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Focus on Alternative and Complementary Therapies

Volume 21, Issue 1

Original Article 

Free Access

The effectiveness of inhaled ginger essential oil in improving dietary

intake in breast‐cancer patients experiencing chemotherapy‐induced
nausea and vomiting
Noor Salihah PhD, BSc 

Nik Mazlan PhD, MSc, BSc

 … See all authors 

First published:25 April 2016

https://doi.org/10.1111/fct.12236

Citations: 2

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Abstract

Background
Evidence suggests the use of complementary therapies may help in relieving the adverse effects of cancer‐
related treatment, including nausea.

Objectives
To evaluate the effectiveness of inhaled ginger essential oil (EO) in improving dietary intake in women
with breast cancer experiencing chemotherapy‐induced nausea and vomiting (CINV). General perception
on the use of ginger aromatherapy was also evaluated.

Methods
A single‐blind, randomised, placebo‐controlled, crossover study was conducted in two oncology clinics in
Peninsular Malaysia. Women received 5 days of aromatherapy treatment using either ginger EO or
fragrance‐matched placebo [ginger fragrance oil (FO)] in an order dictated by the treatment group
sequence. The following aspects were evaluated: nutritional status (BMI, nutritional requirement, dietary
intake) and general perception of aromatherapy.
Results
Sixty women completed the study (age=47.3±9.26 years; receiving highly emetogenic
chemotherapy=86.7%; BMI=25.5±5.4 kg/m2). Energy intakes were significantly higher after patients were
treated with ginger EO than ginger FO at day 3 (P  =0.015) and day 5 (P =0.002). Significant
improvements in energy intake were also observed over time [F  (2,57)=54.21, P <0.001], reaching almost
90% of the energy requirement 5 days’ post‐chemotherapy. Inhaled aromatherapy using ginger EO was
rated marginally more helpful than the ginger FO (63.3% vs. 61.6%). Being delivered via a necklace, the
treatment method was considered feasible for participating women.

Conclusion
The use of inhaled ginger EO for CINV could possibly help patients resume their dietary intake. This
complementary treatment was also favourably received by the participating women.

Introduction
Nausea and vomiting are generally two of the most feared and distressing symptoms for cancer patients
treated with chemotherapy, even with the widespread use of 5HT3 antagonists.1, 2 Prolonged or delayed
chemotherapy‐induced nausea and vomiting (CINV) may cause patients to experience anorexia by
preventing adequate nutritional intake and resulting in a wasting cycle.3 Nausea has been found to
adversely affect the dietary intake of 21–35% of patients receiving chemotherapy from 1 month to 1 year
of treatment.4 Patients who experience nausea may fear that eating will trigger vomiting, so maintaining
adequate nutritional intake can therefore be a challenge. However, symptoms of malnutrition may be
missed, particularly in breast cancer patients, who are often overweight or obese.5-7 Assesment of recent
dietary intake and weight history is therefore important in identifying cancer patients at risk of
malnutrition.

In cancer care, the use of complementary therapies is becoming increasingly popular. Recent scientific
evidence seems to indicate that some complementary therapies (e.g. acupuncture, hypnosis, reflexology
and massage) may help in relieving cancer and related treatment symptoms, such as pain and
nausea.8 Many herbal supplements in the form of tea or aromatherapy are also simultaneously escalating
in popularity within the cancer community and have been recommended for the relief of
CINV;9 particularly the botanical form of ginger (Zingiber officinale  ), which is often advocated as
beneficial for nausea and vomiting in various conditions, including motion sickness, pregnancy and post‐
surgery.10 It is hypothesised that the direct effect of ginger on the gastrointestinal tract may be due to the
aromatic, spasmolytic, carminative and absorbent properties of the herb.11

Aromatherapy [i.e. the inhalation of the vapours of an essential oil (EO) or absorption of the oil into the
skin] is a particular kind of complementary and alternative therapy that is widely used to treat or alleviate
physical and emotional symptoms.12 Generally, the use of scented oils is recognised as an effective
treatment for nausea. It is known that this therapy is inexpensive, non‐invasive and generally has a low
level of adverse effects.12 However, the clinical evidence justifying its use is still debatable. This study
therefore aimed to evaluate the effectiveness of inhaled ginger EO in improving dietary intake in breast
cancer patients experiencing CINV. Patients’ general perception of aromatherapy was also assessed.

