- Noni (Morinda citrifolia) is a medicinal plant from Pacific regions
- Evidence on the effects in cancer patients is lacking
- Few adverse effects have been reported
Noni (Morinda citrifolia), also known as Ba Ji Tian, Cheese Fruit and Indian Mulberry, is a Polynesian plant that has traditionally been used in medicinal remedies. Noni fruit juice has been the main focus of attention in recent years.
A wide range of indications have been proposed for Noni juice and it has been marketed as a general cure-all for conditions including cancer, depression, diabetes, drug addiction, heart disease and obesity. It is also claimed that Noni has general benefits on health.
In vitro and animal studies have shown potential antioxidant action, immune function stimulation, and anti-tumour activity but there have been few trials in humans for any condition and no randomised controlled trials in cancer patients. Preliminary studies have suggested protective effects in heavy smokers.
Few adverse effects have been reported although assessment of safety has been limited to date. Several cases of liver toxicity have been reported but these have not been documented to be caused by Noni juice. The potassium content in some noni juice products may cause problems in people with renal insufficiency, on low potassium diets or taking drugs likely to increase potassium levels.
While apparently widely used, evidence on the proposed benefits in cancer patients is lacking and assessment of safety is limited.
Assessed as up to date in January 2019 by Barbara Wider.
Assessed as up to date in March 2017 by Barbara Wider.
Assessed as up to date in April 2016 by Barbara Wider.
Assessed as up to date in January 2015 by Barbara Wider.
Assessed as up to date in August 2013 by Barbara Wider.
Summary first published in September 2012, authored by Karen Pilkington.
Karen Pilkington, CAM-Cancer Consortium. Noni [online document], http://cam-cancer.org/en/noni. March 15, 2017.
Noni is a small evergreen tree or shrub that grows in Pacific regions including Polynesia, Southeast Asia, India and Australia1,2. The fruits, leaves, flowers, stems, bark, and roots have all been used in traditional remedies2. Currently, most interest is in the yellow-green fruit, which produce a pungent odour while ripening (hence ‘Cheese Fruit’) and are used to produce juice.
Scientific and other names
Morinda citrifolia L. (a member of Rubiaceae, the coffee family)3.
Morinda bracteata Roxb., Ba Ji Tian, canary wood, Cheese Fruit, Hai Ba Ji, Hawaiian Noni, hog apple, Indian Mulberry, Noni juice, Tahitian Noni1,2.
A wide range of components have been identified in the Noni plant. These include alkaloids, anthraquinones, beta-sitosterol, carotene, flavonol glycosides including rutin, iridoids, linoleic acid, ursolic acid and vitamins A and C4. Two fatty acids, caproic (hexanoic) and caprylic (octanoic) acid may be responsible for the pungent odour of the fruit. New anthraquinones and saccharide fatty acid esters have also been isolated5. The unfermented juice also contains glucose, fructose, proteins, lipids, calcium, magnesium, potassium and sodium6,7. Two novel constituents, xeronine and proxeronine, were apparently identified by a researcher in Hawaii but have not been subsequently characterised or reported8. Recently five new saccharide fatty acid esters, named nonioside P, nonioside Q, nonioside R, nonioside S, and nonioside T, and one new succinic acid ester were isolated, along with known compounds, from an extract of the fruit. Some of these showed inhibitory activities against melanogenesis in B16 melanoma cells induced with α-melanocyte-stimulating hormone (α-MSH)9.
Application and dosage
Noni is administered both orally and topically. The fruit and juice are taken orally for a range of health reasons. The fruit and leaves are used in preparations for topical use in conditions such as arthritis, headaches, burns, sores and wounds10. Noni seed oil has also been promoted as a moisturiser for use in skin conditions and joint pain1. Various dose regimens for the fruit juice are recommended by suppliers but no typical dosage has been established2. One ounce (approximately 30ml) every 12 hours has been suggested for ‘overall health maintenance’4. An application to the European Scientific Committee on Food for approval of ‘Tahitian Noni juice’ described the product as a mixture of 89% Noni fruit, 11% common grape and blueberry juice concentrates and natural flavours11. The suggested consumption was 30 ml/day. Commercially manufactured capsules containing 500mg ripe Noni fruit extract have been used in trials in patients with advanced cancer based on a maximum recommended dose of 4 capsules (2 grams) daily12.
