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Show Notes

This is a 1hr + 23 minutes talk and conversation with Thomas Seyfried, Derek Lee and Tomás Duraj ( Juanita Mathews from my group ( about their work on the metabolic and mitochondrial aspects of cancer.

CHAPTERS:

(00:00) Metabolic nature of cancer

(08:52) Mitochondrial theory of cancer

(34:00) Metabolic therapy in practice

(40:39) Mitochondria and morphogenetic fields

(45:21) Ion channels and metabolism

(53:01) Bioelectric control and regeneration

(01:09:03) Mouse versus human models

(01:15:19) Mitochondria, aging, and disease

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Transcript

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[00:00] Thomas Seyfried: We have a lot of information now to show that cancer is predominantly a mitochondrial metabolic disease. We have looked at the number, structure, and function in the mitochondria of all major cancers, and you find abnormalities in these cristae, the number of mitochondria, the function of the mitochondria. It seems to be a common pathophysiological problem in all cancers. They transition from oxidative energy through oxidative phosphorylation to energy through what we have now defined as substrate-level phosphorylation, a very old, ancient way of getting energy. Before oxygen came into the atmosphere two and a half billion years ago, all the cells were fermenters. It was the development of the archaeobacteria and the original fusion between a primitive eukaryotic cell and a type of bacteria that became the mitochondria, which then led to metazoans and all of the development that we know about. Every cancer we look at, all the major ones, are blowing out large amounts of lactic acid and succinic acid. Warburg originally knew that cancer was a disorder of energy metabolism. First, he didn't know about the fermentation of amino acids inside the matrix of the mitochondria and that the TCA cycle itself can be fermented. Second, he made the mistake of assuming that oxygen consumption was an accurate biomarker for ATP synthesis through oxidative phosphorylation. Derek and others clearly showed that the consumption of oxygen in cancer cells is not directly linked to significant ATP production. We found, with our work with Shinopoulos Christos from Semmelweis University in Budapest, that he had long been suggesting there is a substrate-level phosphorylation mechanism, the succinyl-CoA ligase reaction, in the matrix of the mitochondria. We know from our work in cancer that succinic acid, succinate, is released by tumor cells. Succinate should never be released from the TCA cycle. The reason it's being released is that it is the second major waste product of fermentation. It's through the glutaminolysis pathway. The cancer cells are essentially transitioning away from OxPhos and moving toward a fermentation mechanism, substrate-level phosphorylation: one existing in the cytoplasm — the glycolytic (Embden–Meyerhof–Parnas) pathway — and the other in the matrix of the mitochondria itself, which is a fermentation pathway. In his PhD work, Derek showed that if you grow cells in just glutamine, no glucose, even in hypoxia or in the presence of cyanide, you still produce ATP and succinic acid. That pathway is a second major pathway. We found that there is a powerful synergistic parallelism between the glycolytic pathway in the cytoplasm and the glutaminolysis pathway in the mitochondria. The two pathways feed off each other, leading to dysregulated growth. The control of the cell cycle, the checkpoints of the cell cycle, the behavior of cells with respect to one another, contact inhibition, and the behavior of cells in relation to their neighbors is all linked to the calcium currents that are controlled by the mitochondrial-associated membranes and the ER–mitochondrial connections. All of that controls whether a cell should remain quiescent or grow, and if it grows, it's regulated growth. If those calcium currents linking to the inner membrane of the mitochondria and the mitochondrial-associated membranes are abnormal in any way, the cell loses its growth control and no longer responds accurately to environmental cues. The checkpoints of the cell cycle, which are all controlled by calcium–calmodulin signaling, mean the mitochondria control the destiny of the cell. With this behavior, the cells lose growth control; the cadherins that normally would be involved in contact inhibition no longer work. In the morphogenetic field itself, there are mitochondrial waves that link the behavior of cells across these morphogenetic fields.

[04:24] Thomas Seyfried: All of this is related to how the energy and the integrity of the mitochondria work. As far as metastasis is concerned, we know that all metastatic cancers share characteristics with macrophages. Macrophages are genetically programmed to move in and out of tissues, live in the circulation. When we have a disordered growth in the microenvironment, you have inflammation and normal macrophages come in as wound healing cells. They fuse with cancerous stem cells forming these hybrid cells. They have abnormal energy metabolism, but they're genetically programmed to move in and out of the bloodstream. They are rogue macrophages. We know how to kill them because they're so dependent on glutamine and glucose. Our therapeutic strategy, which is ketogenic metabolic therapy, is a press-pulse where we press down glucose with diet and exercise, elevate ketones for the enhancement of mitochondrial function in normal non-neoplastic cells. Then we come in with drugs that will target the glutamine. There's no way these cells can grow without glucose and glutamine. We've interrogated the cells. Derek did beautiful work on going through all the amino acids and all the fuels that cells can possibly use. They're dependent heavily on glucose and glutamine. When you target that in people and mice with metastatic cancer, you slaughter these tumor cells. We know basically how cancer starts. We know what it's dependent on and we know pretty much how to manage it. Now we go into the clinic and start treating people with pancreatic, prostate, breast, and colon cancers. We're starting to see when you do it the right way, the way Thomas Durai and our groups have been divining, people living much longer with a higher quality of life. We never say cure. We only say management because we don't know how long a person will remain in a managed state. As a matter of fact, we have people whose tumors never go away. They persist for years but are indolent. We've transformed them from a very aggressive neoplasm into an indolent one where they can be periodically resected. We did that with a brain cancer patient who lived over ten years having periodic debulkings. We never targeted as glutamine, but we kept the tumor in an indolent state. We know we're seeing remarkable outcomes in the clinic based on our new understanding of how this all works. Of course, I've just summarized massive amounts of data and the experimental evidence is in our papers. Derek is here and Thomas Durai is here. Thomas is doing both the basic research and clinical work. Derek has defined the mitochondrial substrate-level phosphorylation as a major force in driving these tumor cells. So that gives you an overview of where we are and what we're doing with this cancer work.

[08:52] Michael Levin: You guys want to show any slides at all, or are we just talking from here?

[08:59] Thomas Seyfried: I could show you some slides on a screen share.

[09:05] Michael Levin: Yeah only only if you.

[09:06] Thomas Seyfried: I didn't want to give a formal presentation, but I certainly can show you some of the slides. We had some here yesterday, gave a big lecture on this, but I give it in a nutshell. Let's see here. Carol, Cindy Carroll. Let me go back here. I just got Margaret here. Okay. So can you see this? We have to do a slide up.

[09:40] Michael Levin: You can share just. Yeah, just share your screen.