Methods
Study design
This single‐blind, randomised, placebo‐controlled, crossover study was conducted in the oncology clinics
of Hospital Sultanah Nur Zahirah (HSNZ), Kuala Terengganu and Hospital Raja Perempuan Zainab II
(HRPZ II), Kota Bharu, Kelantan, Malaysia. Standard procedures for nausea and emesis prevention and
management were followed in accordance with the standard chemotherapy protocol and each patient's
clinical condition.

Participants
The study inclusion criteria were as follows: (1) women aged 18 years and above with a normal sense of
smell; (2) had a diagnosis of breast cancer; (3) were receiving chemotherapy and experiencing nausea
and/or vomiting of any severity (previously described in our earlier article13); (4) were due to receive at
least two further chemotherapy courses using similar chemotherapeutic agents; and (5) provided consent to
participate in the study. Excluded from the study were women with other malignancies, allergies to ginger,
perfumes or cosmetics or who were undergoing concurrent radiotherapy.

Randomisation
Consenting patients were randomised on recruitment using permuted‐block randomisation, with a block
size of four and an allocation ratio of 1:1.

Interventions
In addition to standard care, patients were asked to wear an aromatherapy necklace containing either two
drops of ginger EO or ginger fragrance oil (FO) (fragrance‐matched placebo) depending on the
randomisation allocation sequence (Figure 1). Patients were blinded to the allocated intervention. Only
researchers were aware of the intervention that each patient was receiving. As this study was susceptible to
investigator bias, researchers avoided this problem by exercising their best judgement during data
collection and data assessment by not transferring their inclinations or attitudes to the patients.
Figure 1

Open in figure viewerPowerPoint

CONSORT flow diagram.

The therapeutic value of FOs is substandard when compared to natural EOs. This is because of changes in
the chemical structure of the concentrated product (extract) and the mixture of synthetic components that
constitute the fragrance oil.14 While EOs and FOs are identical in appearance and texture, fragrance oils
usually smell inferior when compared to the pure EO. Both the ginger EO and ginger FO were obtained
from Take It Global Sdn. Bhd. Butterworth, Penang, Malaysia (an authorised EO dealer for Ungerer
Australia Pty Ltd, Kurnell, New South Wales, Australia).

During the first chemotherapy course, patients in group one received ginger FO, followed by ginger EO for
the next chemotherapy course. In contrast, patients in group two were first given ginger EO on their first
chemotherapy course, and on their subsequent treatment course, were provided with ginger FO. The wash‐
out period was estimated around 2 weeks; the time gap between two consecutive chemotherapy courses.
Patients were instructed to remove the necklace after 5 days of the treatment period ending.

Measurement of variables
Baseline demographic and disease characteristics, including age, cancer diagnosis and treatment
information, were collected from patient medical records. The following outcomes were collected also:
nutritional status (BMI, nutritional requirement, dietary intake) and general perception on aromatherapy.
Nutritional status

The participants’ current weight and height were collected from the most recently recorded values in the
patient medical chart. The weight was routinely recorded by nurses on the day of chemotherapy
administration, which was also the day of the study visit. The BMI was calculated as weight (in kg)
divided by height (in m) squared. The World Health Organization (WHO) classification of BMI was
adapted as normal weight, if BMI was 18.5–24.9 kg/m2, overweight if BMI was 25–29.9 kg/m2 and obese
if BMI was >30 kg/m2.15

Basal energy requirements were estimated based on the WHO formulae for patients aged ≤60 years16 and
the formula devised by Owen et al  .17 for patients aged >60 years, because we considered these to show a
better performance in predicting resting metabolic rate compared to the Harris and Benedict formula.
Estimated daily energy requirements (EERs) were calculated by multiplying the patient's basal
requirements by a 1.2 activity factor. Daily protein requirements were estimated to range between 1.0 and
1.2 g/kg per day to cater for the protein needs of cancer patients.18

