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Farzad Shidfar, Asadollah Rajab, Tayebeh Rahideh, Nafiseh Khandouzi*, Sharieh Hosseini
and Shahrzad Shidfar
The effect of ginger (Zingiber officinale) on glycemic
markersinpatientswithtype2diabetes
Abstract
Background: Ginger (Zingiber officinale) is one of the
functional foods which contains biological compounds
including gingerol, shogaol, paradol and zingerone.
Ginger has been proposed to have anti-cancer, anti-
thrombotic, anti-inflammatory, anti-arthritic, hypolipi-
demic and analgesic properties. Here, we report the effect
of ginger supplementation on glycemic indices in Iranian
patients with type 2 diabetes.
Methods: A double-blind, placebo-controlled, randomized
clinical trial was conducted on 20–60 -year-old patients with
type 2 diabetes who did not receive insulin. Participants in
the intervention and control groups were received 3 g of
powdered ginger or placebo (lactose) (in capsules) daily for
3 months. Glycemic indices, total antioxidant capacity (TAC),
malondialdehyde (MDA), C-reactive protein (CRP), serum
paraoxonase, dietary intake and physical activity were mea-
sured at the beginning and end of the study, and after 12 h
fasting.
Results: Comparison of the indices after 3 months showed
that the differences between the ginger and placebo groups
were statistically significant as follows: serum glucose
(–19.41 18.83 vs 1.63 4.28 mg/dL, p<0.001), HbA
1c
percentage (–0.77 0.88 vs 0.02 0.16 %, p<0.001),
insulin (–1.46 1.7 vs 0.09 0.34 μIU/mL, p<0.001),
insulin resistance (–16.38 19.2 vs 0.68 2.7, p<0.001),
high-sensitive CRP (–2.78 4.07 vs 0.2 0.77 mg/L,
p<0.001), paraoxonase-1 (PON-1) (22.04 24.53 vs 1.71
2.72 U/L, p<0.006), TAC (0.78 0.71 vs –0.04 0.29
µIU/mL, p<0.01) and MDA (–0.85 1.08 vs 0.06 0.08
µmol/L, p<0.001) were significantly different.
Conclusions: This report shows that the 3 months supple-
mentation of ginger improved glycemic indices, TAC and
PON-1 activity in patients with type 2 diabetes.
Keywords: ginger, glycemic markers, paraoxonase, type 2
diabetes
DOI 10.1515/jcim-2014-0021
Received April 18, 2014; accepted December 23, 2014
Introduction
Type 2 diabetes mellitus (T2DM) is a set of metabolic
disorders dominated by hyperglycemia. The main under-
lying mechanism leading to this disorder is poor response
of pancreatic βcells to insulin. High oxidative stress
and inflammation are other characteristics of T2DM.
Hyperglycemia may lead to oxidative stress which, in
turn, can cause cellular damage, insulin resistance and
decrease the antioxidant capacity [1]. The global inci-
dence of diabetes is increasingly growing and over the
next two decades, 500 million people will be expected to
have diabetes [2]. Poor control of micro- and macro-vas-
cular complications of diabetes is associated with a range
of problems that reduce quality of life, increase mortality
and impose high costs to the healthcare system [3].
Therefore, adoption of appropriate strategies to control
the glycemic status in diabetic patients is important for
any healthcare system.
Ginger (Zingiber officinale), of the Zingiberaceae, is
one of the functional foods that is commonly used all
over the world, particularly in the Middle East [4].