Noni has been used by Polynesians for at least 2000 years and is considered one of the more important traditional Polynesian medicinal plants and is still produced locally8. Preparations of Noni were applied topically, the roots were also to produce a clothes dye while the fruit was eaten as a food4. The whole plant (roots, stems, bark, leaves, flowers and fruits) has been used in the preparation of medicinal remedies of which around 40 have been recorded8. These were used to treat a range of common diseases and to maintain overall health4.
Various parts of the plant are still used to make remedies but patterns of use have changed8. The main focus is on the fruit juice which is now manufactured on a large-scale and can be purchased from health food shops, other stores or via numerous websites.
Claims of efficacy
Manufacturers of Noni juice have claimed a wide range of therapeutic effects4. Noni juice supposedly ‘helps protect cells from oxidative damage, contributes to the maintenance of normal bones, to a normal energy-yielding metabolism and to the normal formation of connective tissue'13. There are also claims on various websites of beneficial effects in cancer8. Traditional use is based on claims of beneficial effects in wound healing and treating inflammation and infection8.
A wide range of potential indications have been proposed for Noni juice and it has been marketed as a general cure-all for various chronic conditions14. Among the indications for which Noni is promoted are cancer, depression, diabetes, drug addiction, heart disease and obesity. An application for approval of a Noni juice product in Europe did not specify any indications other than general health benefits similar to those of other fruit juices11.
Mechanisms of action
Studies of the pharmacology of Noni and its constituents have focused on three main areas: cancer, inflammation and metabolic diseases although research is preliminary6. Two constituents, a fatty acid glycoside and an iridoid, were reported to inhibit neoplastic cell transformation in mouse cells6. A polysaccharide fraction obtained from the fruit juice, inhibited tumour activity and stimulated cytokine release15. Prevention of the initiation of carcinogenesis, antimutagenic activity, and inhibition of angiogenesis with capillary vessel degeneration and apoptosis have all been reported6. Inhibition of the growth of several cancer cell types has also been recorded in vitro using high concentrations of the extract6. An anthraquinone isolated from Noni appears to be a potent inducer of an enzyme, quinone reductase, known to be protective against cancer due to its involvement in metabolism and elimination of carcinogens16.
Prevalence of use
Traditionally used in Polynesia and South East Asia, Noni has been marketed in Australia, Canada, Hong Kong, Japan, Mexico, Norway and the USA11. Substantial increases in sales in the USA have been reported but it is not possible to substantiate these claims6,14. Use has also increased in Western Europe11. Women in the USA have reported utilizing noni for the prevention and treatment of breast cancer and as a secondary course of treatment following conventional chemotherapy17.
Food or drink products derived from Noni require authorisation in Europe. Several Noni products have been approved as novel food products in Europe. These include Noni juice in various forms: fresh, puree, concentrated, frozen, dried and mixed with other juices18-20. The dried and roasted leaves have also been approved as a new novel food ingredient for the preparation of infusions21.
Cost and expenditures
The cost of Noni products varies, an average cost for Noni juice (based on online prices April 2017) is approximately EUR 45-47, US$ 40, or GBP 37, per litre. A week’s supply based on 60ml per day (as recommended by the manufacturers) would cost around EUR 20, US$17, GBP 16.13
Systematic reviews, meta-analyses
No systematic reviews of Noni have been published.
Several narrative reviews have been published. Of those published recently, one concluded that some research suggested ‘broad potential health benefits’ and promising results had been reported for several constituents but increased use of Noni was probably due to effective marketing14. A second review of the literature reached similar conclusions, highlighting the fact that knowledge about the chemistry of Noni had increased but there was still a lack of clinical research6.
No randomised controlled trials have been conducted to assess the effects of Noni in cancer patients.
