The Effect of Ginger Biscuit on Nausea and Vomiting in Early Pregnancy

ORIGINAL REPORT
The Effect of Ginger Biscuit on Nausea and Vomiting in Early Pregnancy
Zahra Basirat1*, Ali A. Moghadamnia2, Mehrdad Kashifard3, Atena Sarifi-Razavi1
1 Department of Obstetric and Gynecology, School of Medicine, Babol University of Medical Sciences, Babol, Iran
2 Department of Pharmacology, School of Medicine, Babol University of Medical Sciences, Babol, Iran
3 Department of Gastroentrology, School of Medicine, Babol University of Medical Sciences, Babol, Iran

Received: 15 Oct. 2006; Received in revised form: 4 June 2007; Accepted: 21 Sept. 2007
Abstract: Nausea and vomiting of pregnancy (NVP) are often alleviated by eating dried biscuits or foods.
Natural products such as ginger have been suggested as herbal remedies for its treatment. The purpose of this
study was to determine the effectiveness of ginger in biscuit form for the treatment. Sixty-five women with
NVP at or before 17 weeks of gestation, who attended the antenatal clinic of Yahyanejad hospital in Babol
town, Northern Iran, during 2005-2006 were included in the study. The subjects were randomized in a dou-
ble-blind design and divided into two groups to take biscuits. 0.5g of ginger as fine powder was incorporated
in each biscuit. Subjects received 5 ginger biscuits per day or an identical placebo biscuit for 4 days. They
graded their severity of nausea using visual analog scales (VAS) and recorded the number of vomiting epi-
sodes in the previous 24 hours and again during 4 consecutive days. Five-item Likert scales were used to as-
sess the severity of their symptoms. The average VAS scores of day 1 to 4 of post-therapy minus baseline
nausea was decreased significantly in ginger (2.6±1.77) compared with the placebo group (1.4±1.62)
(P=0.01). The number of vomiting episodes was also decreased in ginger (0.96±0.21) and placebo
(0.62±0.19), the difference being insignificant. A significant difference was seen in inter-group variations per
day in both groups. Likert scale showed an improvement in symptoms in both groups (P=0.43). Therefore,
ginger in biscuit form is effective for relieving the severity of nausea and, to some extent, of vomiting in
pregnancy.
© 2009 Tehran University of Medical Sciences. All rights reserved.
Acta Medica Iranica 2009; 47(1): 51-56.

Keywords: Nausea, vomiting, pregnancy, ginger, biscuit
Introduction
the pathophysiology of nausea and vomiting and on

treatments found to be successful for non-pregnant sub-
Nausea and vomiting during pregnancy (NVP) have a
jects as well (4). Some pregnant women prefer natural,
pervasive impact on women's family, social and profes-
non-pharamacological therapies, such as life-style and
sional life (1). Vomiting affects more than 50% of
nutritional habit changes, pyridoxine and ginger. Herbal
women early in pregnancy and nausea is present in 70-
medication for NVP is common. Ginger, chamomile,
80% (2). Most cases are mild and resolve by the twenti-
peppermint, Echinacea, cranberry and raspberry are
eth week of gestation. At the other end of the spectrum
among the herbs used for this purpose (4, 5).
is hyperemesis gravidarum, characterized by persistent
Ginger (Zingiber officinale) has been used for me-
nausea and vomiting resulting in dehydration, ketosis,
dicinal purposes since ancient times. One of its indica-
electrolyte imbalances and weight loss (3).
tions has always been the treatment of nausea and vom-
The pathophysiology of NVP is poorly understood.
iting. The aromatic, spasmolytic, carminative and absor-
Various hormonal, biochemical, mechanical and psycho-
bent properties of ginger suggest that it has direct effects
logical factors have been implicated.3 Treatment of NVP
on the gastrointestinal tract (6). Ginger has been shown
has traditionally been supportive, with dietary modifica-
to have anti-inflammatory effects. It is also known to
tion consisting of eating small portions of food at fre-
have beneficial effects on motion sickness, anorexia,
quent intervals, ingesting dry toast or crackers initiation,
dyspepsia, and common cold (7, 8).
and eating bland low-fat foods.3 Pharmacological ap-
It has been used as an anti-nausea and anti-vomiting
proaches for the treatment of NVP have been based on
agent in pregnancy. Researchers showed no side effect
* Corresponding Author: Zahra Basirat
Department of Gynecology, Fatemeh Zahra Fertility and Infertility Research Center, Babol University of Medical Sciences, Babol Postal. Code:
4719173716 Iran.
Tel: +98 911111-2979, Fax: +98 111 2274880, E-mail: zahra_basirat@yahoo.com