Meanwhile, in ancient medical practice, ginger has
been used for gastrointestinal disorders such as nausea,
constipation and anorexia [5]. Ginger’s major biological
compounds include gingerol, shogaol, paradol, zingerone,
oily gases and β-bisabolene [6]. In addition to these com-
pounds, ginger contains vitamins B and C, and also the
minerals like calcium, magnesium, potassium and phos-
phorus [7]. Also, it has been proposed to exhibit anti-
cancer, anti-thrombotic, anti-inflammatory, anti-arthritic,
hypolipidemic and analgesic properties [8–11]. Recent stu-
dies, which have been mainly conducted on animals,
*Corresponding author: Nafiseh Khandouzi, Department of Nutrition
and Biochemistry, School of Nutritional Sciences and Dietetics,
Tehran University of Medical Sciences, Tehran, Iran, E-mail:
khandozi_n@yahoo.com
Farzad Shidfar, School of Health, Iran University of Medical
Sciences, Tehran, Iran
Asadollah Rajab, Iranian Diabetes Association, Tehran, Iran
Tayebeh Rahideh, School of Health, Iran University of Medical
Sciences, Tehran, Iran
Sharieh Hosseini, Department of Chemistry, Robat Karim Branch,
Islamic Azad University, Robat Karim, Iran
Shahrzad Shidfar, Worcester Memorial Hospital, University of
Massachusetts, Worcester, USA
J Complement Integr Med. 2015; aop
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indicate that ginger exhibits hypoglycemic properties as
well [12, 13]. In the digestive system, ginger’sphenolic
compoundssuchasgingerolandshogaolinhibitα-amylase
and α-glucosidase enzymes, which are associated with
carbohydrate metabolism and hyperglycemia [14, 15]. In
pancreatic βcells, ginger stimulates insulin secretion,
increases cell viability and decreases the intracellular reac-
tive oxygen species (ROS) [15]. In liver, ginger suppresses
the expression of inflammatory proteins such as tumor
necrosis factor (TNF-α) and interleukin 6 (IL-6), and
reduces the functionality of nuclear factor kappa B (NF-
κB). Also, ginger reduces the activity of glucose-6-phos-
phate dehydrogenase (G6PD), succinate dehydrogenase
(SDH), malate dehydrogenase (MDH) and glutamate dehy-
drogenase (GDH) enzymes [16]. Due to limited controlled
clinical studies on ginger, this study has been conducted to
investigate the effects of ginger on glycemic markers, total
antioxidant capacity (TAC), malondialdehyde (MDA), high-
sensitive C-reactive protein (hs-CRP) and paraoxonase-1
(PON-1) in patients with T2DM.
Materials and methods
Participants
Fifty, nonsmoking, T2DM patients were recruited from the Iranian
Diabetes Society, Tehran, Iran, from May to November 2012. All
patients underwent a comprehensive medical examination and rou-
tine blood tests. The diagnosis of T2DM was confirmed in all parti-
cipating patients with T2DM by a physician endocrinologist and
those with at least 2 years of duration of diabetes were included in
this study. Patients were informed of their rights as volunteers in
this study and signed approved consent forms. The procedures
followed in this study were in accordance with the Helsinki
Declaration and the study was approved by the institutional review
board and the Ethical Committee of Iran University of Medical
Sciences, Tehran, Iran. This clinical trial was registered at Iranian
Registry of Clinical Trial (IRCT) with number IRCT 201109082709N19.
The ethical committee permit number was 89-04-27-12497. Patients
received no monetary incentive. The inclusion criteria were age of
20–60 years, body mass index (BMI) ≤30 kg/m
2
, no use of insulin,
HbA
1c
6–8 %, no use of any dietary supplement for at least 3 months
prior to baseline and also no history of smoking or alcohol con-
sumption. Exclusion criteria were chronic diseases (i.e. heart dis-
ease, cancer, diabetes, and hepatic, kidney and thyroid diseases),
any changes in the type or the dose of hypoglycemic drugs, recently
receiving insulin, anti-hypertensive drugs, multivitamin or nutrient
supplement, any changes in diet or daily exercise program, any
allergic reaction to ginger, lipid-lowering medications, antibiotics,
or sex hormone treatment, pregnancy or breast feeding, use of any
weight loss diet or diet pills in the previous 6 months, and consum-
ing less than 80 % of supplements delivered to the patients at the
baseline.
Design
A double-blind randomized clinical trial of parallel design was used
to compare the effects of ginger with placebo on glycemic markers in
patients with T2DM. The patients were stratified by sex and BMI and
randomly assigned to one of two groups for 3 months: (1) Patients in
the ginger group received 3 g of powdered ginger capsules daily
(each capsule contained 1 g) and (2) patients in the control group
received 3 g of daily placebo (lactose) capsules. Ginger and placebo
capsules of the same weight, appearance and coverage were pre-
pared in collaboration with School of Pharmacy, Tehran University
of Medical Sciences, Tehran, Iran. The capsules were packed simi-
larly in two groups of A and B by the individual outside this project.
To keep the study double blind, the research executive was not
aware of the contents of the capsules.
Anthropometry and questionnaires
Anthropometric measurement of height, waist circumference (WC)
(using stadiometer) and weight (using a balance scale) was per-
formed at the beginning and end of the study. WC was the distance
around the smallest area below the rib cage and above the umbili-
cus. Dietary intake was monitored by the same dietitian throughout
the study and the patients were asked to complete a 3-day dietary
recall questionnaire (two regular days in the middle of the week and
one day at the weekend) at the beginning and end of the study as
well as a lifestyle questionnaire (e.g. physical activity, income, etc.)
at the beginning and end of the study.
