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J Sleep Res.

(2014) 23, 35–43 Fasting and sleep

Intermittent fasting during Ramadan: does it affect sleep?


AHMED S. BAHAMMAM1,2, KHALID ALMUSHAILHI3, SEITHIKURIPPU R.
P A N D I - P E R U M A L 4 and M U N I R M . S H A R I F 1 , 2
1
University Sleep Disorders Centre, College of Medicine, King Saud University, Riyadh, Saudi Arabia, 2National Plan for Science and
Technology, King Saud University, Saudi Arabia, 3Sleep Disorders Centre, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia and
4
Somnogen Canada Inc., Toronto, ON, Canada

Keywords SUMMARY
actigraphy, fasting, Ramadan, rapid eye Islamic intermittent fasting is distinct from regular voluntary or experi-
movement, sleep, sleepiness
mental fasting. We hypothesised that if a regimen of a fixed sleep–wake
Correspondence schedule and a fixed caloric intake is followed during intermittent fasting,
Ahmed S. BaHammam, Professor of Medicine, the effects of fasting on sleep architecture and daytime sleepiness will be
Director, University Sleep Disorders Centre, minimal. Therefore, we designed this study to objectively assess the
College of Medicine, King Saud University, Box
effects of Islamic intermittent fasting on sleep architecture and daytime
225503, Riyadh 11324, Saudi Arabia.
Tel.: 966-1-467-1492; fax: 966-1-467-9495; sleepiness. Eight healthy volunteers reported to the Sleep Disorders
e-mails: ashammam2@gmail.com or Centre on five occasions for polysomnography and multiple sleep latency
ashammam@ksu.edu.sa tests: (1) during adaptation; (2) 3 weeks before Ramadan, after having
performed Islamic fasting for 1 week (baseline fasting); (3) 1 week
Accepted in revised form 30 June 2013;
received 28 February 2013 before Ramadan (non-fasting baseline); (4) 2 weeks into Ramadan
(Ramadan); and (5) 2 weeks after Ramadan (non-fasting; Recovery).
DOI: 10.1111/jsr.12076 Daytime sleepiness was assessed using the Epworth Sleepiness Scale
and the multiple sleep latency test. The participants had a mean age of
26.6  4.9 years, a body mass index of 23.7  3.5 kg m 2 and an
Epworth Sleepiness Scale score of 7.3  2.7. There was no change in
weight or the Epworth Sleepiness Scale in the four study periods. The
rapid eye movement sleep percentage was significantly lower during
fasting. There was no difference in sleep latency, non-rapid eye
movement sleep percentage, arousal index and sleep efficiency. The
multiple sleep latency test analysis revealed no difference in the sleep
latency between the ‘non-fasting baseline’, ‘baseline fasting’, ‘Ramadan’
and ‘Recovery’ time points. Under conditions of a fixed sleep–wake
schedule and a fixed caloric intake, Islamic intermittent fasting results in
decreased rapid eye movement sleep with no impact on other sleep
stages, the arousal index or daytime sleepiness.

The months in the Islamic (Hijri) year follow the lunar


INTRODUCTION
system. As the Hijri year is shorter than the Gregorian year by
Researchers have demonstrated that experimental fasting 11 days, Ramadan occurs during a different season every
alters the sleep–wake pattern of various species (Borbely, 9 years, which results in significant differences in the
1977; Rashotte et al., 1998). However, the results of such durations of day and night. In addition, there are changes
experimental fasting cannot be extrapolated to Islamic in the day–night activity patterns during Ramadan, such as
intermittent fasting during Ramadan because the duration night prayer followed by rising for the pre-dawn meal (Suhur),
of each fasting episode of experimental fasting is usually and other associated lifestyle changes that occur during
more prolonged than the duration of fasting during Ramadan. For example, in some Islamic countries, the
Ramadan. opening of stores and shopping malls until pre-dawn time is a
Ramadan fasting is unique in its intermittent nature. During common occurrence. Moreover, eating habits change during
each day of the month of Ramadan, Muslims abstain from Ramadan; specifically, people prefer fried foods and con-
food, drink and smoking between dawn and sunset, enacting sume excessive sweets. All of these factors indicate that the
a sudden shift in the circadian pattern of food intake. physiological and behavioural changes occurring during the