[09:43] Thomas Seyfried: Share. Right here. Can you see that, Mike?

[09:52] Michael Levin: Yep.

Thomas Seyfried: So let me just go for it. Well, I always tell you how many people are dying. I don't know if that's really important for us. But I do go through all the scientific theories. What we're doing, we're changing the whole, what cancer actually is. Whenever you change the theory, like when you go from geocentrism to heliocentrism, you get massive paradigm changes in man's knowledge. We're going to do the same thing when it comes to cancer because we found that it's not a genetic disease. We use Louis Pasteur compared to Galen. We do the Darwin-Wallace theory of evolution as opposed to special creation. So when we look at the mitochondria in cancer, you see all the nice squiggly green. This is highlighting how these are a very dynamic organelle. They have fission and fusion, and they really regulate the entire physiology of the cell through their interactions, not only within the cell, but outside the cell. So the question that we're confronted with now is, is cancer a genetic disease or a mitochondrial metabolic disease? This paper by Hanahan and Weinberg, I think it's the most highly cited, 75,000 or something like this. They clearly state that cancer is a genetic disease, and it's a silent assumption that people just automatically assume. We go through and show that the reason why they say it is dogmatic ideology. It's no longer linked to rational collection of data. What we've done is we find a number of papers where you can't find any genetic mutations in certain cancers. That's a big problem. Now you can't prove anything by negative data. But Vogelstein and others said it's driver genes that are the really bad ones. That caused dysregulated cell growth. But now we're seeing expression of mutations in driver genes in normal tissues of people — P53 and a number of other mutations in cells that never become dysregulated in their growth. So you have cancers with no mutations, and driver genes in normal cells that don't form dysregulated growth. These are very serious challenges to a statement that cancer is a genetic disease. Some carcinogens like asbestos don't cause mutations, but they cause cancer. Aboriginal tribes rarely have cancer. Our closest relatives, chimps — no breast cancer ever recorded in a female chimp. The nuclear-mitochondrial transfer experiments are pretty much the strongest evidence against that. These experiments from Israel and Schaefer are from University of Vermont. He had an epithelial liver cell that he isolated from the liver of a rat, grew it in vitro, and it became dysmorphic in the way it looked. He took the cells and put them under the skin of the rat. Twelve out of thirteen rats developed a tumor. He didn't know if the original cell was tumorigenic, so he went back, grew up the original cells and put them under the skin of rats, and he didn't see any — 0 out of 11. He questioned whether the formation of neoplasia would be due to mutations in the nucleus or some cytoplasmic event like mitochondria. So he simply swapped nuclei: he took the nucleus of the tumor cell and put it into the cytoplasm of the normal non-neoplastic cell, and put the nucleus of the normal cell into the cytoplasm of the tumor cell. They got results directly opposite of those predicted if cancer were due to somatic mutations in the nucleus. The tumor nucleus in the cytoplasm of the normal cell produced only one out of 72 rats, whereas the normal nucleus in the tumor cytoplasm produced 66 out of 68. These are just the opposite of what you would have expected if cancer were due to somatic mutations. Also, McKinnell did a very similar kind of thing in vivo in frogs, the luck frog. He took cells from a lethal kidney cancer that kills the frogs. He takes the cells out of the frog, separates the cells individually, then isolates the nucleus of the tumor cell and implants it into an enucleated fertilized frog egg. He was able to clone tadpoles, all grown from the nucleus of the kidney tumor. When I spoke to him, he said I could cut the tails off these tadpoles, and they immediately grew a new tail in an exactly regulated way, directed by the nucleus of a tumor cell, which came from a cell that was dysregulated in its growth. I said to him, that's because it's not a genetic disease. He absolutely agreed. Before he passed away, he had long talks with him. Rudy Yanisch down here at MIT cloned mice from the nuclei of melanoma. He also showed these would abort; they wouldn't grow to completion, a whole mouse, because they had a number of chromosomal abnormalities and other mutations, but they never formed dysregulated cell growth.

[14:42] Thomas Seyfried: All of these are inconsistent with cancer as a metabolic disease or a genetic disease. I wrote this big paper summarizing all of this. This figure now appears throughout the literature. It's a summary of dozens and dozens of in vivo and in vitro experiments replicated over and over again. Normal cells beget normal cells. They have a clean genome and they have normal and functional mitochondria. Tumor cells beget tumor cells. They do have genetic abnormalities in the nucleus, and they have abnormalities in number, structure, and function of mitochondria. When you place the nucleus of the tumor cell into the cytoplasm of the normal cell, you get regulated growth, not dysregulated growth. When you place the normal nucleus into the cytoplasm of the tumor cell, you either get dead cells or cells with dysregulated growth. These are the exact opposite. When you look at all of these data together, what I've just gone through, you have to be cognitively impaired to think that cancer could be a gene-driven phenomenon. It's not a gene-driven phenomenon. I blasted the NIH, the National Cancer Institute. We wrote letters saying, "Who's running the ship down there?" Because they say cancer is a genetic disease. People are writing them and saying the evidence, the theory, the data no longer support this. They mindlessly go through the process saying it is, and not carefully evaluating the data that says it can. I view them as Greylag geese. They just do mindless things without any connection to reality. I go after them about that, because the evidence is not there. I told you Warburg had this pegged. He knew, but he didn't know all of the stuff that we now know. Derek cleared up a lot of this mess. So cells ferment glutamine. This is the second major fermentable fuel. All major cancers have Oxphos insufficiency linked to glucose and glutamine fermentation, which is the common pattern; we see it everywhere. If you look at the structure of the mitochondria in cancer—this is glioblastoma—you have the stripes, the cristae. We've never found cancer with normal content or composition of cardiolipin, the major lipid that controls the electron transport chain; it's abnormal in all major cancers. The structure is abnormal in all major cancers. What I find, Mike, is that you and I, most biologists, know that structure determines function. This is a foundational principle of biology. It seems like everybody except oncologists knows this. They all say mitochondria are normal in cancer. I don't know when they look at these pictures what they think. Here's breast cancer: nice stripes in the normal breast cells; abnormal mitochondrial fragmentation in the cancer. Colorectal cancers have ghost mitochondria. I went through and showed all the different cancers—abnormalities in number, structure, and function of mitochondria. All major cancers have accumulation of lipid droplets. Cancer cells can't burn lipids or the ketone body beta-hydroxybutyrate, because if they do they'll produce reactive oxygen species, blow up, and die. They store lipids in the cytoplasm as a protective mechanism against death from reactive oxygen species. We see that this is a signature of Oxphos insufficiency when you see lipid droplets. There are some beautiful studies that I can explain to show how they prove that. These lipid droplets are there because the mitochondria are defective, not the reverse. Most of the energy we get is from Oxphos, with CO2 and water as the predominant waste products. When you look at cancer, the waste products are lactic acid and succinic acid. These are the waste products of glucose and glutamine fermentation. We know that because we've measured it. Derek and others, a lot of us, measured it. We know that oxygen consumption in cancer cells—they consume oxygen, but it's not largely connected to ATP production. It is largely connected to ROS, reactive oxygen species. We showed this in iScience. You can transition away from Oxphos. This is a gradual process. It doesn't happen overnight. It's a slow progression away from Oxphos and a replacement using substrate-level phosphorylation. There's a direct relationship between how much energy comes from substrate-level phosphorylation and how malignant the tumor is.