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Ginger on nausea and vomiting of pregnancy
of ginger when used during pregnancy (9-11). Ginger-
were used to quantify the changes in severity, namely a
containing products at hand include drop form with re-
visual analog and a Likert scale.
gard to its taste and probable not incompliance of some
For the visual analog scales (VAS), patients were
patients . Therefore, this study was conducted to deter-
asked on their first visit to grade the severity of their
mine the effect of ginger in a biscuit form on NVP.
nausea over the past 24 hours (baseline scores) by mark-

ing an "X" corresponding to their perceived states on a
Patients and Methods
10cm vertical line, ranging from 0=no nausea to

10=severe nausea as bad as it could be. On the following
A randomized double-blind clinical trial was conducted
4 days, recording of the severity of nausea were made
on 65 pregnant women with nausea and vomiting of
daily at bed time.
pregnancy, who attended an antenatal clinic of Yahyane-
At a follow-up visit 7 days later, the nausea score
jad hospital in Babol town, Northern Iran, during 2005-
and the number of vomiting episodes before and in dif-
2006. The study was approved by the ethical committee.
ferent days of treatment were used to assess the severity
Subjects of the age of 19-35 years, weighing within
of their symptoms. The average daily nausea scores and
20% of normal weight at the beginning of pregnancy
total scores over 4 days for each subject were calculated.
and being in 7 and 17 weeks of gestation were included.
Then, we compared the average change in the severity
The exclusion criteria were: coexistence of other disease
of nausea (post- therapy minus baseline) in the ginger
that cause vomiting such as thyroid disease, history of
with the placebo groups using the Mann-Whitney U test.
gastroenteritis, or gastrointestinal disease, infections,
Subjects also recorded the number of vomiting epi-
multiple pregnancy, hyperemesis gravidarum, tro-
sodes in the 24 hours before the study, and then during 4
phoblastic disease and psychological disorders.12 This
days. The change in the score of nausea and number of
also applied to women who received antiemetic agents
vomiting episodes in the two groups were compared by
such as vitamin B6, metoclopromide or drugs enhancing
student T-test as well. Inter- and intra-group daily varia-
the condition such as iron tablets during last week.
tions of data were analyzed by repeated measure analy-
After getting informed consent, the subjects were
sis.
randomly entered into a double-blind design to receive
Also, we assessed the general idea of the patients to
either ginger (n=35) or non-ginger containing (placebo)
treatment with five-item Likert scales (much worse,
(n=30) biscuits.
worse, same, better, much better). Chi-square test was
Every subject was handed 20 biscuits. They took five
used to compare these findings.
biscuits daily for four days. Time of consumption was

based on patient’s demand, especially when they experi-
Results
enced nausea. The ginger and identical-looking placebo

biscuits were prepared by an expert confectionary under
In this study, sixty-five women consented to participate.
researcher's supervision. 0.5-g of ginger as fine powder
Thirty subjects were assigned to placebo and 35 to gin-
was incorporated in each ginger biscuit. Placebo biscuit
ger biscuits. Three subjects in ginger group did not con-
was similarly prepared. Both ginger and placebo biscuits
sume the ginger biscuit due to its hot spicy taste and
were similarly packed in an envelope containing 20 bis-
they were excluded from the study. Women were
cuits in it. Before the trial, a research nurse who was not
matched in relation to age, body mass index, gestational
responsible for patient care was asked to use a table of
age and parity in both groups. Differences in baseline
random numbers to prepare the treatment assignment.
characteristics of the two groups were not statistically
The treatment codes were kept in sequence in a sealed
significant.
black envelope that could not be read through. As each
The average change in nausea scores (baseline minus
subjects entered the trial, she received the next envelope
average post-therapy nausea scores of day 1-4 for all
in the sequence which determined her assignment. Nei-
subjects) in the ginger group was significantly greater
ther the physician nor the patients knew the composition
(P=0.01) than that in placebo group (Table 1). The nau-
of the biscuits administered.
sea score of day 4 in the placebo and ginger group was
Subjects graded the severity of their nausea and re-
decreased to 3.03±2.47 from 4.67±1.97 and 3.03±2.19
corded the number of vomiting episodes in the last 24
from baseline score of 5.88±1.83, respectively.
hours before treatment and again during 4 consecutive
Intra-group analysis of variations by repeated meas-
days while taking biscuits. Because nausea is a subjec-
urement showed a significant difference in placebo
tive symptom, two independent measurement scales
(P<0.001) and ginger (P<0.001) groups (Figure 1).