Usual nutritional intake at baseline (during chemotherapy treatment) was derived from the patient's dietary
history, which was completed by a research dietician. Subsequent food records (for 3 consecutive days)
were completed by the respondents. Patients were instructed on how to keep a 3‐day food record using
household measurements; a short reference manual was attached together with the 3‐day food record form.
Patients were required to record their nutrient intake between day 3 and day 5 post‐chemotherapy for each
phase (phases 1 and 2 of the study). All nutrient intakes were estimated using Nutritionist Pro, based on the
Malaysian Food Composition database,19 focusing on energy and protein intake as well as the percentage
of total energy contributions (% of kcal) from fat, carbohydrate and protein.

General perception of aromatherapy

Patients were also required to complete a post‐session evaluation questionnaire related to their general
perception of aromatherapy, and a blinding assessment, at the end of each study phase. The questions were
adapted and modified from previous aromatherapy trials by Gedney et al .20 and Graham et al  .21 Using
9‐point Likert scale, patients were asked to rate the strength of odour (1=very weak; 9=very strong),
pleasantness of odour (1=not pleasant; 9=very pleasant) and the feasibility of aromatherapy administration
using a necklace (1=not feasible; 9=very feasible). Higher scores indicated better responses. Provided with
three categorical responses, evaluation of perceived aromatherapy treatment effects (i.e. very helpful;
helpful; and less helpful) was also completed by patients. Additionally, patients were required to report any
adverse events associated with the aromatherapy inhalation.

Statistical analysis
The sample size calculation was based on our earlier study using the VAS as a primary outcome measure.
A sample size of 60 (30 in each group) was needed to obtain a power of 0.90, with an α of 0.05, using a
repeated measures ANOVA analysis. The Statistical Package for the Social Sciences (SPSS), version 16.0
(SPSS Inc., Chicago IL, USA), was used for data compilation and statistical analysis. Descriptive statistics
and parametric tests were applied. The modified ITT approach was applied for efficacy analysis whereby
only patients who had completed all study phases and received both inhaled ginger EO and ginger FO were
included in the analysis. Two‐factor (group and time) analyses of variance with repeated measures were
performed on the dietary intake comparing differences between ginger EO (study group) and ginger FO
(placebo group) taking treatment sequence into account. Main effects were evaluated for differences
between the study (ginger EO) and placebo (ginger FO) group as well as effects over time. Tests for
possible carry‐over effects were performed by comparing sequences (between‐groups factor) and checking
for treatment sequence by time interaction (within‐subjects factor). The Bonferroni adjustment was used
when necessary and significant level was fixed at 0.05.

Ethics
Permission to conduct the study was obtained from the Malaysia Ministry of Health's Research and Ethics
Committee (MREC) [Ref. no: (2) dlm.KKM/NIHSEC/08/0804/P11‐42].

Results
From December 2011 to January 2014, a total of 145 breast‐cancer patients undergoing chemotherapy
treatment were screened, of which only 75 patients were enrolled and randomised: 37 into group one and
38 into group two. Figure 1 depicts the recruitment process for potential participants and the reasons for
exclusion and discontinuation of participation. Overall, 30 patients from each group completed all study
visits, providing a total of 60 evaluable patients for data analysis.

The mean age of patients was 47 years, and the majority of them were Malay. Patients were predominantly
in the early stage of disease (stage I and II) (66.6%) and were receiving highly emetogenic chemotherapy
(anthracycline and cyclophosphamide combinations; 86.7%). All patients were prescribed standard
antiemetics. The baseline characteristics were equivalent across treatment groups (Table 1).22

Table 1. Patients’ baseline data at the time of enrolment

Characteristics Ginger Ginger All

FO/Ginger EO/Ginger patients
EO (n  =30); FO (n  =30); (n  =60)
group one group two

Age (years); mean±SD 45.9±9.5 48.7±8.9 47.3±9.3

20–39 years, n  (%) 10 (33.3) 4 (13.3) 14 (23.3)

Characteristics Ginger Ginger All
FO/Ginger EO/Ginger patients
EO (n  =30); FO (n  =30); (n  =60)
group one group two

40–59 years, n  (%) 17 (56.7) 23 (76.7) 40 (66.7)