Two trials assessed the effects of Noni on levels of substances thought to increase the risk of developing cancer. A double-blind, placebo-controlled trial was conducted to assess antioxidant activity of Noni in smokers22. A total of 285 heavy smokers were randomly allocated to placebo, 29.5ml (1 fluid ounce) Noni juice or 118ml (4 ounces) Noni juice per day for 30 days. Levels of plasma superoxide anion radicals and lipid hydroperoxide were reported to have decreased in the Noni groups. A second related study assessed levels of aromatic DNA adducts, a surrogate biomarker for risk of lung cancer, again in smokers who drank Noni juice for a month23. Of 283 smokers recruited for the trial, 203 completed the study. The results indicated that Noni juice daily may reduce cancer risk in heavy cigarette smokers by blocking carcinogen-DNA binding or removing DNA adducts from genomic DNA. Both were preliminary studies. Over 25% of participants did not complete the trial although all patients were included in the analysis. Noni juice and the placebo seemed well matched but contained a mixture of grape and blueberry juice which could have contributed to some of the beneficial effects reported.
A phase 1 dose finding trial was carried out in 29 cancer patients12. Patients with advanced cancer were treated with capsules containing 500mg of ripe Noni fruit extract. A dose of 2g was used initially then doses were increased by 2g to a maximum of 10g (20 capsules) daily. A minimum of 5 patients were observed at each dose level for 28 days. Quality of life, symptom status, response, toxicity and pharmacokinetics were measured. Effects on several quality of life measures were reported although these did not reach statistical significance, except for decrease in pain. No adverse effects or tumour response attributable to Noni were observed.
Pre-clinical studies have shown a range of actions potentially beneficial in cancer. Several of these are described under Mechanism of action. Preventative effects based on anti-carcinogenic activity via inhibition of TPA5, tumour cell-selective anti-proliferative effects,24 anti-angiogenic activity25, and stimulation of the immune system26 have all been reported. A recent report describes that Noni Juice was useful in suppressing tumour growth in a mice model for HER2/neu breast cancer in amounts equivalent to human dosages below 90 ml/day27. Other actions not directly related to cancer have also been reported.
Limited assessment of safety has been carried out but there have been few adverse effects reported after using Noni and the fruit has been consumed as food for many years1,2,11. In 2002, a review of safety of one Noni juice product by the European Scientific Committee on Food concluded that there were no indications of adverse effects from animal studies on subacute and subchronic toxicity, genotoxicity and allergenicity11. A double-blind safety study of Noni fruit juice sponsored by a manufacturer carried out in 96 healthy volunteers did not reveal any significant adverse effects with up to 750ml noni juice daily for 28 days28.
Between 2005 and 2011, 7 cases of hepatotoxicity in previously healthy people were reported, 2 involving a tea or other herbal product, 4 involving a Noni juice and 1 involving an energy drink2. It is unclear whether Noni juice was the cause of liver toxicity. Liver function tests improved once the Noni product was stopped but other ingredients or treatments may have been responsible. The possibility of product contamination during production was also raised as the root and bark contain anthraquinones10. Subsequent analyses did not detect anthraquinones in the juice and several studies did not reveal toxicity28-30. A review of the first 4 cases by the European Food Safety Authority (EFSA) in 2006 concluded that there was ‘no convincing evidence for a causal relationship between the acute hepatitis observed in the case studies reported and the consumption of noni juice’19. In 2008 an EFSA Panel concluded that, on the basis of data provided, the use of dried Noni leaves for preparation of infusions was safe21.
Noni contains relatively high levels of potassium (similar to levels in orange and tomato juice) and a case of hyperkalaemia was reported in a patient with chronic renal insufficiency7. Mineral content of commercial noni juices has been shown to vary widely31.
It is recommended that Noni is avoided in people with liver dysfunction1,2. It is also suggested people with hyperkalaemia, kidney dysfunction, on low potassium diets, taking potassium-sparing diuretics or other drugs that increase potassium levels such as ACE inhibitors avoid using it1,2. Toxicity tests in animals did not find evidence of toxicity from Noni juice to developing embryos and foetuses32. However, large amounts of the fruit have been reported to cause an abortion and historically Noni root bark has been used as an abortifacient indicating it may be unsafe in pregnancy.