52 Acta Medica Iranica, Vol. 47, No. 1 (2009)

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Z. Basirat, et al.
Table 1. The Average changes of nausea score in different days to the baseline of two group of study
Baseline
Day 0-day 1
Day 0-day 2
Day 0-day 3
Day 0-day 4
average
day0-avarage
(day0)
1- 4
1-4
Placebo(n=30) 4.67±1.97 1.03±0.999 1.43±1.38 1.47±2.25 1.63±2.51 3.27±1.84 1.39±1.62
Ginger(n=32) 5.88±1.83 2.03±1.93 2.34±2.08 3.06±1.74 2.84±2.09 3.30±1.80 2.57±1.77
*P value 0.008
0.021
0.048
0.003
0.023
0.99
0.010
* Mann –Whitney U test
† Data are presented as mean± SD of the difference (baseline minus post therapy) in nausea scores.
But repeated measurement could not detect signifi-
inter-group variation (P=0.969).
cant differences in a inter-group variation analysis
On follow-up visits, five-item Likert scales were re-
(P=0.543).
cruited to assess patient's subjective response to treat-
All subjects in two groups of the study had one or
ment. Twenty-eight of 32 (87.5%) ginger-treated women
more vomiting episodes during 24 hour before treament.
reported that their symptoms had improved, compared
The average change (±SEM) in the number of vomit-
with 21 out of 30 (70%) in placebo group. Ginger-
ing episodes (baseline minus average post therapy vom-
treated women felt much better and chi-square test
iting number of day 1-4) in ginger biscuit group was
found a significant difference between these findings of
(0.96±0.21) compared with (0.62±0.19) in the placebo
two groups (P=0.043, Table 3).
biscuit group, although there was no significant differ-

ence (P=0.243, Table 2).
After 4 days of treatment, the proportion of women
who had no vomiting in the ginger group (11 out of 32
7
patients, 34%) was greater than that in the placebo group
6
placebo
(6 out of 30, 18%). When the average number of vomit-
5
Ginger
r
e
ing episodes over the 4 days of treatment was subtracted
o
c
s
a 4
from the corresponding baseline value for each patient,
e
s
u
a
and the overall change in the number of vomiting epi-
3
n
f
o
sodes for subjects in the two groups was compared, a
S 2
A
V
greater reduction in the number of vomiting episodes
1
was found in the ginger group, but no significant differ-
0
ence was seen (Table 2). The comparison between the
0
1
2
3
4
variation of number of vomiting before, during and after
Nausea score per day
4 days in a within group analysis by repeated measure-
ment showed a significant decrease in placebo
Figure 1. Trend lines of the nausea scores in days of study in
(P<0.001) and ginger group (P<0.001; Figure 2).
two groups. Number of patients in placebo and ginger groups
However, there was no significant differences in a
were 30 and 32, respectively.

Table 2. The average changes of the number of vomiting episodes in different days to the baseline of two groups of study
Baseline
Day 0-day1
Day 0-day
Day 0-day 3
Day 0-day
average day
Day 0- average
(day0)
2
4
1-4
1-4
Placebo
1.3±1.3 0.33±0.175 0.67±0.18 0.77±0.28 0.73±0.31 0.74±0.21
0.62±0.19
(n=30)
Ginger
1.63±1.18 0.84±0.216 0.94±0.24 1.09±0.22 0.97±0.25 0.66±0.17
0.96±0.21
(n=32)
*P-value
0.426
0.073
0.384
0.367
0.556
0.78
0.243
* Student T-test
† Data are presented as mean ± SEM of the differences (baseline minus post therapy) in number of vomiting scores.
Acta Medica Iranica, Vol. 47, No. 1 (2009) 53

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Ginger on nausea and vomiting of pregnancy
bread, tarts, and cookies) (6). In this study, we used gin-
1.8
ger and non-ginger containing (placebo) biscuit for
1.6
NVP.
1.4
Our result showed a reduction in nausea severity
1.2
i
t
i
n
g
Simple
score in the group receiving ginger biscuit compared to
Ginger
v
o
m
1
placebo biscuit (P=0.01). Although the decrease in the
o
f
0.8
number of vomiting was greater in ginger group, the
b
e
r
0.6
difference was not statistically significant (P=0.24).
n
u
m
0.4
There are only few data on the actions of ginger.
0.2
Gingerols, in particular 6-gingerol, have been identified
0
as the active ingredient of ginger, and are also responsi-
0
1
2
3
4
ble for its characteristic taste. There are several mecha-
number of vomiting per day
nisms which could explain the possible antiemetic ef-
fects of ginger. In an animal model, for instance, it was
Figure 2. Trend lines of the vomiting scores in days of study
demonstrated that 6-gingerol enhanced gastrointestinal
in two groups. Number of the patients in placebo and ginger
transport. This and other compounds of ginger have also
groups were 30 and 32, respectively.
been shown to have anti-hydroxytryptamine activity in