60–79 years, n  (%) 3 (10.0) 3 (10.0) 6 (10.0)

Race, n  (%)

Malay 29 (96.7) 30 (100) 59 (98.3)

Other (Siamese) 1 (3.3) – 1 (1.7)

Time after diagnosis (months); mean±SD 11.6±12.7 12.0±12.6 11.8±12.5

≤1 year, n  (%) 24 (80.0) 23 (76.7) 47 (78.3)

˃1 year, n  (%) 6 (20.0) 7 (23.3) 13 (21.7)

Breast cancer stage; n (%)

Stage I 3 (10.0) 2 (6.7) 5 (8.3)

Stage II 18 (60.0) 17 (56.7) 35 (58.3)

Stage III 7 (23.3) 8 (26.6) 15 (25.0)

Stage IV 2 (6.7) 3 (10.0) 5 (8.4)

Chemotherapy cycle; n  (%)

Second 11 (36.6) 7 (23.3) 18 (30.0)

 Characteristics Ginger Ginger All
FO/Ginger EO/Ginger patients
EO (n  =30); FO (n  =30); (n  =60)
group one group two

Third 8 (26.7) 7 (23.3) 15 (25.0)

Fourth 8 (26.7) 8 (26.7) 16 (26.7)

Fifth 3 (10.0) 8 (26.7) 11 (18.3)

Chemotherapeutic agentsa

High (˃90%) emetic risk n  (%)

5‐ 24 (80.0) 21 (70.0) 45 (75.0)

Flouracil+epirubicin+cyclophosphamide

(FEC)

Docetaxel+doxorubicin and 5 (16.7) 2 (6.7) 7 (11.7)

cyclophosphamide (TAC)

Low (10–30%) emetic risk n (%)

Docetaxel 1 (3.3) 7 (23.3) 8 (13.3)

 EO, essential oil; FO, fragrance oil.

 a
 American Society of Clinical Oncology guidelines, 2011.22

Table 2 presents the baseline nutritional characteristics of the patients.18, 23, 24 The mean BMI for all
patients at study entry was 25.5±5.4 kg/m2. Although over half of the patients (51.7%) were categorised as
normal weight, 23.3% of individuals were found to be overweight and 20.0% obese. A one‐way repeated
measures ANOVA revealed that there was no statistically significant difference in weight
[F  (2,58)=3.09, P  =0.053] or BMI [F (2,58)=3.02, P =0.057] between the three time points (i.e. baseline,
first follow‐up and second follow‐up), although a continuous decreasing trend in weight within the 2‐
month study period deserved nutritional attention (61.7±13.6 kg→61.2±13.5kg→60.9±13.4 kg).

Table 2. Nutritional characteristics at baseline (n =60)

Characteristics Value

BMI (kg/m2), mean±SDa 25.5±5.4

Underweight n  (%) 3 (5)

Normal n (%) 31 (51.7)

Overweight n  (%) 14 (23.3)

Obese n (%) 12 (20)

Estimated energy requirement (EER) 1626.7±148.0

(kcal/day), mean±SD

Protein requirement (g/day), mean±SDb 59.3±9.6

Value Recommended
(mean±SD) range

Baseline dietary intake

Energy intake 1630.6±142.6 1780–2180c

(kcal/day)

Protein (g/day) 69.5±18.2 51–55c

Percentage of 53.8±7.7 55–70c

carbohydrate

(%)
 Characteristics Value

Percentage of 17.1±4.5 10–15c

protein (%)

Percentage of 29.1±6.7 20–30c

fat (%)

Dietary fibre 6.1±3.6 20–30d

(g/day)

 a
 Categorical variables are also presented as counts (%).
 b
 Calculated based on 1.0–1.2 g/kg body weight/day.18
 c
 Recommended nutrient intakes for Malaysia, National Coordinating Committee on Food and
Nutrition, Ministry of Health Malaysia, 2005.23
 d
 Malaysian Dietary Guidelines, Ministry of Health Malaysia, 2010.24