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36 A. S. BaHammam et al.

month of Ramadan may be different from those that occur (month 8, Hijri), the second week of Ramadan (month 9,
during experimental fasting (Azizi, 2002). Hijri), and the second week of Shawwal (month 10, Hijri)
Polysomnographic (PSG) studies showed that Ramadan during the Hijri year 1432. The study period corresponded to
fasting affects sleep architecture. Two previous studies the dates between 25 June and 30 September 2011 on the
demonstrated a significant reduction in rapid eye movement Gregorian calendar. During the BLF, dawn (the beginning of
(REM) sleep towards the end of Ramadan (BaHammam, fasting) occurred at about 03:37 hours and sunset (the end
2004; Roky et al., 2001). Similar findings have been reported of fasting) occurred at about 18:47 hours and, during the
in animal studies (Kotrbacek et al., 1990). With regard to sleep second week of Ramadan, dawn occurred at about
latency and total sleep time (TST), conflicting results have 04:00 hours and sunset at about 18:34 hours. A non-random
been reported. While one study reported a significant increase sample of eight non-smoking, healthy Muslim males between
in sleep latency and a significant reduction in TST (Roky et al., the ages of 20 and 35 years who were not on vacation
2001), a second study reported a significant drop in sleep during the study period (except for the Eid holiday: Ramadan
latency at the end of Ramadan and no change in TST 25–Shawwal 5), not on any medications, did not drink
(BaHammam, 2004). No significant changes were reported in alcohol and who did not perform shift work were recruited.
non-REM sleep (NREM) sleep stages, arousal index, stage None of the participants had irregular sleep–wake schedules
shifts and cardio-respiratory parameters during Ramadan or sleep complaints. None of the participants travelled
(BaHammam, 2004). Using an experimental model of fasting, 2 weeks prior to or during the study. Their work hours were
significant reductions were observed in the number of arous- from 07:30 to 16:30 hours before and after Ramadan, and
als and arousal index, as well as a significant reduction in from 10:00 to 15:00 hours during Ramadan. The reason for
periodic leg movement during fasting (Michalsen et al., 2003). the small number of subjects is due to the time constraints of
Conflicting data have been reported with regard to the the study period as the study has to be conducted during a
effect of Ramadan fasting on daytime sleepiness (Baham- specified period of time.
mam, 2006). However, many of the previous studies did not
use objective methods to assess sleep, sleepiness and the
Study protocol
characteristics of the sleep–wake schedule. Moreover, some
studies did not account for the possibility that attendant This is a descriptive study with repeated measures that was
cultural and lifestyle changes that occur during Ramadan, carried out at the Sleep Disorders Centre (SDC). The study
such as delays in starting school and work, increased activity was approved by the Institutional Review Board at our
in malls until late at night, and other changes in the day–night institute, and written informed consent was obtained from all
activity patterns may affect the sleep patterns of individuals participants.
regardless of fasting (BaHammam, 2003, 2005; BaHammam The study group was recruited in early Rajab, and a
et al., 2010). Additionally, previous studies did not account teaching session was organised to introduce the protocol and
for the possibility of prior sleep restriction on the nights before its objectives to the participants, and to obtain informed
assessing sleep in the laboratory. This limitation is important consent.
because chronic partial sleep restriction may influence The participants were asked to report to the SDC at
daytime sleepiness (Balkin et al., 2008). Finally, the previous 18:00 hours on five occasions. During each visit, the subject
studies did not assess the effect of intermittent Islamic fasting spent 24 h in the SDC (Fig. 1).
performed outside the month of Ramadan on sleep architec- 1. Adaptation (last week of Rajab). The purpose of the first
ture and daytime sleepiness. visit was to have a medical check-up and to adapt to the
We hypothesised that if a fixed sleep–wake schedule and environment before the start of the study. All participants
a fixed caloric intake are followed during intermittent fasting were given a wrist actigraphy monitor (Mini Mitter
during or outside Ramadan, the effects of intermittent fasting Company, Bend, OR, USA) for 1 week to assure a fixed
on sleep architecture and daytime sleepiness will be minimal. sleep–wake schedule before starting the study. Thereaf-
Therefore, we designed this study to objectively assess the ter, monitoring of their nocturnal sleep (nTST), nap
effect of Islamic intermittent fasting on sleep architecture and duration, wake-up time and bedtime was performed
daytime sleepiness outside of Ramadan (baseline fasting, throughout the study period on a daily basis via
BLF) and during Ramadan when controlling for sleep–wake actigraphy, and the means were used in the analysis.
schedule, caloric intake, meal composition, light exposure Participants were instructed not to consume caffeinated
and circadian rhythm. products in the 24 h prior to and during monitoring in the
SDC.
2. BLF. During the first week of the month of Shaban
MATERIALS AND METHODS
(3 weeks before Ramadan), the participants were asked
to fast (abstain from food and drink from dawn to
Study group
sunset) for 1 week. They reported to the SDC during the
This explorative study was conducted during the last week of last day of the week while fasting for PSG and the
Rajab (month 7, Hijri), the first and last weeks of Shaban multiple sleep latency test (MSLT) the next day. This