isolated guinea pig ileum. Galanolactone, another con-
stituent of ginger, is a competitive antagonist at ileal 5-
HT3 receptors. Thus antiemesis could be brought about
Table 3. Symptoms assessed by likert scales
by effects on the gastric system through 5-HT3 antago-
Symptom rating
Placebo (n=30)
Ginger (n=32)
nism. This hypothesis is weakened by the results of a
Same 9(30%)
4(13%)
randomized, placebo-controlled crossover study in hu-
Better 4(13%)
1(3%)
man volunteers reporting that oral ingestion of powdered
Much better
17(57%)
27(84%)
ginger root did not affect gastric emptying rate. In con-
Data are presented as frequency (%); chi-square test, p=0.043.
trast, effects on the central nervous system may be in-
* because of no data of much worse and worse items of likert scales,
they were not included.
volved. This notion is strengthened by the finding that in

an animal model, oral 6-gingerol prevented vomiting in
response to cyclophosphamide. A central effect is also
implicated by studies reporting that ginger partly pre-
Compliance as assessed by biscuit count. The result
vents motion sickness symptoms in healthy human vol-
showed that all women finished the study in the placebo
unteers (6).
and ginger group received 5 biscuit daily.
We chose a study period of 4 days because a previ-
Regarding the side effects, there was no complaint in
ous study (9, 11) showed that the effect of ginger was
placebo group whereas in ginger group one patient
evident within a few days of treatment and too long a
(3.12%) complained from dizziness and one (3.12%)
period would result only in a higher rate of subject in-
from heartburn due to ginger biscuit, which were mild
compliance and, thus, fewer individuals to follow-up.
and did not result in stopping consumption. No subjects
We used VAS to quantify nausea severity, because these
in this trial took any other medications for nausea or
scales give an objective measure, have construct validity
vomiting as rescue dose. The side effects were reported
and are reproducible (13-15).
by subjects as minor and didn't preclude them from tak-
In a small crossover study on 27 women suffering
ing their prescribed medication.
from NVP a significantly greater symptomatic benefit
No abnormal pregnancy and delivery outcome
after administration of ginger compared with placebo
ocurred and no infants had any congenital abnormalities
has been shown (P<0.05) (11).
recognized and all were discharged in good condition.
In a study conducted by Smith C, women with NVP

in less than 16 weeks of gestation were randomly allo-
Discussions
cated to receive either 1.05g of ginger or 75mg of vita-

min B6 daily in a blind fashion for 3 weeks. Their re-
Ginger, known scientifically as Zingiber officinale, is a
sults showed that ginger was as effective as vitamin B6
perennial native to many Asian countries. It can be used
in reducing nausea, dry retching and vomiting (16).
as a spice to enhance the flavor of food (e.g. ginger
The result of our study showed that ginger is effec-
54 Acta Medica Iranica, Vol. 47, No. 1 (2009)

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Z. Basirat, et al.
tive for relieving the severity of nausea of pregnancy,
182: 931-7.
which is consistent with previous studies (9).
2. Safari HR, Alsulymar OM, Gherman RB, Goodwin TM.
Willets et al. performed a study on women with
Experience with oral methylprednisolone in the treatment
NVP; 120 women underwent treatment with 125mg of
of refractory hyperemesis gravidarum. Am J Obstet Gyne-
ginger extract (equivalent to 1.5 gram of dried ginger) or
col 1998; 178: 1054-8.
placebo given four times per day for 4 days. They found
3. Meltzer DI. Complementary therapies for nausea and
the nausea experience score was significantly less for
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the ginger extract group compared to the placebo group,
570-73.
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episode did not reveal any statistical significant differ-
16(3): 224-28.
ence (P=0.969). This finding was seen in the nausea
6. Ernest E, Pittler MH. Efficancy of ginger for nausea and
score as well, It could be concluded that the biscuit
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alone can be effective in relieving nausea and vomiting,
British journal of Anesthesia. 2000; 84(3): 367-71.
although the effect of ginger is considerable and statisti-
7. Grzanna R, Lindmark L, Frondoza CG. Ginger – an herbal
cally greater than placebo (Table 1,2). As the traditional
medicinal product with broad antiinflammatory actions. J
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Med food 2005; 8(2): 125-32.
(3), it can be due to effect of biscuit form.
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Regarding the probable adverse effects, in this study
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one patient (3.12%) reported dizziness and one (3.12%)
9. Vutyavanish T, Kraisarin T, Ruangsri R. Ginger for nausea
heartburn after consumption of ginger biscuits which
and vomiting in pregnancy: Randomized, double- masked,
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(10, 18).
Effectiveness and safety of ginger in the treatment of preg-
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105(4): 849-56.
gastrointestinal symptoms and sedation, of which none
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