At baseline, the energy intake was 1630.6±142.6 kcal/day (range=1300–2000 kcal/day), and the protein
intake was 69.5±18.2 g/day or 1.2 g/kg body weight. While on chemotherapy, nearly 60% of the patients
were meeting their individual daily energy requirements and another 40% met at least 80% of their
requirements. For macronutrient analysis, the intakes were close to the acceptable range for carbohydrate
(53.8%; acceptable range=55–70%) and protein (17.1%; acceptable range=10–15%), and within the
acceptable range for fat (29.1%; acceptable range=20–30%). However, during the first week post‐
chemotherapy, there was a significant reduction in energy intake (P <0.001). Half of the patients reported
that nausea had caused them to limit their food intake for at least 2 weeks after receiving chemotherapy.

There were significant differences between the two treatment groups in terms of mean energy intake
[F  (1,58)=23.88, P <0.001] and percentage meeting energy requirements [F  (2,57)=3.26, P  <0.001;
Table 3]. Energy intakes were significantly higher after patients were treated with ginger EO than ginger
FO at day 3 (P  =0.015) and day 5 (P =0.002). Significant improvements in energy intake were also
observed over time [F  (2,57)=54.21, P <0.001], with patients meeting almost 90% of their energy
requirements 5 days post‐chemotherapy.

Table 3. Comparison of dietary intake between ginger essential oil (EO) and ginger fragrance oil (FO) at
each study phase (phase 1 and 2) and overall treatment effect
 Phase 1 Phase 2 Treatment mode

Ginger FO Ginger EO P  a Ginger EO Ginger FO Ginger FO Ginger EO

(group one) (group two) (group one) (group two)

N 30 30 30 30 60 60

Energy (kcal), mean±SD

Baselin 1626.3±170.4 1635.0±110.9 0.816 – – 1630.6±142.6

Day 3 1240.4±244.8 1250.8±242.4 0.869 1274.2±240.3 1235.2±262.9 1237.8±251.9 1262.5±23

Day 4 1357.6±233.2 1344.1±245.1 0.829 1369.8±256.2 1321.6±218.2 1339.6±224.7 1357.0±24

Day 5 1402.3±239.6 1365.6±320.5 0.730 1427.2±253.2 1382.8±234.1 1392.5±235.0 1424.9±23

Time 53.26

(<0.001)

F (P  )c Group×Time 0.45 (0.638

Group 23.88

(<0.001)

Energy requirement met (%), mean±SD

Baselin 100.5±7.0

Day 3 75.8±14.5 77.9±14.4 0.574 77.9±14.5 76.8±14.6 76.3±14.5 77.9±14.3

 Phase 1 Phase 2 Treatment mode

Ginger FO Ginger EO P  a Ginger EO Ginger FO Ginger FO Ginger EO

(group one) (group two) (group one) (group two)

Day 4 83.0±14.2 83.8±14.7 0.833 83.7±15.6 82.4±13.5 82.7±13.8 83.7±15.0

Day 5 85.6±14.0 88.7±13.6 0.391 87.0±14.1 86.1±14.0 85.9±13.9 87.8±13.7

Time 54.21

(<0.001)

F (P  )c Group Time 0.50 (0.604

Group 23.36

(<0.001)

Carbohydrate (%), mean±SD

Baselin 53.4±6.7 54.3±8.6 0.664 – – 53.8±7.7

Day 3 58.8±8.9 59.3±11.0 0.841 57.2±11.2 59.3±11.1 59.0±10.0 58.2±11.1

Day 4 56.8±9.3 57.0±10.9 0.935 57.1±10.3 59.7±10.4 58.3±9.9 57.1±10.5

Day 5 57.6±9.5 56.7±10.2 0.750 56.8±9.0 56.8±10.1 56.8±9.7 56.8±9.5

Time 1.98 (0.142

 Phase 1 Phase 2 Treatment mode

Ginger FO Ginger EO P  a Ginger EO Ginger FO Ginger FO Ginger EO

(group one) (group two) (group one) (group two)