[19:31] Thomas Seyfried: The malignancy to fermentation is so strong. It's an absolute, a very strong linkage. We have a threshold here because we think there's a point when it becomes irreversible, when you can no longer recover a sick cell. It's an arbitrary threshold; it might differ for different cancers, different types. This is what Derek put together. When you have glucose and glutamine coming through the two major glycolytic and glutaminolysis pathways, the byproducts of these pathways cross-connect, and thereby you can produce tremendous biomass, very rapid growth. As long as you have these two fuels working together in a syngeneic way, they'll survive a little bit and grow a little bit on glucose alone, and the same thing with glutamine alone. When you put the two together, they just explode with growth. Lactic acid and succinic acid are the metabolic waste products. They acidify the extracellular microenvironment, preventing radiation, chemo, and immunotherapies from working effectively because you've acidified. Succinic acid also paralyzes the immune system to prevent immune system killing. This summarizes 100 years of cancer research. We know what causes cancer: any number of environmental or even the rare inherited germline mutations. We showed in a big paper that they all damage OxPhos in one way or another. All of these—inflammations, oncogenes, carcinogens, intermittent hypoxia—produce reactive oxygen species causing the mutations in the nucleus: the chromosomal abnormalities, the point mutations; all that's downstream effects. The retrograde signal system that mitochondria signal to the nucleus turns on HIF-1 alpha and MYC, opening the floodgates to glucose and glutamine, so you can then drive dysregulated growth and energy metabolism. Son and Sheen and Sato talk about the default state. The default state of cells is proliferation. The default energy state is fermentation. That's linked to dysregulated cell growth, because it's the calcium currents controlled by the mitochondria that control the cell cycle. When the cell cycle is no longer under control, the cells fall back on their default state, which is proliferation driven by a fermentation metabolism. We went through and showed sustained angiogenesis. All of these things can be tracked back to mitochondrial dysfunction. For metastasis, it's a fusion hybridization between a macrophage, microglia, and a cancer stem cell forming a hybrid cell. This hybrid cell is driven by glucose and glutamine, and we now know how to kill and manage metastatic cancer. We've shown that in the mouse beautifully, and now we're seeing it in humans. This is Derek's big paper: amino acid–glucose fermentation maintains the constant ATP. He did a magnificent job. We worked with Christos Chianopoulos, world expert on mitochondrial substrate-level phosphorylation. Then we published a big paper on the Warburg hypothesis and the emergence of the mitochondrial metabolic theory. Tom Dorai is showing the difference between the Crabtree effect and the Warburg effect and the confusion that everybody has made when talking about Warburg effects. If we know what to do, how do we manage it? We need to lower blood sugar and elevate ketone bodies. You can do that with water-only fasting or calorie restriction. This is one of our early studies with Bernard Mukherjee. Just by cutting calories and cutting a high-carbohydrate diet by 40%, which is like water-only fasting in humans, you get a huge reduction in tumor growth. We know that when you lower blood sugar—each of these are mice under a different diet—ketone bodies go up as an evolutionarily conserved adaptation to food restriction, and when blood sugar goes down, tumor size goes down. We were the first to do this in the mouse. Now people are looking at prostate, colon, breast cancer. When people have high blood sugar, overall survival is generally much reduced; tumors grow much faster. When you put the patient or the animal into a state of nutritional ketosis, you reduce inflammation and angiogenesis, and you actually kill tumor cells. This is going to be the new tool Derek is working on. We're working on the glucose ketone index. You measure the molar, millimolar ratio of glucose to ketones, and you get a quantitative biomarker that's linked to managing and preventing cancer. We've defined 2.0 or below as a biomarker for killing and managing cancer. This will be the new standard of care for cancer once people come to realize that it's a mitochondrial metabolic problem. So we press down glucose with ketone supplements, stress management, exercise, and then bring in specific low-dose targeting of glucose and glutamine.

[24:20] Thomas Seyfried: Hyperbaric oxygen will kill tumor cells when the patient is in nutritional ketosis. Right now, our group and the group that we work with, we're perfecting dosage timing and scheduling. We bring people from sick to managed state and with improvements, we are hoping to get resolution on this. Proof of principle, a very aggressive glioblastoma. This is the VM3 mouse, natural spontaneous glioblastoma. We showed how we managed by targeting glutamine with this drug DON and putting the animals into a calorie restricted ketogenic diet. We could get tremendous increase in overall survival. And again, all the papers that Purna put out, all the information is in the main paper. The blue line is high carbohydrate by itself. The green is diet by itself. The red is drug DON by itself. When you put the drug and the diet together, you get long-term survival and we're seeing much more improved overall survival. How does it work in humans? Let's show you some evidence. This is a glioblastoma from a human. You can't cut these out in every person; it's a very deadly tumor. The purple cells are the tumor cells around blood vessels. They spread throughout the whole neocortex, so you can't really surgically resect glioblastoma. I always like to show these curves. These are the survival curves. We have a problem in science today. Half the stuff in the cancer field can't be reproduced when you go and try to reproduce it. But one thing can be reproduced and that's how fast glioblastoma kills you. These are the data from five different surgical institutions. You can see the standard of care; very few people survive beyond 40 months. I said, no improvement in a hundred years. Bailey and Cushing, 1926, 8 to 14 months with no therapy. Today, with all the stuff, we get 17 to 18 months, almost no improvement. I always show people why, because when you irradiate the brain of cancer patients, you break apart the glutamine-glutamate cycle, freeing up massive amounts of glutamine. You give steroids because the brain swells from the radiation. This makes hyperglycemia and you get high glutamine and these patients die from a combination of bad tumor together with the absurdity of trying to treat them, the crazy way they're doing it. We tried this on a guy from Egypt; this is one of our first clinical papers. This is the corn guy. He was 28 years old. He had glioblastoma. We put him on a metabolic therapy, a weight craniotomy. We pushed radiation off for three months. They wanted to push the radiation. After a couple of weeks, we said no. They eventually had to irradiate and give him temozolomide. He did well. At about 29 or 30, he had some headaches and he died. Alsaka did an autopsy on his brain to see what was going on, and they didn't find tumor cells. He died from radiation-induced brain liquefaction necrosis, so he was killed by the treatment rather than by the tumor. We always like to showcase reports of people who have suffered immensely, like this young girl, Brittany, diagnosed with GBM in 2014. Here's her husband. She received the standard of care. You can see her face is swollen. This is moon face from high-dose steroids, meaning that her blood sugar levels are going to be very high. She decides she doesn't want to live anymore. So she goes into People Magazine. Brittany, 29 years old, plans to end her own life. In three weeks, she goes to Oregon, dies with dignity with her family. As I always say, it's bad when your patients kill themselves rather than go through the treatment you're offering them.