Biochemical measurements
Patients were required to provide venous blood samples after 12 h
overnight fasting at the beginning and end of intervention. A volume
of 5 mL of blood samples was obtained from each patient, using
disposable syringe by experienced nurses. All samples were
collected while the patients rested in a supine position for 10 min.
The samples were centrifuged, then sera were separated and
the required biochemical measurements were performed
immediately.
The concentration of fasting blood glucose was measured by
enzymatic method using Elitech kit (via Hitachi machine) from
French company of Feppim 717. HbA
1c
was determined using turbi-
dimetric inhibition immunoassay method with commercial kit
(Roche, Germany) on the Cobas MIRA analyzer (Roche Diagnostic,
Basel, Switzerland). TAC was determined using spectrophotometric
method as described by Miller and Rice-Evans [17]. Insulin resistance
was assessed using the homeostatic model assessment of insulin
resistance (HOMA-IR) ¼[fasting glucose (mmol/L) fasting insu-
lin (mU/L)]/22.5 [18], which included measurement of insulin by
immunoassay method using commercially available kit (Roche,
Germany) and measurement of glucose by enzymatic method using
commercially available kit (Elitech, France) which performed on
Hitachi 717 autoanalyzer. MDA was determined using spectrophoto-
metric method as described by Satoh [19]. Hs-CRP was measured by
turbidimetric method using commercially available kit (Roche,
Germany) on the Cobas MIRA analyzer (Roche Diagnostic). PON-1
activity was also measured by the colorimetric method [20].
2Shidfar et al.: Ginger on glycemic markers
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Statistical analysis
This study was designed with 90 % power, with two-sided α¼0.05
(type I error), to detect a 5 % difference in serum glucose between
the two groups. On the basis of SDs observed in the current study,
the number of patients needed to treat to detect this difference was
19/group. Given an anticipated dropout rate of 25 %, we set the
enrollment target at 25 patients.
All data were expressed by means SD. The level of significance
was chosen to be P<0.05. Statistical analyses were performed with
PC SPSS 13.0. Normal distribution of the variables was checked by
the Kolmogorov–Smirnov test; Student’st-test was used to test
whether mean differences of parameters between two groups were
significant and in the case of non-normality the Mann–Whitney test
was used. Differences in the same participants before and after 12
weeks of intervention were evaluated by paired t-test but in the case
of non-normality, the Wilcoxon test was used. Diet records were
analyzed by using Food Processor II software. For qualitative vari-
ables (e.g. sex, physical activity, education, occupation, income,
etc.), a χ
2
-test was used.
Results
Forty-five of 50 randomly assigned T2DM patients com-
pleted the study. Five patients could not adhere to the
group meeting schedule and were not included in ana-
lyses. Participant’s baseline characteristics are shown in
Table 1. There were no significant differences in age,
weight, BMI, WC, physical activity and dietary intakes
between two groups at the beginning of study and also
no significant difference was seen between two groups at
the end of study (Table 1).
Duration of diabetes were 5.5 3.42 and 5.1 3.42
years, in the ginger and control groups, respectively, and
no significant difference was observed between the two
groups (p¼0.62).
Patients in the ginger and control groups were given
oral medications such as metformin, glibenclamide or
both to control blood sugar. The type of these medica-
tions had no significant difference between the two
groups (p¼0.4).
After 3 months, in ginger group, compared to placebo
group, change of serum glucose (–19.41 18.83 vs 1.63
4.28 mg/dL, respectively), HbA
1c
percentage (–0.77
0.88 vs 0.02 0.16 %, respectively), insulin (–1.46 1.7
vs 0.09 0.34 μIU/mL, respectively), insulin resistance
(–16.38 19.2 vs 0.68 2.7, respectively), hs-CRP (–2.78
4.07 vs 0.2 0.77 mg/L, respectively), PON-1 (22.04
24.53 vs 1.71 2.72 U/L, respectively), TAC (0.78 0.71 vs
–0.04 0.29 µU/mL, respectively) and MDA (–0.85
1.08 vs 0.06 0.08 µmol/L, respectively) were signifi-
cantly different (p<0.001, for all variables) (Table 2).
In the ginger group at the end of study, there was
significant difference in serum glucose (p<0.05), HbA
1c
parentage (p¼0.0001), insulin (p¼0.001), insulin
resistance (p¼0.001), MDA (p¼0.0001), TAC (p¼
0.0001), hs-CRP (p¼0.0001) and PON-1 (p¼0.0001)
compared to beginning values of study (Table 2).