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Intermittent fasting and sleep 37

Fasting protocol
Last week of Rajab
Week
AdaptaƟon During BLF, the participants were asked to fast during the
1
AcƟgrapgy first week of Shaban (7 days). During this period, we aimed
to assess the effects of Islamic intermittent fasting in the
absence of the lifestyle changes and eating habits that occur
during Ramadan. During the last 3 weeks of Shaban (before
1st week of Shaban
Ramadan), the participants practiced their routine activities
Week FasƟng:
2 Baseline fasƟng (BLF) and eating habits. The participants performed fasting during
PSG and MSLT the entire month of Ramadan. During Shawwal, the partic-
ipants did not fast, and they returned to work during the
second week of Shawwal.
Last week of Shaban
Week Normal rouƟne: No fasƟng
Meals
3 Baseline (BL)
PSG and MSLT While in the SDC for sleep studies, each participant received
meals with a fixed caloric content and fixed proportions of
carbohydrates, fats and proteins based on their ideal body
2nd week of Ramadan weight. During BL and Recovery, three meals were served:
Week FasƟng dinner at 20:00 hours, breakfast at 07:15 hours and lunch at
4 Ramadan 12:00 hours. During BLF and Ramadan, three meals were
PSG and MSLT served: Fatoor at Maghreb (sunset) prayer (between 18:30
and 18:55 hours); dinner at 21:00 hours; and Suhur between
03:00 and 03:15 hours.
Eid Holidays
No Work between Light exposure protocol
Ramadan 25 – Shawwal 5
Light exposure was maintained at the same level during the
participants’ stay in the SDC during the four study periods
(BL, BLF, Ramadan and Recovery). The light level was
2nd week of Shawwal measured using a Spectral Star Light Meter LX-1 (Japan).
Week Normal rouƟne: No fasƟng From 18:00 hours until bedtime and during Suhur, the light
5 Recovery level was maintained at 50 lux. During the PSG and MSLT
PSG and MSLT
recordings, all lights were turned off and the light level was
<1 lux.

Figure 1. Study protocol.


PSG
fasting was performed 3 weeks before Ramadan to
avoid any overlap with Ramadan fasting and any The sleep studies were performed at the SDC. Alice 5
carryover effect. diagnostic equipment (Respironics, Murrysville, Pennsylva-
3. Baseline (non-fasting; BL). During the last week of the nia, USA) was used for data acquisition. The subjects were
month of Shaban, the participants performed their normal asked to avoid napping during the study day. During BL
daily routines and reported to the SDC during the last day and Recovery, the study began at 23:00 hours and was
of the week for PSG and MSLT. completed at 07:00 hours. During BLF and BLF, the study
4. Ramadan. During the second week of Ramadan, the began at 23:00 hours. During Ramadan, the participants
participants performed Ramadan fasting and reported to were awakened at 03:00 hours for Suhur, and the study
the SDC during the last day of the week while fasting for was resumed at 03:45 hours until 07:45 hours. During
PSG and MSLT. Ramadan, the participants were awakened at 03:15 hours
5. Recovery. During the second week of the month of for Suhur (to account for the shift in dawn prayer time),
Shawwal, the participants performed their normal daily and the study was resumed from 04:00 until 07:45 hours.
routines and reported to the SDC during the last day of The participants were awakened at a specified time in
the week for PSG and MSLT. To minimise any potential the study protocol regardless of the number of hours
carryover effect of Ramadan fasting, the recovery they slept.
assessment was conducted 2 weeks after the end of A level I attended overnight sleep study with neuro-cardio-
Ramadan. pulmonary monitoring was performed (Iber et al., 2007).