[29:10] Thomas Seyfried: Now, this is our man here, Pablo. Thomas and I, we've all spoken to Pablo. We knew him really well. Nice guy. He came to me in 2014. He was one of these purest guys. He didn't want any radiation, no chemo, no steroids, nothing. They told him he'd be dead in nine to 12 months if he didn't do radiation and chemo. They told him his tumor was inoperable. He survived for 10 years. Here is his tumor when it was first detected; they said it was inoperable. He did metabolic therapy for a couple of years and you can see how big the tumor became, but it was indolent because these tumors will kill you in months — this was years. So we told him, yeah, take it out, so he went in and got it out, and he did really well. Then we measured; we have five years of measurements from his blood glucose and ketone. A massive amount of data on this one person. We recalculated his GKI. We take the ratio of blood sugar to blood ketones, and you can see we replotted his GKI. Look how low it was. Beautiful. So he was managed predominantly by metabolic therapy. Pablo died. Thomas and I had a long conversation with him a week before he passed away. He was laughing; we were having a good time. He was a very sharp guy. He was going for his fourth surgical procedure for a tumor which they originally told him was inoperable, and yet now he was going for it. He came out of the surgery really well, thumbs up. He had a big conversation with his wife that day, but he died that night from a cerebral hemorrhage as the result of the surgery. So he never died from the tumor. He lived 122 months. This is our most recent study out of Greece, where my colleagues did standard of care: temozolomide radiotherapy, and temozolomide radiotherapy with ketogenic metabolic therapy. You can see this tremendous difference. Four out of six of the guys on the ketogenic diet survived three years or longer, whereas only one out of 12 on the standard diet survived three years. This diet wasn't bad: salmon, olive oil, sardines, avocado, and some of these kinds of things. Some of these guys refused to give up their sugar. They said, "I'd rather die than give up my sugar," and they did die. That's their choice. But you can see how powerful metabolic therapy is in managing these cancers. There's another little guy — this is Danny Sheen from Marshfield, Massachusetts — diagnosed with pineoblastoma. Look at his face, all swollen from steroids. Here he is a week before he died. Surgery, radiation, all the same **** they give to these little kids. It's tragic. It's just so terrible what they're doing to these kids. I have a big paper that's going to come out.

[34:00] Unknown: It's Cell Reports Medicine.

[34:03] Thomas Seyfried: Cell Reports Medicine. This is provisionally accepted. We took the glioblastoma cells and put them into pediatric young mice 20 days old representing what basically what Danny Sheen's was. Here you see the control guys. We had restricted ketogenic diet, DON, and Bendazole. This is a parasite medication that targets glutamine. We target glutamine and glucose at the same time. These damn mice live so much longer. They have a high quality of life. It's just so much different. This is a person, Robin; she's still alive with us today. She was from Cleveland, Ohio. She had breast cancer that metastasized to her lungs and brain, and femur and her bones. They said there's nothing more we can do. All the standard of care stuff wasn't working. She got on a plane and went to our colleague. We have a big clinic over there in Istanbul, Turkey, where we're using metabolic therapy. He put her on metabolically supported chemo. You bring in a very low dose of chemo when you're in a state of nutritional ketosis. All of this disappeared. The infiltration and the metastasis were all killed. This was 2025, but we're talking with Slocum recently. She's still doing really well. We're going to do a big follow-up seven years out now. We got a lung cancer guy who's still alive. Adam Amadotus had lung cancer spread to his brain and his liver and everything. My colleague Thanasis—even Julio—said, "We're going to put him on a high-fat diet." One of the attending oncologists said, "Oh, you've got to be careful. He'll have elevated cholesterol, and that would be dead." The guy was going to be dead in three weeks, for Christ's sake. They're worried about elevated cholesterol. The guy's still alive. He's still alive today with a little bit of dyslipidemia, but he's alive. It works tremendously in prostate cancer. This is Thomas Doray's big paper here with all the folks that are now participating in managing cancer. We have a framework, a ketogenic metabolic framework for managing glioblastoma. We have a lot of nutritionists, dietitians, basic scientists, clinicians. They all want to get on board now and start working this out. I always like to show our dog. We put a metabolic therapy on a dog that was destined for death.

[37:20] Thomas Seyfried: He had a big mast cell tumor under his nose. Here's his face and nose. And the woman followed what we said. She cut the calories down, gave the dog raw chicken with the bones still in the meat, some fish oil, and some raw egg, and the tumor melted off the dog's face. The doctor said, you're going to have to have it cut off. The vet said the dog was going to get sick, get diarrhea and everything. They didn't do any of that. No surgery, no radiation, no chemo. What happens is when you take animals and people and you fast them, the body will attack the tumor and use the tumor as fuel for the rest of the body. It's called autolytic cannibalism. This dog died from old age; the cancer never came back. It lived 15 and a half years and died from cardiac failure from old age; the cancer never came back. So people say terminal cancer; it's not terminal. We know now we can keep people alive if you do it the right way. We published this big paper with Christos and myself showing that the somatic mutation theory is essentially like geocentrism deferents, equants, and epicycles trying to figure out. And now if we move the mitochondria to the center of the problem, you're going to have a much greater opportunity to manage cancer because it's a mitochondrial metabolic disorder. So I conclude by saying I went through this kind of fast. I give a course a whole semester on this to the students so they can really dive deep into the science supporting all this. Thomas and I are starting this new International Society of Metabolic Oncology, where clinicians and dietitians are all getting together. We're going to standardize treatment for cancer based on cancer being a mitochondrial metabolic disease. We have to work out some of the dosage, timing, and scheduling issues. We're trying to formulate the society right now. Right now, the funding that supports my research in this lab is philanthropy and private foundations. We don't get money from the NIH. We're getting a lot of people coming on board who want to see this happen. We have a lot of case reports under work. More and more people will be publishing this. We're not ready to do a large clinical trial because the only way we can do that is if we do it. Thomas, myself, and Derek are the ones that do this because we're the only ones that really understand all the nuances. We're trying to train these physicians to know what to do and how to do it. The dietitians need to know what kind of foods they should be using. Once we have that, then we're going to run bigger and bigger trials. That's the goal of this new society. We're in the plan to drop the death rate on this disease, no question about it. The biggest problem standing in the way is that the people at NIH think it's a genetic disease. So as long as they consider it a genetic disease, you're not going to be able to make the kind of advances that you need to make. That's the biggest block right now. The NIH is part of the problem rather than the solution. Until they can get on board and recognize what's going on, we're going to have to suffer 1,700 people a day dying from cancer, or 626,000 this year that's predicted. That's where we stand. I've given you an overview, but to do a deeper dive, you have to look at the science, the control experiments that we've done, and how we've run all these experiments. Tom is here. Derek did a lot of these experiments and got his PhD on this. They could answer any questions that you might have on that.