Discussion
In this study, 3 g/day of ginger supplementation in T2DM
patients for 3 months significantly decreased glucose, insu-
lin, insulin resistance, hs-CRP and MDA but significantly
increased PON-1 and TAC compared to the control group.
Limited clinical studies have been conducted to
investigate the potential beneficial effects of ginger in
T2DM patients. Moreover, the results of the researches
conducted on human and animals have turned out to
Table 1: Baseline characteristics of participants who received ginger (3 g/d) or placebo.
Characteristics Ginger group, n¼22 Placebo group, n¼23 p-Value
Week 0 Week 12 Week 0 Week 12
Age (y) 45.2 7.64 –47.1 8.31 –0.33
Body weight (kg) 81.2 13.25 80.02 13.2 78.5 14.1 78.2 13.4 0.42
BMI (kg/m
2
) 29.5 2.8 29.6 2.1 29.2 3.1 29.6 2.8 0.96
Waist circumference (cm) 98.1 9.1 97.9 7.9 97.5 8.1 96.9 10.1 0.99
Physical activity [n (%)] 0.6
Light 10 (45.5) 11 (50) 8 (43.4) 9 (47.3)
Moderate 5 (22.7) 7 (31.8) 7 (34.7) 6 (31.5)
Vigorous 7 (31.8) 4 (18.1) 4 (21.7) 4 (21.1)
Energy intake (kcal/d) 1,498 556 1,525 554 1,609 527 1,610 539 0.49
Carbohydrate intake (g/d) 183.9 79 179.8 68 200.9 80 204.1 70 0.48
Protein intake (g/d) 57.3 26 58.4 29 60.5 22.8 62 32 0.69
Fat intake (g/d) 62 27 65.7 26 64.5 23 62.5 26 0.74
Shidfar et al.: Ginger on glycemic markers 3
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be contradictory. The significant decrease of serum glu-
cose, insulin and insulin resistance in our study was
consistent with Nammi et al., Goyal and Kadnur,
Bhandari et al., Shirdel et al. and Zhang et al. [21–25].
However, these were animal studies and ethanolic or
methanolic or hydroalcoholic extracts of ginger were
used. These animal studies reported that the effects of
extracts of ginger were exactly equal to the glibenclamide
in decreasing serum glucose [24].
One of the possible effects of ginger hydroalcoholic
extract is inhibition of the hepatic glycogen phosphorylase
enzyme to prevent glycogen breakdown in liver and also
inhibition of hepatic glucose phosphatase enzyme. On the
other hand, it increases the activity of the enzymes
involved in glycogen synthesis [25].
Similarly, Mozaffari-Khosravi et al. [26] and Arablou
et al. [27] in a double-blind clinical trial reported decrease
of insulin resistance and serum glucose. However, they
used 3 g ginger for 8 weeks and 1,600 mg for 12 weeks.
This action of ginger was attributed to facilitation of
insulin-dependent glucose uptake by increasing translo-
cation of glucose transporter GLUT4 to the muscle cell
plasma membrane surface, together with small increase
in total GLUT4 protein expression [28]. It was also
reported that ginger promoted glucose uptake in insu-
lin-responsive 3T3-L1 adipocyte [29]. The finding of Isa
et al. strongly lends support to the result of our present
study by suggesting that the glucose-regulating and insu-
lin-sensitizing effects of the active component(s) of ginger
could be at least in part attributed to peroxisome prolif-
erator-activated receptor-γ(PPAR-γ) agonistic activity
and/or upregulation of adiponectin [30].
It has been reported in patients with coronary artery
disease that 4 g of ginger powder for 3 months neither
affected the level of blood glucose nor lipid [31]. Such
discrepancy of results may be attributed to the variation
in chemical composition of the administered ginger
extracts, the preparation method, product origin, dura-
tion of storage or disparity in patient’s response [32].
Low-grade inflammation, as a common feature in
T2DM, plays a major role in pathogenesis of its secondary
complications such as atherothrombosis. The decrease of
MDA and hs-CRP (as lipid peroxidation and inflammatory
biomarkers, respectively) and increase of antioxidant
capacity in our study were consistent with the studies of
Shanmugam et al., Mahluji et al. and Lebda et al. [33–35],
who reported decreased activities of superoxide dismu-
tase, catalase, glutathione peroxidase and glutathione
reductase in hepatic and renal tissues, which resulted in
an increment of glutathione level and a decrease of MDA
level. Therefore, the production of ROS was reduced and
the resultant oxidative damage to the liver and kidneys
was attenuated [33–35].