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38 A. S. BaHammam et al.

Analysis and scoring of the sleep studies Statistical analysis


The analysis and scoring of the electronic raw data were The data are expressed as the mean  SD. The compari-
performed manually by a trained PSG technologist in a sons between BL, BLF, Ramadan and Recovery were
blinded manner. Epoch-by-epoch analyses of the following performed using the related-samples Friedman’s repeated-
sleep parameters were carried out: lights off; lights on; TST; measures one-way analysis of variance (ANOVA) by ranks.
sleep period time; and sleep-onset latency. Additionally, the Post hoc analysis was performed using the Wilcoxon signed
following parameters were scored according to established rank test between levels of repeated measures. The results
criteria: stages of sleep and the percentage of TST; the were considered statistically significant if P ≤ 0.05.
sleep-onset latency; the slow-wave sleep-onset latency and A standard statistical software program (Statistical Package
duration; the REM onset latency and duration; the number of for the Social Sciences, version 17.0; SPSS, Chicago, IL,
sleep cycles; stage shifts (total number of changes in sleep USA) was used for the data analyses.
state from the lights-out to lights-on period); and arousals
(American Sleep Disorders Association, 1992; Iber et al.,
RESULTS
2007). The reports were generated using Alice-5 software.
At enrolment, the participants had a mean age of
Daytime sleepiness 26.6  4.9 years, a mean body mass index of 23.7 
3.5 kg m 2, and a mean ESS score of 7.3  2.7. Table 1
Daytime sleepiness was assessed subjectively using the reveals the weight, ESS and sleep schedules followed when
Epworth Sleepiness Scale (ESS) and objectively using the the participants slept at home at BL, BLF, Ramadan and
MSLT. Recovery. There were no significant changes in weight or the
ESS score in the four study periods. Based on the clinical data
ESS collected from actigraphy, we found no significant changes in
bedtime, nTST, or nTST + nap between BL, BLF, Ramadan
The ESS is a validated questionnaire that assesses the
and Recovery. However, the bedtime and wake-up time were
likelihood that the subject will fall asleep during certain
delayed during Ramadan.
activities (Johns, 1991). The ESS was performed at the same
Table 2 presents the PSG characteristics before Ramadan
time in the four study periods at 11:00 hours.
(BL and BLF), during Ramadan and during Recovery. There
was no significant difference in the TST, sleep efficiency,
MSLT sleep-onset latency and REM-onset latency between the BL,
A standard MSLT was performed in accordance with Amer- BLF, Ramadan and Recovery periods. The slow-wave sleep
ican Academy of Sleep Medicine (Littner et al., 2005). Four latency, arousal index and stage shifts did not differ signif-
tests (naps), about 2 h apart, were performed at the same icantly between the BL, BLF, Ramadan and Recovery
time during BL, BLF, Ramadan and Recovery at 09:15, periods. The proportion of different NREM sleep stages in
11:15, 13:15 and 15:15 hours. The routine hook–up was relation to TST did not change significantly in the BLF and
performed with the exception that the leg electromyogram Ramadan periods compared with BL. However, the REM
and cardio-respiratory sensors were omitted. The technician sleep percentage and duration were significantly lower at
performed calibrations prior to each test. The scorers of the BLF (17.8  8.1%) and Ramadan (19.8  10.7%) compared
MSLT were blinded to the sleep protocol used the night with BL (27.6  4.7%) and Recovery (26.6  7.4%). The
before. The sleep latencies of all naps were averaged and average number of REM cycles did not change between BL,
indicated on the report form. BLF, Ramadan and Recovery.