[40:39] Michael Levin: Thanks very much. That's remarkable. Absolutely remarkable. I have one basic question that probably won't need a bunch more on the metabolism side. You mentioned at the beginning this notion of how the mitochondria participate in the morphogenetic fields that are multicellular at scale. Could you talk about that a little bit? Because we're very interested in that. I want to understand what you're thinking about the mitochondria.

[41:05] Thomas Seyfried: We learned more about that from Picard, from Columbia University. He's one of the leaders on the communication of mitochondria, not only how they communicate or how they regulate the internal intra-physiological state of the cell, but I was surprised to see from his work how they actually communicated across different cells and also through the morphogenetic field itself, through regulatory bioenergetic signaling. I didn't know how extensive the knowledge is about how mitochondria communicate across fields. When Son and Sheen and Soto talk about the tissue organizational field theory and how cancer originates that way, it's very clear from Picard's work how you could damage mitochondria in a group of cells by disrupting the morphogenetic field itself. That's new to me and we're still working that out. What was clear to us within the cell itself, because ultimately what starts is dysregulated cell growth from an individual cell dumping out fermentation waste products. We knew this transition from OXPHOS to fermentation was the key for driving the dysregulated growth. But what is the linkage to make the cell dysregulated in its growth? That was what was most interesting. That relates to the calcium signaling and the control of the cell cycle. It goes beyond that: why the cells are no longer responding to the cues from the environment, why they lost contact inhibition. That's because calcium controls cadherins on the surface of the cells. Then I started looking more, and Picard says you've got communication signaling not only internally and to a few cells outside; there's a way through water channels and all kinds of things that were unknown to me about how mitochondria control the overall bioenergetic system of the whole body. Because they've all derived from a population of mitochondria in the fertilized egg. The egg itself comes into a maternal system. They all become slightly different in different organs. Liver is a little bit different than brain or kidney, depending on what they have. But they all have a commonality in how they work. They communicate throughout the whole body through fields. I was shocked about this. When we look at chronic diseases, we see obesity, type 2 diabetes, coronary disease, neuropsychiatric problems, dementia, cancer. All of these are mitochondrial failures. All of these are attacks on mitochondrial function. We're learning about that. The best answer to know more about that would be to look up the work of Picard. He's discussed this in great detail about how these cells communicate with each other through mitochondrial bioenergetic linkages and signaling. So we're starting to put this together in a broader way. And as he says, the "powerhouse of the cell" is just that one little bit that people talk about. But what he's talking about is an altogether new kind of networking that exists for general health and what we call metabolic homeostasis throughout organs and systems, all linked to the capability of this one organelle. That organelle controls how genes are turned on and turned off in the nucleus. Through epigenetic signaling, the mitochondria control what the nucleus is doing from one cell to another. I think we're learning a lot more about this. This is the new horizon. This is going to be really important.

[45:21] unknown: I want to say this is awesome. I'm a big mitochondria fan. When I did my PhD, it was metabolic engineering for hydrogen production. I did a lot of fermentation experiments trying to get increased hydrogen. I've always kept in mind the metabolism and what was going on and looking at the mitochondria specifically. Everything that you're saying is resonating with things that I've read and what I've looked into. I've also found that the mitochondria communicate across the cell membranes with one another. They have direct communication with mitochondria that are on opposing membranes, which I thought was really fascinating. One of the things that I'm also interested in is we work with bioelectric modulation with a lot of different drugs that change different ion channels and their function. One of the things that we're seeing is that mitochondria have their own ion channels and potassium channels and calcium channels. Some of those channels are really important for the function of the mitochondria. It's in pre-print right now, so I can go ahead and tell you the name of the drug. We're working with clofilium, which is a potassium channel blocker. It's not just a potassium channel blocker. It has all these other promiscuous effects on different channels. One of the things that it's been known for is that it can change the metabolic output of mitochondria. It switches them more towards a pentose phosphate pathway metabolism in the cells, and also apparently increases the pH around the cell. They're producing some other fermentation product from it. What they did find with it is a defect where you basically have impaired mitochondrial biogenesis. If you add clofilium to those models, you actually increase the mitochondrial output. It increases mitochondrial biogenesis. It also increases oxidative phosphorylation. In my work, it increased the membrane potential of the mitochondria over time. There's things that our ion channel drugs are doing to the mitochondria and may actually be directly working on the metabolism of the mitochondria. It'd be really great to work with you guys to analyze those effects and also to screen different compounds that we work with to see what they do to those metabolic outputs. We don't have any equipment here. All the mitochondrial studies, usually you isolate the mitochondria and then you do the experiments on the isolated mitochondria. All we have are biosensors. We have calcium, we have ROS, and we can also look at turnover with the mitochondria. It'd be great to work with you guys if you have the specialized equipment to do the isolation and to actually look at what's going on when we block those ion channels.

[48:53] Thomas Seyfried: When Mike Kiebish was working in my lab, he's the senior scientist for Berg. He isolated and purified the mitochondria out of the cells. It's laborious, but we're going to be doing that. We're going to be trying to do mitochondrial transfer, that's another thing that we plan to be working on too, is seeing whether we can reverse pathology. It's like putting a new engine in your car, can you transform everything back to a normal state by removing or putting a new engine into the system? The potassium channel blockers and what that might be doing. The answer is we don't know; we would have to look at the systems that we have. How did you measure oxidative phosphorylation? Did you...

[49:53] unknown: We're looking at the membrane potential of the mitochondria. It was the far red divided by green. You take MitoView Deep Red, which looks at the potential, and divide it by MitoView Green, which looks at the amount of mitochondria. That gives you what your mitochondrial potential is.