Ginger bears anti-inflammatory effect that can pre-
vent arachidonic acid metabolism following inhibition of
cyclooxygenase and lipooxygenase pathway, which leads
to reduction of prostaglandin synthesis, and also, it sup-
presses leukotriene biosynthesis by inhibition of 5-lipoox-
ygenase [34]. So, intake of ginger in our study was
associated with decreased oxidative stress and lipid per-
oxidation. Contrary to the result of our study, Abdul
Hanif et al. reported no effect of ginger on oxidative
stress and MDA, but it was an in vitro study [36].
Significant increase in serum PON-1 activity in the
ginger group compared with the control group could be a
beneficial effect on reduction of cardiovascular disease
(CVD) complications in T2DM patients. Connelly et al.
and Shidfar et al. reported that increased serum PON-1 in
T2DM could be useful and it was inversely associated with
glucose concentration, which was concordant with the
Table 2: Serum biochemical variables in the participant groups who received ginger supplements (3 g/day) or placebo
during the intervention.
Characteristics Ginger group, n¼22 Placebo group, n¼23 p-Value*
Week 0 Week 12 Change Week 0 Week 12 Change
Glucose (mg/dL) 161.5 58
a
142.09 47.9 –19.4 18.8 155.47 81.83 157.1 81.83 1.6 4.2 0.001
HbA
1c
(%) 7.37 1.86
b
6.6 1.26 −0.77 0.88 7.39 1.31 7.3 1.32 0.02 0.16 0.001
Insulin (μIU/mL) 5.97 2.76
c
4.51 2.01 −1.4 1.7 6.43 3.98 6.52 4.14 0.09 0.34 0.001
HOMA-IR 46.4 37.44
d
29.66 20.77 −16.3 19.2 42.08 31.65 42.76 32.49 0.68 2.7 0.001
hs-CRP (mg/L) 14.98 10.02
e
12.19 8.56 −2.78 4.07 26.38 36.71 26.58 36.38 0.2 0.77 0.001
Paraoxonase (U/L) 79 37.32
f
101.04 34.48 22.04 24.53 68.21 41.45 66.5 41.41 −1.71 2.72 0.006
TAC (μmol/L) 2.11 0.61
g
2.89 0.89 0.78 0.71 2.34 0.69 2.3 0.6 −0.04 0.29 0.015
MDA (μmol/L) 3.75 1.38
h
2.9 0.98 −0.85 1.08 2.89 0.66 2.95 0.62 0.06 0.08 0.001
*Student’st-test between the two groups.
a
Wilcoxon test, p<0.05.
b
Wilcoxon test, p¼0.0001.
c
Paired t-test, p¼0.001.
d
Paired t-test, p¼0.001.
e
Paired t-test, p¼0.0001.
f
Paired t-test, p¼0.0001.
g
Paired t-teat, p¼0.0001.
h
Wilcoxon test, p¼0.0001.
4Shidfar et al.: Ginger on glycemic markers
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results of our study [37, 38]. Furthermore, increased serum
PON-1 activity in our study could reduce the inflammation
and oxidative stress associated with atherosclerosis, inhibit
the oxidation of low-density lipoprotein (LDL) (and cell
membrane), reducing macrophage cholesterol efflux bio-
synthesis, negatively associated with high-density lipopro-
tein (HDL) peroxide and positively associated with HDL
antioxidant ability [37–39]. All these appear to be impor-
tant in the vascular inflammatory response that prevent
atherogenesis and also show a dose-dependent decrease in
cholesterol biosynthesis in macrophages [37–39]. These
may be beneficial effects in reducing the risk of CVD in
T2DM patients in ginger group.
Conclusions
Supplementation of ginger 3 g/day for 12 weeks in T2DM
patients beneficially affects glucose homeostasis and
antioxidant capacity. The negligible side effect of ginger
makes it a viable approach, either food based or supple-
mental, in the treatment of diabetic complications.
Further studies are being undertaken to fully explain
the mechanism(s) of the glucose and lipid metabolism
regulating activities of ginger.
Author contributions: All the authors have accepted
responsibility for the entire content of this submitted
manuscript and approved submission.
Research funding: None declared.
Employment or leadership: None declared.
Honorarium: None declared.
Competing interests: The funding organization(s) played
no role in the study design; in the collection, analysis,
and interpretation of data; in the writing of the report; or
in the decision to submit the report for publication.
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6Shidfar et al.: Ginger on glycemic markers
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