F (P  )c Group×Time 0.16 (0.856

Group 1.66 (0.202

Protein (%), mean±SD

Baselin 17.5±4.6 16.7±4.4 0.513 – – 17.1±4.5

Day 3 16.3±5.1 15.4±4.0 0.446 16.6±5.2 15.9±5.7 16.1±5.4 15.9±4.6

Day 4 15.9±5.1 17.4±4.9 0.233 16.8±5.4 16.2±5.2 16.0±5.1 17.1±5.1

Day 5 15.6±4.6 17.2±6.8 0.280 16.6±5.6 16.1±4.4 15.8±4.5 16.9±6.2

Time 0.60 (0.551

F (P  )c Group×Time 0.99 (0.379

Group 2.23 (0.141

Fat (%), mean±SD

Baselin 29.1±6.5 28.9±7.1 0.953 – – 29.0±6.7

Day 3 24.9±8.9 25.3±9.3 0.868 26.3±10.8 24.9±9.5 24.9±9.1 25.8±10.0

Day 4 26.1±7.9 25.6±9.9 0.824 26.0±8.8 24.1±8.5 25.7±8.5 25.8±9.3

 Phase 1 Phase 2 Treatment mode

Ginger FO Ginger EO P  a Ginger EO Ginger FO Ginger FO Ginger EO

(group one) (group two) (group one) (group two)

Day 5 27.3±6.7 26.1±8.4 0.538 26.6±8.2 27.1±8.9 27.2±7.8 26.3±8.3

Time 2.05 (0.138

F (P  )c Group×Time 0.81 (0.451

Group 0.18 (0.675

Fibre (g), mean±SD

Baselin 6.0±3.9 6.1±3.3 0.977 – – 6.1±3.4

Day 3 5.6±3.8 5.6±3.0 0.989 5.3±3.4 5.8±3.3 5.7±3.5 5.4±3.2

Day 4 6.0±4.2 5.8±3.4 0.811 5.8±3.4 5.7±3.1 5.9±3.7 5.8±3.4

Day 5 5.4±3.9 6.2±3.9 0.407 5.9±3.2 6.2±3.2 5.8±3.1 6.0±3.5

Time 0.92 (0.405

F (P  )c Group×Time 0.60 (0.552

Group 0.12 (0.732

 Group×Time, treatment group and time interaction.
 a
 Independent t  ‐test; significant at P  <0.05.
 b
 Paired t  ‐test; significant at P <0.05.
  Two‐way mixed design repeated measure ANOVA was applied adjusted for treatment sequence
c

assuming no carry over. No significant interaction between treatment sequence and time (P >0.05).
Overall, no significant mean difference by treatment sequence was detected.

Post‐hoc  tests using a Bonferroni correction showed that the differences in energy intake between each
time point were all significant. For both measured variables (i.e. energy intake and percentage meeting
energy requirement), there was no significant interaction between time and treatment groups or between
time and treatment sequence. Overall, no significant mean difference by treatment sequence was detected.
Therefore, the results showed that the use of inhaled ginger EO could elicit a statistically significant
increase in energy intake in patients with CINV, helping patients to meet their energy requirements.
However, the mean differences in the percentage of energy intake and fibre intake were all non‐significant
with regard to time or between treatment‐group comparisons.

Table 4 shows data from the post‐treatment questionnaire. More patients rated the ginger EO as being
more helpful than the ginger FO (63.3% vs. 61.6%). The most frequent positive comments from patients
following ginger EO inhalation included aiding to decrease intestinal gas, relieve flatulence and alleviate
bloating. The strength and pleasantness of both ginger oils were mostly rated in the middle of the range,
scoring from 4.3–5.0. The feasibility of aromatherapy treatment delivered using a necklace was observed
to be more on the positive side with a rating close to six out of a maximum value of nine.

Table 4. General perception of aromatherapy administration

Characteristics Ginger Ginger P  ‐

(n  =60) essential fragrance value
oil oil

Strength of 4.3±1.5 4.6±1.6 0.227b

odour,a mean±SD

Pleasant‐smelling of 4.6±1.9 5.0±2.0 0.393b

odour,a mean±SD

Feasibility of 5.7±2.0 5.9±2.0 0.341b

treatment,a mean±SD

Perceived treatment effect, n  (%)

 Characteristics Ginger Ginger P  ‐
(n  =60) essential fragrance value
oil oil

Very helpful 8 (13.3) 5 (8.3)

Helpful 30 (50.0) 32 (53.3) 0.9999c

Less helpful 22 (36.7) 23 (38.4)

 a
 Scales ranged from one (very weak; very unpleasant; not feasible) to nine (very strong; very
pleasant; very feasible).
 b
 Paired t  ‐test; significant at P <0.05.
  McNemar test; significant at P  <0.05, variable was recoded into dichotomous – helpful and less
c

helpful.