[50:21] Thomas Seyfried: By looking at amounts.

[50:23] Unknown: Are you doing this in a cancer cell model or?

[50:28] unknown: Yeah, colon cancer cells.

[50:30] Unknown: Isolated mitochondria or just--?

[50:32] unknown: This is in the cells, intact cells. I was pretty surprised because I thought if this was causing some ROS buildup, I would see a decrease in the mitochondrial potential from uncoupling, but I didn't see that at all. I found these papers on PLOG mutations and how Clofilium, even at low concentrations, was rescuing these PLOG defects. It's definitely doing something to the mitochondria to make them more effective.

[51:06] Unknown: I think this would be the topic of discussion that we could have. In our view, if you already have a cancer cell line, then the mitochondria are definitely there, depending on the model. But oxidative phosphorylation itself would be insufficient on its own to keep proliferation active. And that's why they shift to fermentation. Within a model, you can increase or decrease different parameters of what you would call OxPhos, oxidative phosphorylation, through different measurements. If you measure oxygen consumption with your treatment, maybe it goes up, but that doesn't really tell us much about the functional adaptability of those cells to different fuels or whether oxidative phosphorylation would be sufficient to keep them proliferating or to keep them alive as you would see in a normal cell. Then you would need a positive control with a normal cell; perhaps that would be a much better comparison between a normal cell and a tumor cell.

[52:19] unknown: We have just scratched the surface on mitochondrial stuff. Right now, it's proliferation and membrane potential that we've looked at, and we haven't looked at any other parts of that. I would love to look at that because I think these ion channels we're blocking with these compounds that are very promiscuous and hitting all sorts of different ion channels. I think that they may be hitting mitochondrial ion channels in some cases. If that's the case, what does that do to the energetics? Is it something that could potentially boost metabolic therapy?

[53:01] Unknown: I wonder in cell culture, and I think this also was discussed in one of Dr. Slevin's papers, from your perspective, the bioenergetic field or the connection in cell culture is already altered somehow. They are not part of a larger morphogenetic field, but they grow out of control in a 2D plane. Maybe extrapolating from that to the in vivo system is also complicated. We could learn what happens inside the cell, but making the connection to the larger tissue is difficult.

[53:40] unknown: Absolutely. I'm 100% with you on that. One of the things that I've been really trying to work on is developing a better in vitro model, something that is more clinically relevant. We use a bunch of different cell lines. We use the cancer cell line, we use endothelial cells, and then we use fibroblasts all from that same tissue. We mix those together, make a spheroid, embed that in a fibrin gel that has human dermal fibroblasts that excrete the growth factors that are necessary for the endothelial cells to start sprouting. It's a very complex multicellular model that gives you more of what the tumor microenvironment would look like in that area. You could even go further than that and look at what natural killer cells are going to be doing in those types of systems. That's about as close as you can get unless you're constantly doing animal studies. We've got that system down pat. It's a beautiful system. You can see intravasation, you can see angiogenesis, and you can see proliferation of the cancer cells themselves in that type of a system. We could potentially look into that.

[55:05] Unknown: Yeah, absolutely. I think there's some basic metabolic requirements that cells need in general and cancer cells in particular. It's not often discussed, but most in vitro studies require either serum substitutes or dialyzed serum for the cells to actually divide. Otherwise, they just sit there. So there are some growth factors and other things; that's the whole discussion about the default state of the cell, but if some of those things are missing, the cell simply cannot progress through the cell cycle and through proliferation. And the same for if you're going to be combining different cell types and they all secrete different things into the microenvironment, it might get a little complicated to measure all these things in such a system, but it could definitely be interesting to see how they behave, if they behave differently from the subculture system. I have a question for Michael. I saw most of the work on cancer that your group has been doing has been focusing more on non-mammalian systems in the past. I know you had that paper where you overexpressed KRAS in Xenopus laevis, and then with depolarization you could control the proliferation in melanocytes; I also saw some papers. Is that because these models are more available in your group, or is it perhaps an evolutionary disconnect when you go from—these are invertebrates or I wouldn't say less specialized vertebrates, but perhaps the mammalian systems through evolution lost the capacity for regeneration to hyperspecialize the tissues, where it's more difficult to alter some of these bioelectric fields or bioelectric states? Or is it simply that you're working on it, but you haven't got to these systems yet? I think you're muted.

[57:23] Michael Levin: Certainly, we are moving into mammals and human tissue. As Juanita's prior work shows, and she has some papers coming soon that you'll see, we're absolutely going into mammals. We've also done work on breast cancer with Madeleine Uden and some other collaborators. I don't think there's any evolutionary issue here. I think the basic mechanisms are very highly conserved. One of the reasons that we do like Mesonopus and some other regenerative systems is that the regenerative kinds of responses are exactly what we need to normalize cells. Part of our lab does regenerative medicine approaches to try to induce regeneration of mammals. I suspect we can get it working there. We think it can. There are mammals that have deer antlers and spiny mice and things like this. I certainly think we can get it activated. I think that would ultimately be the kind of treatment that you would have. It would be a regenerative response that would grab strong morphogenetic control, but also metabolic control over these cells. We treated it as a stepping stone because the optogenetics and everything else that we did was much easier to do in Xenopus. We showed proof of concept there. Now we're moving into mammals and humans. That's the future work with Juanita and others.

[59:02] Unknown: I just wanted to ask out of curiosity: that was Rose and Wallingford, where they put the frog tumor into a salamander limb, and then they amputated the limb with the tumor in the middle. As it was growing, it integrated and normalized the tumor. I've seen you cite that paper a couple of times. I was thinking whether something similar couldn't be done in regenerating liver, where you would put a hepatoma in the liver and then do a partial hepatectomy and see what would happen. I wonder if anybody has repeated it. This is like the nuclear transfer experiments, which is a foundational piece of evidence that I feel should be getting more attention. Those were frog cells in a salamander. I don't know how the immune system works there, but the innate or active immune system during regeneration, including macrophages, might have rejected those cells. I wonder if this could be done in mammalian systems such as the liver, and if you have been doing some of these experiments.