Table 1 The ESS scores, weight and sleep pattern obtained using actigraphy when sleeping at home

Variable BL BLF Ramadan Recovery P-value

Weight (kg) 69.1  8.4 67.5  7.8 66.3  12.3 69  8.7 0.271
ESS 7.3  2.7 7.3  2.7 7.3  2.7 7.3  2.7 1.000
Bedtime (24 h) 0.6 + 1.4 1.5 + 1.6 2.7 + 0.9* 0.7 + 1.2 0.004
Wake-up time (24 h) 5.5  1.1 6.2  1.5 8.8  2.8* 6.3  1.1 0.034
nTST (h) 5.3  1.2 5.3  1.2 5.1  1.3 5.8  2.1 0.134
nTST + NAP (h) 5.9 1 6.2  2.9 7  2.9 6.5  3.3 0.539

BL, non-fasting baseline; BLF, baseline fasting; ESS, Epworth Sleepiness Scale; nTST, nocturnal sleep.
*The difference is statistically significant compared with BL, BLF and Recovery.

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Intermittent fasting and sleep 39

Table 2 PSG characteristics during the BL, BLF, Ramadan and Recovery phases

Variable BL BLF Ramadan Recovery P-value

TST (min) 375.8  46.4 333  59.8 353.9  42.7 390.5  34.3 0.165
Sleep efficiency 79.3  9.6 70.7  11.1 74.2  7.3 81.5  7 0.336
Sleep latency 29.6  24.2 33.7  33.6 32.8  29.3 9.4  5.5 0.224
REM latency 80.6  26.9 108.9  47.8 73.5  40.1 76.8  22.8 0.185
Stage shifts 66.3  13.9 74.9  20.5 64.1  16.7 62.6  10.6 0.327
Stage N1% 5.2  2.6 8.2  3.7 5.4  2.4 4.9  2.3 0.092
Stage N2% 58.6  4.8 63.2  9.3 64.3  6.1 57.7  9.7 0.070
Stage N3% 8.7  7.3 10.8  6.4 10.6  7.1 10.8  6.8 0.136
Stage REM% 27.6  4.7 17.8  8.1* 19.8  10.7* 26.6  7.4 0.024
REM cycles 4.1  1 3.8  0.9 3.8  1.3 4.1  0.4 0.400
REM duration (min) 101.3  25.5 60.4  29.3* 78.1  46.7* 103.3  28.8 0.044
REM 1 (min) 23.3  16.1 17  9 14.3  6.4 18.5  10.9 0.652
REM 2 (min) 27.4  11.5 11.8  7.8† 15.6  10.3 16.8  8.8 0.06
REM 3 (min) 24.7  16.3 12.9  14.5 21.3  21.3 30.4  18.1 0.158
Arousal index 9.1  3.6 8.9  4.8 7.9  3.3 10.9  5.7 0.369
Periodic leg movements index 2.7  1.6 3.8  3.4 4.7  3.5 4.9  3.5 0.217

BL, non-fasting baseline; BLF baseline fasting; REM, rapid eye movement; TST, total sleep time.
*BLF and Ramadan were significantly lower than BL and Recovery.
†BLF was significantly lower than BL.

Table 3 The MSLT characteristics associated with the BL, BLF, Ramadan and Recovery phases

BL BLF Ramadan Recovery P-value

Sleep latency (NAP1) 8.4  6.2 8.7  7 9.7  7.2 7.1  6.3 0.572
Sleep latency (NAP2) 5.2  2.9 10.8  7.5 11.3  8.5 11.4  7.6 0.141
Sleep latency (NAP3) 10.3  6.6 11.6  7.9 13  8 8.9  6 0.186
Sleep latency (NAP4) 12.3  8.5 14.4  6.7 13.4  7.2 12.1  6.6 0.824
Sleep latency (mean) 9  4.4 11.4  5.9 11.5  6.2 9.9  5.4 0.403
Sleep-onset REM frequency 0.1  0.1 0.2  0.3 0.2  0.2 0.1  0.2 0.960
Stage shift during Nap 1 3.8  1.2 4.8  2.5 3.3  1.2 3.9  2.3 0.492
Stage shift during Nap 2 3.9  2.2 3.6  1.1 2.6  1.4 3  1.5 0.604
Stage shift during Nap 3 4.5  2.5 3.8  2.4 2.8  1.9 4.6  4 0.514
Stage shift during Nap 4 2.6  1.8 2.4  1.8 3.8  4 3.4  2.8 0.874
Stage shift (mean) 3.7  1.5 3.6  1.1 3.1  1.7 3.7  1.6 0.539
Stage N1% (mean) 31.7  20.7 23.7  6.9 22.7  16.4 26  18.4 0.789
Stage N2% (mean) 61.3  23.5 64.2  11 53.5  27.7 63.3  15.5 0.93
WE during Nap 1 32.6  16.8 43.4  29.4 40.1  29.5 38.1  31.1 0.476
WE during Nap 2 56.8  35.4 24.4  10.8 53  40.9 49.4  34.6 0.089
WE during Nap 3 56  34.4 46.1  25.4 65  38.1 47.1  29.8 0.57
WE during Nap 4 77.7  27.4 69  42.6 62.5  32.7 54.2  30.2 0.55