One case has been reported of resistance to the anticoagulant, coumadin, due to the vitamin K content of the particular Noni product being used by the patient33.
A single-dose, randomized, open-label and 2-period crossover study in 20 healthy volunteers showed that the aqueous fruit extract influenced the motor activity of the gastrointestinal tract. The fruit extract enhanced the rate and the extent of ranitidine absorption, partly due the ability of its active component scopoletin to stimulate the 5-HT4 receptor34.
Other problems or complications
Commercial preparations of Noni occasionally contain Morinda officinalis as well as Morinda citrifolia which have been reported to stimulate the kidneys and can exacerbate urinary difficulties.
- National Center for Complementary and Integrative Health (NCCIH). Herbs at a glance: Noni. (updated November 2016). Available online. Accessed 15th March 2017.
- Natural Medicines Comprehensive Database. Noni monograph. Available online. Accessed 15th March 2017.
- Kew Royal Botanic Gardens. Scientific Research and Data. Rubiaceae. Available at: http://www.kew.org/science-research-data/directory/teams/rubiaceae/index.htm. Accessed April 2012.
- Wang MY, West BJ, Jensen CJ, Nowicki D, Su C, Palu AK, Anderson G. Morinda citrifolia (Noni): a literature review and recent advances in Noni research. Acta Pharmacol Sin. 2002 Dec;23(12):1127-41.
- Akihisa T, Matsumoto K, Tokuda H, Yasukawa K, Seino K, Nakamoto K et al. Anti-inflammatory and potential cancer chemopreventive constituents of the fruits of Morinda citrifolia (Noni). J Nat Prod 2007; 70(5):754-757.
- Potterat O, Hamburger M. Morinda citrifolia (Noni) fruit--phytochemistry, pharmacology, safety. Planta Med. 2007 Mar;73(3):191-9. Epub 2007 Feb 7
- Mueller BA, Scott MK, Sowinski KM, Prag KA. Noni juice (Morinda citrifolia): hidden potential for hyperkalemia? Am J Kidney Dis. 2000 Feb;35(2):310-2.
- McClatchey W. From Polynesian healers to health food stores: changing perspectives of Morinda citrifolia (Rubiaceae). Integr Cancer Ther. 2002 Jun;1(2):110-20; discussion 120.
- Akihisa T, Tochizawa S, Takahashi N, Yamamoto A, Zhang J, Kikuchi T, Fukatsu M, Tokuda H, Suzuki N. Melanogenesis-Inhibitory Saccharide Fatty Acid Esters and Other Constituents of the Fruits of Morinda citrifolia (Noni). Chem Biodivers. 2012 Jun;9(6):1172-87.
- MD Anderson Cancer Center. Complementary/Alternative Medicine Education Resources, Therapies: Noni Juice. Available at: http://www.mdanderson.org/education-and-research/resources-for-professionals/clinical-tools-and-resources/cimer/therapies/herbal-plant-biologic-therapies/Noni.html. Accessed April 2012.
- European Commission Scientific Committee on Food. Opinion of the Scientific Committee on Food on Tahitian Noni® juice. 2002. Available online. Accessed April 2012.
- Issell BF, Gotay CC, Pagano I, Franke AA. Using Quality of Life Measures in a Phase I Clinical Trial of Noni in Patients With Advanced Cancer to Select a Phase II Dose. J Diet Suppl. 2009;6(4):347-59.
- Tahitian Noni International. Noni is the difference. Available at: http://research.tni.com/united_kingdom/uk_english/research/difference.html. Accessed April 2012.
- Pawlus AD, Kinghorn DA. Review of the ethnobotany, chemistry, biological activity and safety of the botanical dietary supplement Morinda citrifolia (noni). J Pharm Pharmacol. 2007 Dec;59(12):1587-609.
- Hirazumi A, Furusawa E. An immunomodulatory polysaccharide-rich substance from the fruit juice of Morinda citrifolia (noni) with antitumour activity.Phytother Res. 1999 Aug;13(5):380-7.
- Pawlus AD, Su BN, Keller WJ, Kinghorn AD. An anthraquinone with potent quinone reductase-inducing activity and other constituents of the fruits of Morinda citrifolia (noni). J Nat Prod. 2005 Dec;68(12):1720-2.
