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Observing Ramadan and sleep-wake patterns in athletes: a systematic review, meta-analysis and meta-regression
  1. Khaled Trabelsi1,
  2. Nicola Bragazzi2,
  3. Sahar Zlitni1,
  4. Aimen Khacharem3,
  5. Omar Boukhris1,
  6. Kais El-Abed1,
  7. Achraf Ammar4,
  8. Saber Khanfir5,
  9. Roy J Shephard6,
  10. Ahmed Hakim7,
  11. Wassim Moalla1,
  12. Hamdi Chtourou8,9
  1. 1 UR15JS01: Education, Motricité, Sport et Santé (EM2S), High Institute of Sport and Physical Education, University of Sfax, Sfax, Tunisia
  2. 2 Department of Health Sciences (DISSAL), Postgraduate School of Public Health, University of Genoa, Genoa 16132, Italy, Genoa, Italy
  3. 3 UVHC, DeVisu, Valenciennes, France; LIRTES - EA 7313, Université Paris Est Créteil Val de Marne, Valenciennes, France
  4. 4 Institute of Sport Science, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
  5. 5 Faculty of Medecine of Tunis, University of Tunis El Manar, Tunis, Tunisia
  6. 6 Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
  7. 7 Laboratory of Pharmacology, Faculty of Medicine, University of Sfax, Sfax, Tunisia
  8. 8 Activité Physique: Sport et Santé, UR18JS01, Observatoire National du Sport, Tunis, Tunisie
  9. 9 Institut Supérieur du Sport et de l’Education Physique de Sfax, Université de Sfax, Sfax, Tunisie
  1. Correspondence to Dr Khaled Trabelsi, High Institute of Sport and Physical Education of Sfax, Tunisia, Sfax, Tunisia; trabelsikhaled{at}


Objective To evaluate the effect of observing Ramadan on athletes’ sleep patterns.

Design Systematic review and meta-analysis.

Data sources The entire content of PubMed/MEDLINE and Web of Science.

Eligibility criteria for selecting studies Single-group, prepost and cross-over design studies conducted in athletes aged ≥18 years, training at least twice a week and published in English before 12 July 2018 were included. Studies assessing sleep quantity, quality, daytime sleepiness and/or daily naps based on objective or subjective methods were deemed eligible.

Study appraisal The methodological quality was assessed using ‘QualSyst’.

Results Of 13 selected articles, 7 were of strong quality, 3 were moderate and 3 were weak. 11 studies evaluated total sleep time (TST); this decreased during Ramadan in 4 studies, increased in 1 and remained unchanged in 6. Pooled TST findings indicated a moderate effect size (− 0.97, SE=0.37, 95% CI −1.69 to −0.25, t=−2.64, p=0.01) with significant heterogeneity but no publication bias. Meta-regressions showed no effects of study year, age, sample size, type of sport or competition level, but there were effects of country (with France and Tunisia being the most affected countries and Turkey the least affected, Q=32.14, p<0.0001) and study design (Q=7.74, p=0.02). Four studies measured self-reported sleep quality and it decreased in three studies. One study of sleep architecture reported more frequent waking and more light sleep during Ramadan. Daily nap duration was increased in two studies, but daytime sleepiness remained unchanged in four studies.

Conclusion When athletes continue to train at least two times/week while observing Ramadan, TST is decreased compared with athletes’ baseline levels.

  • athletes
  • daytime sleepiness
  • naps
  • Ramadan effects
  • sleep characteristics
  • training recommendations

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  • Contributors All the authors made a substantial contribution to the design, the drafting and the revising of the manuscript and have read and approved the final version. None of the authors has a direct or indirect commercial financial incentive associated with publishing this article. All the authors agree to be accountable for all aspects of the work to ensure that questions related to the accuracy or integrity of the work are appropriately resolved.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.