BL, non-fasting baseline; BLF baseline fasting; REM, rapid eye movement; WE, wake efficiency.

Table 3 summarises the MSLT findings. There were no ery. Fig. 2 demonstrates the distribution of sleep latencies of
significant differences in either the sleep latencies of individ- naps in BL, BLF, Ramadan and Recovery. The time of day of
ual naps or their mean between BL, BLF, Ramadan and the nap had no significant effect on sleep-onset latency
Recovery. A further examination of the wake efficiency (WE) during fasting.
and the sleep-onset frequency revealed no significant differ-
ences between BL, BLF, Ramadan and Recovery in either
DISCUSSION
the individual naps or their mean. An analysis of the sleep
stages during the MSLT revealed no significant differences in To our knowledge, no study has assessed the effects of
the mean of all naps between BL, BLF, Ramadan and Islamic intermittent fasting outside the Ramadan season. In
Recovery. None of the participants progressed into N3 during this study, under conditions of a fixed sleep–wake schedule
the naps. The frequency of sleep-onset REM showed no and caloric intake, we assessed the effects of intermittent
differences between BL, BL Fasting, Ramadan and Recov- fasting on sleep architecture and daytime sleepiness. Then,

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40 A. S. BaHammam et al.

16 end of Ramadan. Another experimental study conducted on


piglets demonstrated that REM sleep did not occur after 18 h
14
of fasting but recurred after feeding (Kotrbacek et al., 1990).
Sleep latency in minutes