- Boon HS, Olatunde F, Zick SM, Trends in complementary/alternative medicine use by breast cancer survivors: comparing survey data from 1998 and 2005. BMC Women’s Health 2007, 7, article 4.
- National Archives Foods Standards Agency. Noni Product Accepted. 2006. Available at: http://food.gov.uk/news/newsarchive/2006/jan/nonihnllc. Accessed 15th March 2017.
- European Food Safety Authority. Opinion on a request from the Commission related to the safety of noni juice (juice of the fruits of Morinda citrifolia). The EFSA Journal 2006; 376: 1-12.
- European Food Safety Authority. Opinion on the safety of Tahitian Noni® ‘Morinda citrifolia (noni) fruit puree and concentrate’ as a novel food ingredient. The EFSA Journal 2009; 998: 1-16.
- European Food Safety Authority. Safety of ‘leaves from Morinda citrifolia L.’: Scientific Opinion of the Panel on Dietetic Products, Nutrition and Allergies. The EFSA Journal 2008; 769: 1-17.
- Wang MY, Peng L, Lutfiyya MN, Henley E, Weidenbacher-Hoper V, Anderson G. Morinda citrifolia (noni) reduces cancer risk in current smokers by decreasing aromatic DNA adducts. Nutr Cancer. 2009;61(5):634-9.
- Wang MY, Lutfiyya MN, Weidenbacher-Hoper V, Anderson G, Su CX, West BJ. Antioxidant activity of noni juice in heavy smokers. Chem Cent J. 2009 Oct 6;3:13.
- Arpornsuwan T, Punjanon T. Tumor cell-selective antiproliferative effect of the extract from Morinda citrifolia fruits. Phytother Res 2006; 20(6):515-517.
- Beh HK, Seow LJ, Asmawi MZ, bdul Majid AM, Murugaiyah V, Ismail N et al. Anti-angiogenic activity of Morinda citrifolia extracts and its chemical constituents. Nat Prod Res 2012.
- Brown AC. Anticancer Activity of Morinda citrifolia (Noni) Fruit: A Review. Phytother Res 2012; 26(10):1427-40. .
- Clafshenkel P, King TL, Kotlarczyk MB,Cline JM, Foster WG, Davis VL,Witt-Enderby P. Morinda citrifolia (Noni) Juice Augments Mammary Gland Differentiation and Reduces Mammary Tumor Growth in Mice Expressing the Unactivated c-erb B2 Transgene. Evidence-Based Complementary and Alternative Medicine 2012; doi: 10.1155/2012/487423.
- West BJ, White LD, Jensen CJ, Palu AK. A double-blind clinical safety study of Noni fruit juice. Pac Health Dialog. 2009 Nov;15(2):21-32.
- West BJ, Jensen CJ, Westendorf J. Noni juice is not hepatotoxic. World J Gastroenterol. 2006 Jun 14;12(22):3616-9.
- West BJ, Su CX, Jensen CJ. Hepatotoxicity and subchronic toxicity tests of Morinda citrifolia (noni) fruit. J Toxicol Sci. 2009 Oct;34(5):581-5.
- West BJ, Tolson CB, Vest RG, Jensen S, Lundell TG. Mineral variability among 177 commercial noni juices. Int J Food Sci Nutr. 2006 Nov-Dec; 57(7-8):556-8.
- Wang MY, Hurn J, Peng L, Nowicki D, Anderson G. A multigeneration reproductive and developmental safety evaluation of authentic Morinda citrifolia (noni) juice. J Toxicol Sci. 2011 Jan;36(1):81-5.
- Carr ME, Klotz J, Bergeron M. Coumadin resistance and the vitamin supplement "Noni". Am J Hematol. 2004 Sep;77(1):103.
- Nima S, Kasiwong S, Ridtitid W, Thaenmanee N, Mahattanadul S. Gastrokinetic activity of Morinda citrifolia aqueous fruit extract and its possible mechanism of action in human and rat models. Journal of Ethnopharmacology 2012; 142: 354–361.