[1:00:28] Michael Levin: A couple of things. First, I think there are a couple of other papers that were native salamander that didn't have any foreign cells. So I can try to send you what I have. This is also known in planaria. Planaria are very cancer resistant, but if you do manage to give them a tumor, then amputating, and in fact, it's non-local, so you can amputate at the other end of the animal, and as they regenerate, they clear up. There's data like this, but I agree with you. I think the liver would be a fantastic test of this. I've heard claims, and I don't have the clinical knowledge to know if this is true, but I've heard claims that the liver, because of its constant regenerative renewal, normalizes tumor foci all the time, that it's a rare case that one actually continues and becomes a problem, but that they come up from time to time and that the regenerative processes basically normalize them. I don't know if they disappear or if they just become normal. The liver also has some very interesting bioelectric properties. It's been known for a long time that it hangs out in a middle position between the strongly polarized—most of the tissues of the body are post-mitotic and quiescent—versus the depolarized stem cells and cancer cells. So the liver's kind of in the middle. It retains some of that depolarized character. Are you guys in a position to do something like that? I think it'd be a great experiment.

[1:02:02] Unknown: I was just thinking about it. Technically, yes, but we would need funding for that, which is a separate question. I think that's the point of discussion: whether, in your view, when you talk about the breakdown of the communication from the morphogenetic fields and the larger goals of the tissue, even though it's mediated by secondary messengers and something inside the cell in the bioelectric perspective, that would be a reprogramming. If a cell loses the connection to the larger goals of the organism, that is not per se a defect inside the cell that is irreversible; it will be simply a disconnect. Speaking for myself, when you look at advanced tumors—perhaps more malignant ones that are selected for persistently malignant tumor cells—even if you fix them temporarily or inhibit proliferation, they tend to revert back to this proliferative state, which we would think is something happening inside the cell that cannot be recovered through signaling from the outside. I don't know what their thoughts would be on that, because even the oncogenes, KRAS, make all these things; they are happening inside the cell. From our perspective, the mitochondrial alterations would also be happening inside the cell. They have connections to the outside too, and they might be mediating the disconnect from reversion to unicellular behavior. But they do happen inside. If you have a single cell in a single well, and you put oncogenes on top of it—which we would argue damage oxidative phosphorylation and mitochondrial function—you just have one cell and you can make it a tumor cell without ever having any connection to the outside.

[1:04:22] Michael Levin: I'm not saying that after the disconnection has happened that it doesn't accumulate additional defects that might really make it difficult to work it back into the collective. That's possible. The jury is still out on how much and at what point it really becomes the hardware problem and physically broken and irreversible. I'm not sure about that. One of the issues we study is the way that collectives versus single cells navigate various problem spaces. Anatomical space is one, transcriptional space is another. We've shown that groups of embryos actually have a quite different transcriptome than single embryos. One of the things they do is they exchange information. We can see these calcium waves passing between embryos that allows them to resist various teratogens much better. Large groups resist better than small groups, which resist better than singletons. What we haven't done is ask how larger collectives versus smaller collectives navigate metabolic space. This may involve physical defects, but it may be a computational problem as well as a physical problem, because the way that you move in the space of metabolic possibilities, the way that you process metabolic information, the decisions you make about what you do when certain things happen may be quite different in a group versus in disconnected cells. That's worth taking a look at: whether what we're looking at is really defects in the way they process metabolic information and move through the space. We have to be careful how much of this is a hardware defect and how much is software bordering on cybernetic cognitive defect?

[1:06:21] Thomas Seyfried: When you mentioned that, that's what Picard was talking about: the computational aspects of how mitochondria control the morphogenetic fields. He's going into that depth of what you've just described, but it's pretty much cutting edge, or a lot of it is conceptual right now with data that needs to be further collected. He was speaking exactly about that, this computational. When you speak about the hardware and the software, it involves both of these aspects, and trying to get a handle on it right now has been difficult because of the types of experimental design you would need to separate hardware from software, which requires a very different perspective. Now you're asking a different kind of question, and when you start introducing new questions you start thinking about how you're going to design experiments to answer that. Before you could even formulate a question, you had a lot of things that you saw that you couldn't really put together. I think now, in light of what we're seeing, these kinds of things become more relevant and a lot more thinking needs to go into this.

[1:07:47] Michael Levin: We're set up for a lot of that, though not on the metabolic side. We track other things. We track bioelectric states, we track transcriptional states, we track morphogenesis in these exact kinds of experiments that track the computational capacities of smaller and larger groups. We haven't pursued the metabolic aspects, but we probably should.

[1:08:09] Unknown: I think that the bioenergetic question might be very important for your work, because when you talk about all the sodium and potassium channels, the chloride channels, the calcium channels. All of these things require energy. Our focus in the lab has been interrogating the bioenergetic states, which we feel is more relevant for the therapy, because the idea is to alter and inhibit the energy production of the tumor cells on the therapeutic side. I don't know, with these electroceuticals that you have been testing—did you see any good results? I think you tested the proton pump inhibitor on some of these things?

[1:08:52] unknown: Taprozol, we tested it; it worked really well, especially in combination with other things.

[1:08:57] Unknown: On cells or also in the mice to inhibit tumor growth.

[1:09:00] unknown: No, we only tested it in cells.

[1:09:03] Michael Levin: Can I ask about that, the question of mice in general? What do you think of mice as a model system for this? I'm not an expert. What I hear from people is that mouse cancer has been solved 1,000 times. The hard part is getting it into humans. But everybody uses mice as an assay. What's your opinion on that?

[1:09:23] Thomas Seyfried: I can speak to that. We've never cured any mouse in our lab. The mice that we work with are all natural. A lot of times you have these genetically engineered things where you've made them and you've programmed them in a certain way. And you grow human cells in a mouse, like in xenografts; the mice have a compromised immune system. You've got 50 million years of evolutionary difference between a human cell and a mouse cell, and you're putting them in these totally different environments. The human cells never grow to the aggression that you see them growing in humans when you put them into the mice. That's why we work with all syngeneic, orthotopic kinds of things. It's a ***** trying to cure those things. We can't. A lot of people don't use that because they think patient-derived xenografts and all this kind of stuff. They're not natural. These are artificial. When you work with artificial systems, you get artificial information. You have to really work with the natural host, the natural environment from where the cells come. A lot of human cells don't metastasize. When you say, look at all the metastatic models, what they're doing is they're injecting human cells into the tail vein of a mouse. This is not metastasis. They do spread to different organs, but it's not because they spread naturally; they were forced to do that. I've broken down these models for so many years, knowing what's the most informative model. When you talk to the field, they seem to be locked into the models that they've developed to get their answers. Often you get a lot of misinformation from that, and therefore discount the whole system. Dogs have cancer; you can use dog models. Or humans—the best model you have is the human. The reason why we've had so much success in humans is because we worked it out in natural models in the mouse. Ultimately the test is with the human. You can ferret out mechanisms in vitro and in natural systems. Ferreting out molecular mechanisms, we usually have to go to the in vitro system, but you don't want to try to ferret out a molecular mechanism for a phenomenon that doesn't exist. You want to document the phenomenon and then try to break it down in another system. Then you put it back and test it in vivo, and ultimately you test it in the person that has the cancer. Our in vivo systems in the mouse are the most natural. The reason why we've made the advances we have is because we use only natural systems. When we get to humans, Mike, we get much, much better outcomes in humans than in mice. We developed a system in the mice, but when we tested in humans, we get so much better response because of the difference in basal metabolic rate. This is so important that people completely overlook it. The basal metabolic rate of the mouse is seven times faster than that of the human. The human body has a much greater opportunity to work on things where the mouse is super-accelerated. You really have to be careful about knowing that. A mouse without food lives about six days if he's lucky. Humans, depending on how much body fat you have, can live for months. You have a very different metabolic environment in a human than you do in a mouse. If you have natural systems in the mouse, you can translate them into humans, as long as you understand differences in basal metabolic rate, which comes down to bioenergetics and bioelectric relationships to the energetics. We have to be aware of all those things.

