John Nuttall was a British long-distance runner who competed at the highest Olympic and international levels until he was 31, ran in competitive races until he was 40 and coached world-class international runners until he died of a heart attack at age 56.

How could a fit and healthy runner die of a heart attack at such a young age? Research evidence shows that exercise strengthens the heart, helps to prevent heart attacks and strokes, and prolongs lives (Circulation, 2018;137(18):1896-1898). The more frequently people exercise, the less likely they are to die of heart disease (JACC Cardiovasc Imaging, 2017;10:1461-1468).

A Lifetime of Running
Nuttall was born in England and was winning races at an early age. At age 18, he won the 3000 meter race at the English Schools’ Athletics Championships in record time, placed third at the 1985 European Athletics Junior Championships, and raced in the 1986 IAAF World Cross Country Championships and World Junior Championships in Athletics. He won a scholarship to Iowa State University and led his team to the NCAA title as the individual 1989 NCAA Division I Cross Country Champion. He also won eight Big Eight Conference titles and was the 3000-meter runner-up at the NCAA Indoor Championships in 1991. After college, he competed at the highest level before retiring from racing at age 40. He then coached runners until his sudden death.

A Family of Running Champions
Nuttall married fellow English distance runner Alison Wyeth, who ran on the British Olympic teams in 1992 and 1996, as well as at three World Championships. She won AAAs Championship titles at 1500m (1993), 3000m (1989) and 5000m (1995), and twice won the UK Athletics Championships title at 1500m (1990–91). They had two children, Hannah Nuttall, a world-class long-distance runner, and Luke Nuttall, a champion para-Olympic athlete. They divorced in 2012.

In 2014, Nuttall married Liz McColgan, the winner of the 10,000 meters at the 1991 World Championships and a silver medal over the same distance at the 1988 Olympic Games. She won the 1991 New York City Marathon, 1992 Tokyo Marathon and 1996 London Marathon. He became stepfather to her daughter, Eilish McColgan, who was the 2022 Commonwealth Games 10,000-meter champion and record holder, and 5000 meter silver medalist.

Does Ultra-Endurance Exercise Harm the Heart?
Many studies show that long-term, extreme-endurance exercise is associated with increased health:
• Olympic endurance athletes followed for up to 17 years had no evidence of any damage whatever to the size, shape and function of their heart’s main pumping chamber (left ventricle) and suffered no evidence of heart damage or disease (J Am Coll Cardiol, 2010;55(15):1619-1625).
• A review of fourteen articles on the life spans and death rates of elite endurance athletes shows that they live longer than the general population and suffer far less from heart disease (J of Sci and Med in Sport, July 2010;13(4):410-416).
• A review of 174 studies shows that ordinary exercise and more strenuous activities are associated with a lower risk of heart disease, strokes, breast cancer, colon cancer, and diabetes, and that the largest risk reductions come with increasing intensity and duration of exercise (British Med J, August 9, 2016).

Plaques and Heart Attacks
A heart attack is not caused by plaque buildup on the inner lining of arteries. They are usually caused by a sudden complete obstruction of the blood flowing to part of the heart muscle. A 90-percent blockage of an artery does not cause a heart attack because blood can still flow through and the heart muscle can still get some oxygen. The sudden complete obstruction of blood flow to a part of the heart muscle is usually caused by a plaque breaking off, which is followed by bleeding. Then a clot forms at the bleeding site, and the clot can extend to block completely the flow of blood to the part of the heart muscle supplied by that artery. The part of the heart muscle deprived of blood flow dies, and that is the definition of a heart attack.

Calcium Scores
Older competitive endurance athletes usually have more plaques than non-athletes. Doctors can often predict a person’s likelihood to suffer a heart attack by doing a Calcium Score, a special CT X-ray or sound wave test that measures thickness of plaques on the inner lining of arteries. Endurance athletes usually have higher calcium scores (larger plaques), even though they are at extremely low risk for heart attacks, because their plaques contain more calcium (which stabilizes plaques), and because endurance athletes have larger heart arteries that are harder to block than those of non-exercisers.

If an athlete and a non-exerciser have the same thickness of plaque, the athlete would have a higher calcium score because he has a larger artery. However, athletes have much more stable plaques that are far less likely to break off to cause a heart attack (American Journal of Roentgenology, March 2015;204(3):W249-W260). The stability of a plaque depends on how much calcium is in the plaque. Stable plaques have much thicker layers of calcium on their inner linings and that is what helps to prevent plaques from breaking off to cause heart attacks. Signs of plaque stability include extensive calcification on the inner lining of the plaque, less fat-rich areas, decreased scarring and structural changes (as seen by the pathologist interpreting the CT scan). See Does Ultra-Endurance Exercise Harm the Heart?

My Recommendations
Ultra-endurance athletes are at extremely low risk for heart disease and most live longer than non-exercisers. Your heart attack prevention program should include both healthful eating and exercise. Since exercise helps to stabilize plaques to help keep them from breaking off from arteries, almost everyone should try to exercise. Dedicated exercisers need to eat large amounts of food to meet their caloric needs, but they should still follow an anti-inflammatory diet — avoiding red meat, processed meats, sugar-added foods, sugared drinks (except during exercise), and fried foods. If you eat a lot of those foods, you can expect to have a lot of plaques in your arteries no matter how much you exercise, and be at increased risk for having a heart attack (Journal of the American College of Cardiology, July 2017;70(4)). Check with your doctor if you have evidence of heart disease caused by a faulty diet: high blood pressure, high blood cholesterol, triglycerides, blood sugar, or CRP, an abnormal EKG, or chest pain particularly with exercise.

Caution: Intense exercise can cause heart attacks in people who have blocked arteries leading to their hearts, irregular heartbeats or other abnormalities. Heart attacks during exercise are more likely to occur when a person starts a new exercise program or increases the speed or duration of exercise. Check with your doctor.

John Barry Nuttall
January 11, 1967 – November 9, 2023