12 Several theories have been proposed to explain the


10 reduction in REM sleep during fasting. A shift in cortisol
and insulin rhythms has been reported during Ramadan, with
8
an increased level at night (Al-Hadramy et al., 1988; Iraki
6 et al., 1997). The reduction in REM sleep during fasting may
be due to a nocturnal rise in cortisol and insulin (Born et al.,
4
1989; Sangiah and Caldwell, 1988). The eating of meals
2 exclusively at night during Ramadan has been proposed to
0 increase the nocturnal body temperature (Roky et al., 2000,
BL BLF Ramadan Recovery 2001). Because REM sleep is inversely proportional to core
Nap1 Nap2 Nap3 Nap4 temperature (Krueger and Takahashi, 1997), a nocturnal
Figure 2. The distribution of sleep latencies of naps during the
increase in temperature would be expected to decrease REM
baseline (BL), baseline fasting (BLF), Ramadan and Recovery sleep (Libert et al., 1988). In addition, animal studies have
stages. Data are expressed as mean  SE. proved that imposed meal times and temporally restricted
feeding are potent synchronisers for secondary clocks in
we assessed the same parameters after the completion of peripheral organs and in certain brain regions (Challet and
the fasting month (Recovery). The study demonstrates that Mendoza, 2010). Even when animals were exposed to a
Islamic intermittent fasting results in decreased REM sleep light–dark cycle, timed calorie restriction was found to be a
with no impact on other sleep stages, arousal index or powerful synchroniser of the suprachiasmatic clock (Challet
daytime sleepiness. and Mendoza, 2010). In addition, a predictable daily meal-
The study revealed no difference in sleep latency at night time triggers the expression of neural and circadian clock
between the four study periods (BL, BLF, Ramadan and gene perturbations in many mammalian species, which is
Recovery). Previous studies have reported conflicting find- considered to be guided by a food-entrainable clock (Challet
ings with regard to the effects of fasting on sleep latency. In a and Mendoza, 2010; Mistlberger, 2009). As REM sleep
well-designed study that assessed sleep architecture among follows an endogenous circadian rhythm (Czeisler et al.,
performers of Ramadan fasting, Roky et al. (2001, 2003) 1980; Johnson, 1980), the interaction between changes in
reported an increase in sleep latency during Ramadan. meal time and the biological clock may influence the
However, Michalsen et al. (2003), in a home-based 1-week rhythmicity of REM sleep and hence its duration. Future
modified fasting experiment, reported no change in sleep studies should assess the effect of meal time and composi-
latency. A third study reported no change in sleep latency in tion during Ramadan on REM sleep. Another plausible
the first and third weeks of Ramadan (BaHammam, 2004). mechanism is the relationship between orexin, fasting and
The difference in sleep latency between the Roky et al. study REM sleep. Orexin, also called hypocretin, is a hypothalamic
and the current study can be explained by the different neurotransmitter that regulates arousal, wakefulness and
protocols used. For example, in the Roky et al. study, the appetite. Orexin gene expression has been shown to be
time difference between dinnertime and bedtime was 1 h upregulated during fasting in animals (Sakurai et al., 1998).
(dinner was served at 22:30 hours, and PSG recording Reduced leptin levels and hypoglycaemia may activate
started at 23:30 hours), while the difference was 2 h in the orexin-secreting cells (Griffond et al., 1999). Studies have
current study (dinner was served at 21:00 hours, and PSG shown that Ramadan fasting influences the level and the time
recording started at 23:00 hours). It is quite possible that late of the acrophase of serum leptin concentration (Bogdan
dinners affect nTST. Therefore, the relationship between et al., 2005; Kassab et al., 2003). However, orexin has been
dinnertime during Ramadan and nTST should be assessed in proposed to suppress REM sleep (Hagan et al., 1999).
future research. Infusion of orexin into the cerebroventricular space has been
In the present study, REM sleep was reduced during BLF shown to decrease REM sleep duration (Hagan et al., 1999).
and Ramadan compared with BL and Recovery. The level of Theoretically, intermittent fasting may increase orexin levels
REM sleep returned to normal after the completion of fasting through changes in serum leptin levels, which in turn may
(Recovery). However, there were no significant differences suppress REM sleep (Komaki et al., 2001). However, previ-
between the two fasting periods (BLF and Ramadan) and BL ous data on the effect of orexin on REM sleep were obtained
with regard to NREM sleep stages, arousal index and stage from studies on animal models that utilised prolonged
shifts. Two previous studies assessed sleep architecture underfeeding. Future studies should explore the changes in
during Ramadan using a level I attended sleep study the leptin–orexin system in intermittent fasting. Another
(BaHammam, 2004) and a level II comprehensive unat- possible explanation for the reduction in REM sleep during
tended sleep study at home (Roky et al., 2001). Both studies Ramadan is the interruption of sleep for the predawn meal
demonstrated a significant reduction in REM sleep toward the during the early morning hours, the time period in which a

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Intermittent fasting and sleep 41