[1:13:38] Unknown: Gotcha. I definitely agree that not every mouse is created equal, especially with the different mouse models people are using. But if I could ask one question, Michael, I'm very interested in the differences between morphogenetic fields in culture, different types of culture, and the mouse itself. It seems clear — I believe from your work directly, or at least work you've cited — that changing the morphogenetic field can be an initiating factor that's necessary and sufficient to induce proliferation. Do you also feel that it's that way in vivo, in a mouse system as well? Is it an initiating factor at times? Is it just sufficient, but not always necessary? Could you talk a little bit about that?

[1:14:30] Michael Levin: Our work is not so much in vivo in mice on this, although we've done human cells and MSCs and things like that in cell culture with David Kaplan and so on. As far as I can see, the evidence is that it plays that role in vivo normally and even in mammals. It's not the only thing, of course; there are chemical factors and biomechanical forces and things like that too, but it plays that role. Partly what it does is coordinate proliferation rates across distance — the kind of allometric scaling that makes things scale. I think so.

[1:15:19] Thomas Seyfried: Okay, if you guys would like to consider more on how we could work together that would be certainly an important thing. There are things that we can provide for you and there's things that you can provide for us to move the field in this general direction. We don't have answers to a lot of these things. I think the energetics of how the mitochondria control bioenergetics, the electrical signaling, the signaling cascades that I'm now learning — we've always been nuclear centric in everything we've been doing in cancer and in biology in general, genomic sequencing and reductionism to the point where we've lost sight of what the bigger issues are. Learning that there is an interesting connection between individual cells and the outside world and the way this works is hard to quantify when you try to do a genomic screen on things because you have no clue whether the gene expressions are associated with protein production. It's hard to link those gene expression profiles to actual changes in the morphogenetic activities. Whereas the mitochondria seem to be that organelle that offers the opportunity to, for the first time, make these connections. And the nucleus will just obey whatever the mitochondria is doing. People talk about epigenetics, and we've known that the mitochondria control the epigenetic signaling inside the nucleus. I always found it interesting that the mitochondria have relinquished most of their genes to the nucleus but they've kept 13 of them that they never relinquished, and those 13 control the destiny of the cell. They have a circular genome and multiple circular genomes, so it's a fascinating organelle in that regard. Bits and pieces of mitochondrial genome have become integrated into the nuclear genome as pseudogenes; they're really not expressed, but they integrate into the nuclear genome in many different ways. Why those 13 genes have never been allowed to be part of the nuclear genome, even though the nucleus controls some parts of the proteins of the electron transport, is interesting. The key ones that determine the destiny of the cell are retained in that mitochondrial genome. If you can have someone do the job for you, why should you waste the time doing it? That organelle, knowing that you have a big *** nucleus with a lot of DNA and a lot of chromosomes, and if that can follow the directions of the mitochondria, that saves this organelle. Why should I have to replicate everything this other organelle is doing? Therefore it would give it much greater control. It's a controlling organelle. It really controls the destiny of the whole physiology. The other thing about aging is we die from the second law of thermodynamics: entropy. All humans, mice, and different organisms have a defined life limit on the planet. The way you live longer is you keep your mitochondria healthy. That will just delay entropy, the second law of thermodynamics, because eventually people die and they die from disorder. It's interesting when people die of old age: often they're pretty alert up until two or three days before they die. It's almost like the entire mitochondrial energy system just turns off and you die. But as long as you can keep the system healthy, you can live longer and prevent a lot of different diseases that you are confronted with. Each one of these chronic diseases, in one way or another, increases entropy in a particular organ or in the system itself, and you don't live as long. Clearly, understanding aging is understanding mitochondrial energetics. It's hard to get cancer if your mitochondria are healthy. It's hard to get type two diabetes if your mitochondria are healthy.

[1:19:13] Thomas Seyfried: You exercise, your mitochondria stay healthy. Ketone bodies, as we've written, are a super fuel. When you burn ketones, you reduce reactive oxygen species. You get more energy per breath of air when you're burning a ketone than when you break down pyruvate or even fatty acids; they uncouple the mitochondria and create more ROS. All of these things are interesting points to consider when we study biological systems. I think the reason why we haven't spent as much time on the mitochondria is that they're hard to see. When you look under electron or light microscopy, you see a big nucleus; you're focusing on that. The mitochondria is a morphic organelle that's diffused through the cytoplasm. You didn't really start to see it until electron microscopy was developed. Warburg did all his work based on chemical measurements. He never looked at mitochondria. He didn't have the tools to do that. He based it entirely on readouts of fermentation. When you start looking at it in a more dynamic way with microscopy and other techniques, we're starting to take a deeper look at mitochondria. I think you're going to find them to be controlling elements of biological systems' function. It's going to be related to the efficiency of energy use and the interaction of different organ systems. We're just beginning now to turn our attention in this direction, especially because it's related to chronic diseases, which are crippling our country and the world. This is now becoming a major problem, and a lot of it has to do with mitochondrial dysfunction in different ways. We always wonder, in the brain you have Parkinson's disease. This is a mitochondrial reactive oxygen process in the cells of the substantia nigra. These cells die. They don't become cancer. We've always wondered why cardiac myocytes and neurons of the brain rarely, if ever, become tumorigenic. They can't switch to a fermentation metabolism. Their energetic requirements require oxidative phosphorylation, and when that goes down, they die. They don't become cancer cells. We're starting to see why some cells are more prone to become neoplastic and other cells are not neoplastic, and how all this works together. We're starting to see a lot of these connections for the first time. I'm looking forward to a dynamic future, but we have to start by addressing certain questions that we do not have answers to at this time.