Discussion
Nutritional evaluation using BMI categorisation revealed that only 5% of participants were underweight
while the other 95% were normal, overweight or obese. The high proportion of patients with normal or
excess weight may sometimes compromise the identification of those in need of dietetic intervention.
Adding to this clinical concern, patients undergoing chemotherapy experience many symptoms that
negatively affect their dietary intake. Previous research has demonstrated that nausea is the most common
symptom experienced by patients undergoing chemotherapy.4, 25-27 The symptom is a major concern as
nausea has been found to adversely affect dietary intake in 21–35% of patients receiving chemotherapy
from 1 month to 1 year of treatment.4 In our study cohort, half of the patients reported that nausea had
caused them to limit their food intake for at least 2 weeks after receiving chemotherapy. The impact of
CINV symptoms on dietary intake was particularly prominent during the early days post‐chemotherapy,
resulting in lower energy intake than the usual intake.

Despite presenting with CINV symptoms, energy and nutrient intake were within normal range, with all
patients meeting at least more than 80% of their energy requirements at baseline. Mean protein intake was
reported to be in excess of the actual requirement. Negative nitrogen balance is still a major concern for
cancer patients,28-30 especially among those who receive chemotherapy since antineoplastic drugs are
known to cause this side‐effect.31 Another study indicates that a significant negative nitrogen balance may
be experienced by cancer patients who gain or maintain their weight while undergoing chemotherapy.32

Energy intake was significantly higher following ginger EO inhalation compared to ginger FO inhalation.
A significant improvement in energy intake was also observed over time, with patients meeting almost
90% of their energy requirements at day 5 post‐chemotherapy. In our earlier publication, we documented
that there was a significant reduction in the severity of acute nausea following inhaled ginger EO
application.13 Dietary intake of cancer patients is usually compromised by a variety of symptoms
including nausea and vomiting.33-35 These symptoms constitute barriers to dietary intake. Thus, it is
conceivable that with improved control of nausea and vomiting, spontaneous dietary intake could be
improved. Although the improvement seemed to be limited, even a slight increase in dietary intake could
actually offer supportive measures to prevent further deterioration in the nutritional intake and nutritional
status of this vulnerable population.

Several possible limitations of this study should be considered when interpreting the data. There was a
potential for selection bias attributable to the method used in recruiting the patients. Patients with low
literacy and a higher symptom burden were mostly declined from participating in the study because of the
requirement for the completion of a substantial list of self‐reported instruments. Patients selected for this
study therefore represented a more educated and ‘healthier’ sample of those affected by CINV. Although
biochemical parameters such as serum albumin and haemoglobin would have enhanced the results of the
present study, all these parameters were subject to homeostatic mechanisms and may be altered by
underlying disease and/or treatment.36 With regards to this issue, anaemia is the most common
haematological abnormality in cancer patients receiving chemotherapy, and serum albumin remains a non‐
specific parameter of nutritional status because of its relatively long half‐life and correlation with stress
and illness,37 hence limiting the value of such measurements.

Conclusion
Essentially, our findings suggest that certain positive benefits can be observed through the use of inhaled
ginger EO for CINV, possibly by helping patients to resume their dietary intake. Administration of ginger
EO using a necklace was also favourably received by most patients. Indeed, in our current cost‐conscious
era, in which cost‐effective treatments are constantly sought, this aromatherapy intervention could be an
important breakthrough in upcoming research. It would therefore be highly encouraging to use these
preliminary findings as a basis for the design of larger, more robust studies recruiting larger samples with
various cancer diagnoses and chemotherapy regimens to reconfirm the exact benefits of widespread
aromatherapy interventions.

Conflict of interest
The authors have no conflicts of interest to declare.
References
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