larger amount of REM sleep usually occurs. We tried to Two previous objective studies have assessed daytime
compensate for the lost sleep time during Suhur by delaying sleepiness in Ramadan using the MSLT to evaluate sleep-
the awakening time by 30 min (TST was not different iness (BaHammam, 2004; Roky et al., 2003). One study
between BL, BLF and Ramadan). Apart from the above using a portable, at-home PSG recording device demon-
results, we found that the sleep architecture was within strated increased daytime sleepiness at 10:00 hours and
normal parameters, and revealed no difference between BL 12:00 hours toward the end of Ramadan (Roky et al., 2003).
and BLF. During experimental fasting consisting of 7 days of In the other study (BaHammam, 2004), a standard MSLT was
underfeeding, Michalsen et al. (2003) reported no changes in performed in the sleep laboratory, circumventing the limita-
TST or sleep stages, and a significant reduction in the tion of the previous study. No differences in sleep latency,
arousal index. Moreover, the participants reported improve- sleep-onset frequency and WE were observed between the
ment in the quality of sleep during the fasting period first and third weeks of Ramadan and BL (BaHammam,
(Michalsen et al., 2003). 2004). However, previous studies measured TST for only
Using subjective and objective assessment tools, the 1 night prior to performing the MSLT. Therefore, the possi-
current study revealed no difference in daytime sleepiness bility of prior sleep restriction on the nights before the PSG
between BL and BLF. Previous studies have reported and MSLT tests was not taken into account. This limitation is
conflicting data on the effect of Ramadan fasting on daytime important because chronic partial sleep restriction may
sleepiness. Although some studies using the ESS have influence daytime sleepiness (Balkin et al., 2008). In the
reported a significant increase in daytime sleepiness during current study, we monitored TST at home prior to each
the entire month of Ramadan (Bahammam, 2006), others monitoring in the sleep centre using actigraphy to ensure that
found no significant change (BaHammam, 2004, 2005; the participants maintained the TST at home. In the free living
Margolis and Reed, 2004). This difference may be attributed environment, the bedtime and awakening time were delayed
to the different groups studied. Previous studies recruited during Ramadan only, which may reflect the delay in starting
different groups of volunteers, including medical and univer- work during Ramadan (Bahammam, 2006). Delays in awak-
sity students, who may have had irregular sleep habits or a ening time have been reported in some Islamic countries that
shortening of mean sleep length due to life constraints. delay the starting time of work (Bahammam, 2006).
Concern has been raised about the effects of lifestyle Recent clinical observations demonstrated an early (within
changes during Ramadan on nTST and thus daytime few days) favourable effect of medically supervised fasting
sleepiness (Bahammam, 2006; BaHammam et al., 2010). (for 7–20 days) on depressive symptoms, and an improve-
We tried to control for these effects by studying the effects of ment in mood, alertness, pain and a sense of tranquility
fasting outside the Ramadan period, and by controlling for (Fond et al., 2013; Michalsen, 2010). The effect of Ramadan
TST and light–dark exposure during the laboratory monitor- intermittent fasting on mood and depressive symptoms
ing. Our data demonstrated no subjective or objective remains to be determined in well-designed studies.
evidence of increased daytime sleepiness during Ramadan The study has a few limitations that need to be addressed.
fasting when the participants were kept under controlled First, the non-random small sample of subjects recruited in
conditions of fixed TST, caloric intake and light exposure. this study. Nevertheless, small participant numbers are
Researchers have found that food deprivation increases typical in studies that use objective assessment methods
wakefulness in different species (Rashotte et al., 1998). and must be conducted within a limited time (the month of
This effect could be related to the fasting effect on orexin. It Ramadan), as both of these factors limit the number of
has been shown that monoaminergic neurons express recruited volunteers (BaHammam, 2004; Roky et al., 2001).
orexin receptors and are heavily innervated by orexin Second, the lack of a control group; nonetheless, the
neurons (Ohno and Sakurai, 2008). In addition, orexin has recruited subjects acted as a control group for themselves
been shown to activate these wake-promoting neurons in this case-crossover study as the same subjects were
(Ohno and Sakurai, 2008). Direct injection of orexin A into tested in the four study periods.
the laterodorsal tegmental nucleus (a pontine site involved In summary, this study showed that under conditions of afixed
in the regulation of the behavioural states) of cats resulted sleep–wake schedule, a fixed light–dark exposure and a fixed
in an increase in wake time and a decrease in REM sleep caloric intake, Islamic intermittent fasting results in decreased
time (Xi et al., 2001). However, fasting in such experiments REM sleep with no impact on other sleep stages, the arousal
is usually more prolonged than fasting during Ramadan, so index or daytime sleepiness. We anticipate that future critical
we do not know if this evidence can be applied to Islamic research will be performed to help understand the effect of
intermittent fasting. Moreover, recent data have showed that decreased REM sleep during fasting on cognitive function.
intermittent fasting induced brain-derived neurotrophic fac-
tors (BDNFs) in different regions of the brain (Mattson,
ACKNOWLEDGEMENTS
2005). BDNF can improve learning and memory, protect
neurons against oxidative and metabolic insults, and This study was supported by a grant from the National Plan
stimulate neurogenesis (Mattson, 2005; Mattson et al., for Science and Technology, Saudi Arabia. The authors A. S.
2002). B, K. A, S. R. P and M. M. S were equally contributed.

ª 2013 European Sleep Research Society


42 A. S. BaHammam et al.

Hagan, J. J., Leslie, R. A., Patel, S. et al. Orexin A activates locus


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