(ISBN: 0-646-40644-2, English Edition, PhosADD Australia)
A review by J.C. Waterhouse, Ph.D.

This is an English translation of a book that has already been published in German, French and Italian. Hertha Hafer, an experienced research pharmacist, reports on a theory explaining, and treatment for, Attention Deficit Hyperactivity Disorder - the terms ADHD and ADD will be used interchangeably in this review - based on the effects of excess phosphate on phosphate sensitive individuals. In this book, evidence is reviewed and a theory is proposed to explain the effects of the low phosphate diet that Hafer presents as a treatment for ADHD. Lists of foods that are prohibited are found at the end of the book. More research needs to be done to test this theory, but the book presents evidence of several types.

First, there is evidence that phosphate in the diet is above the optimal level and has been increasing in the last 20-30 years, as it has become more widely used in many types of processed foods. This agrees with the findings of FDA researchers Calvo and Park ("Changing phosphorus content of the U.S. Diet: Potential for adverse effects on bone." Journal of Nutrition 126:1168S-1180S, 1996). The latter published a study that revealed that dietary phosphorus levels have increased enough to potentially contribute to osteoporosis. In particular, the ratio of calcium to phosphorus in the diet has declined. Phosphate additives are used in buffer solutions, emulsifiers, stabilizers, thickeners, and antioxidants. They are also used in the meat industry, cheese spreads, soups, sauces, creams and chocolates. Phosphate as an additive can be found as a flour improver, a flow conditioner in bulk goods, an aerator and as a component of modified starch. Hafer reports that Feldheim calculated an intake of 1570 mg per day as contrasted with a recommended level of 750 mg. [Editor's Note: phosphorous is also found in some calcium supplements, such as bone meal and hydroxyapatite and is not always listed on labels.]

Hafer describes a number of experiments with a low phosphate diet. For instance, a psychiatrist - Dr. Roy-Feiler - found a low phosphate diet to be helpful in treating ADD in the clinical setting. Fifteen children with ADD, whose symptoms had been under control for several months with the low phosphate diet, were tested in a double blind manner. Capsules containing a 6.9 pH buffer solution of 75 mg PO4 (a very physiological form of phosphate) were used in the test and the children reacted quite violently to the phosphate, with reoccurrences of their previous symptoms that lasted for days. Hafer's book has led to low phosphate diet support groups in Europe and a low phosphate diet cookbook (at this time, the cookbook is only available in French).

The requirements for the diet may vary among individuals. Hafer (personal communication) finds that in some mild cases, children will improve simply by removing sausage, hot dogs, ham and other processed meats as well as phosphate-containing beverages (which includes sodas and sports drinks). It is difficult to summarize the diet here, but many of the items can be avoided by avoiding processed foods and anything for which ingredients are not listed. Most items at health food stores in the U.S. will not have added phosphates, but that does not mean that they will all be permitted in the diet. Items that are excluded in this diet are: sausage, hot dogs, ham and many other processed meats, phosphate-containing sodas, anything containing lecithin or phosphate-containing baking powder, egg yolks, milk, cheese, yoghurt, ice cream, mushrooms, sweet corn, soy, peas, beans, lentils, citrus fruits, tomatoes, oats, sugar, honey, instant starches, instant coffee, citrus drinks, all nuts (except coconut), chocolate, popcorn, instant soups and sauces, mayonnaise and ketchup. This is just an approximate idea of the diet; more detail is included in the book.

The reasons for excluding some of the above items are not completely clear to me, and are not explained in all cases in the book. It is mentioned that there is some trial and error involved. It is my view that the benefit from excluding some of these items may be related more to their being common allergens, than their containing particularly high levels of phosphate. Individuals can start by eliminating all the items mentioned and then reintroduce each of the excluded items to see if they cause symptoms. It may be that many may need to exclude only some of these foods. Even if avoidance of allergens is partly responsible for the reported benefits of the diet, the above experiment involving blinded challenge testing indicates that the phosphate may well be an important issue as well. Dr. William Rea (Environmental Health Center, Dallas, Texas - personal communication) has also found some patients sensitive to phosphate using the sublingual challenge test, though he did not have much success in finding neutralizing doses, as is done in the typical provocative/neutralization testing as practiced by the American Academy of Environmental Medicine.

It is interesting to compare Dr. St. Amand's approach to fibromyalgia and ADD-like symptoms in children that he believes may actually be fibromyalgia at an early stage (pre-fibromyalgia), (see Issue 4 of the Newsletter of the Chronic Illness Support and Research Association (CISRA) - link below - and the book, What Your Doctor May Not Tell You About Pediatric Fibromyalgia, by St. Amand and Marek, Warner Books.

Hafer's approach to ADD works on reducing phosphate intake, while Dr. St. Amand's approach increases phosphate excretion by the kidneys by using the safe and inexpensive guaifenesin (originally extracted from a tree bark and now synthesized and used as a mucolytic and expectorant - it had been used for "rheumatism" decades ago, however). I believe that the excess phosphate theory is strengthened by the fact that the two approaches were arrived at independently of one another, yet came to the same general conclusion, that is that excess phosphate is an unappreciated cause of illness and can be treated.

It is also interesting that Hafer connects neurodermatitis and asthma with excess phosphate as well, and Dr. St. Amand also sees these conditions frequently in his patients. In many cases they improve with guaifenesin treatment. Although many people with fibromyalgia and/or Chronic Fatigue Syndrome and related conditions may benefit from reducing phosphate in their diet, it seems more likely that Hafer's approach of reducing phosphate intake will be more helpful in children than adults. Adults have typically had several decades during which they might accumulate fairly large amounts of phosphate in their cells. According to Dr. St. Amand, this excess intracellular phosphate, accompanied by calcium, is the cause of the fibromyalgia lesions (also known as tender areas), with their low ATP and constantly contracted muscles. In people who have this accumulated phosphate from many decades, it seems likely that guaifenesin will prove to be more effective in reversing illness than simply reducing phosphate intake.

© 2000, J.C. Waterhouse, Ph.D., reprinted by permission, from CISRA's Synergy Health Newsletter (Chronic Illness Support and Research Association).
Disclaimer: This material is intended for information only and is not medical advice. Neither CISRA nor the above author receive funding from any doctor, laboratory, or manufacturer of any medication or associated products.

Dr J.C. Waterhouse's website http://synergyhn.com is about chronic illness and support in general, with particular reference to chronic fatigue syndrome and fibromyalgia. The site gives detailed information on food and chemical allergies and sensitivities. The site reports the work of Dr St Amand who, like Hertha Hafer, views the high intake of phosphate as a possible explanation for illness.


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