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.
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