By Khaleel Ahmed MD, DABSM, Sleep medicine specialist, and Mohammed Saleem. Originally published in June 2016.
Ramadan brings plenty of uplifting experiences—the awareness of God in meeting the challenge of fasting throughout the day, the joys of breaking our fast with family and friends, the increased sense of community, and the spiritual highs of more prayer and reading the Qur’an. Out of the grace of God, good deeds are easier to do, the mosques are packed, and even fasting can feel easier as our bodies become accustomed to it as the month progresses.
One thing however never seems to get easier. We get tired, really tired. We get sleepy, or even worse, we can’t sleep when we want to. The disruptive effects of Ramadan on our sleep pattern are well-known to many who observe the month. Short-term spiritual adrenaline alone may help mitigate the effects briefly, but typically it is followed by a crash of fatigue, often at the times we want to be increasing our spiritual efforts the most in the second half of the month. Persevering throughout the month requires us to take notice of our body’s needs so it can serve our spiritual needs better. Just as we should pay attention to when and how we consume in the month, we need to do the same with our sleep. (Short on time? To proceed directly to sleeping tips for Ramadan, click here)
How We Eat Affects How We Sleep
Ramadan for most of us is distinguished by an abrupt change in eating habits. Caloric intake increases at night, meal times are shifted, and cortisol and insulin levels become increased at night in Ramadan. Cortisol is important in times of stress, as too little of it leaves us feeling chronically fatigued. It plays a major role in nutrition in regulating energy and under stress it provides the body with glucose. But it also influences our appetite and cravings for high-calorie foods. It can be assumed that this shift in cortisol and insulin rhythms during Ramadan may in fact help by increasing our appetite for the meal before dawn (suhur). When chronically elevated however, cortisol can have harmful effects on weight, immune function, and chronic disease risk.
If higher levels of cortisol — and the resulting stimulation of appetite — are potentiated by our own poor food choices during Ramadan, deleterious changes on our health and sleep can result. Though most research confirms temporary weight loss for most (which typically returns after Ramadan), studies conducted in volunteers in Saudi Arabia reported a significant increase in caloric, fat, carbohydrate and protein intake, as well as a significant increase in body weight, despite a significant reduction in meal frequency during Ramadan. This can be attributed to the result of excessive eating during the night. Such excessive eating, particularly prior to sleep, leads to sleep disorders and increased acid reflux into the esophagus, which affects sleep quality. So if we want to sleep well in Ramadan, it can be argued that we need to eat even more moderately and healthier in Ramadan than other times, which would be more consistent with its spiritual goals.
The fact that we fast for an entire month may allow a physiological adaptation to the stress of fasting given its duration. Following the Sunnah of regular habitual fasting on Mondays and Thursdays, as well as other recommended times, could help acclimatize our bodies for the more intensive fasting period of Ramadan. Moreover, the health benefits of regular fasting are well documented, including a 2008 study conducted in Utah which found it decreased the risk of contracting coronary disease, and a 2014 follow up study that found that fasting instigates metabolic changes that lowers “bad” cholesterol levels and blood sugar levels. We must always keep in mind that these health benefits of fasting observed in scientific research are tied to an overall decreased caloric intake. This is consistent with the Prophetic approach to eating less overall when fasting, contrary to the practice of many Muslims who eat more during Ramadan, basically negating the medical (and often spiritual) benefits.
Having a background level of “fasting fitness” prior to Ramadan could help lessen the severity of the abrupt physiologic changes that can occur if we were to otherwise approach Ramadan like the “weekend warrior” who is usually sedentary until jumping into sudden rigorous physical activity, unprepared and thus more liable to injury. A gradual or regular exposure to fasting as found in the voluntary Sunnah may also lessen the subjective intensity of the swings in our sleeping patterns that inevitably occur in Ramadan.
Ramadan & Rapid Eye Movement Sleep (REM)
Researchers have long recognized that food deprivation has been shown to increase wakefulness and markedly reduce rapid eye movement sleep (REM), the phase of the sleep cycle which requires the most brain energy use and associated with dreaming. Graeme Mitchison and Francis Crick proposed in 1983 that the function of REM sleep "is to remove certain undesirable modes of interaction in networks of cells in the cerebral cortex", a process they characterize as "unlearning". As a result, those memories which are relevant are further strengthened, whilst weaker, transient, "noise" memory traces disintegrate. REM sleep helps us with preservation of certain types of memories, specifically procedural memory, spatial memory, and emotional memory.
Does fasting in Ramadan then decrease our REM sleep? Most likely, it can, though it may not be across the board for everyone. Participants fasting in Ramadan in a study published in Sleep and Biological Rhythms were found to have a significant reduction in sleep latency (the duration it takes for a person to fall asleep) and REM sleep during the third week of Ramadan; otherwise, there was no significant effect on their sleep architecture. In other words, for a period during the month, they fell asleep faster, but had less REM sleep.1 Another study confirmed that fasting only decreased REM sleep but had no other effect on other sleep stages.
If an individual is REM sleep-deprived, their body will want to recover by increasing the number of attempts to go into the REM stage when they sleep again. On these “recovery” nights, he or she will most likely move into deeper stages of sleep (stage 3 and 4) and REM sleep more quickly. This REM rebound allows the person to catch up on their REM sleep. If however no recovery takes place and REM sleep- deprivation becomes complete, mild psychological disturbances, such as anxiety, irritability, and difficulty concentrating may develop and appetite may increase. Whether and how long-term REM deprivation has psychological effects remains a matter of controversy.
Although studies show that Ramadan fasting can decrease the duration of our REM sleep stages, there may be positive consequences of REM deprivation. Some symptoms of depression are found to be suppressed by REM deprivation, and most antidepressant medications selectively inhibit REM sleep. It has been suggested that acute REM sleep deprivation can improve certain types of depression when depression appears to be related to an imbalance of certain neurotransmitters. Fasting in itself has also been clinically observed to have a favorable effect on depression, even after only a few days, with improved mood, alertness, pain and a "sense of tranquility".
Ramadan, Daytime Sleepiness and Performance
With a potential decrease in total sleep duration and fasting leading to food deprivation, it has been assumed that fasting in Ramadan makes us feel sleepier during the day. While subjectively this may seem true, a study of employees of King Khalid University Hospital found no objective evidence for increased sleepiness during fasting. Research demonstrated shifts in sleep schedules, with delayed bedtimes and wake times, while other studies showed a reduction in total sleep time of about 1 hour from the normal baseline.
Though self-reported fatigue increases during Ramadan, several studies, including those in fasting athletes, showed performance did not suffer. Despite the observed disturbances in sleep patterns in a group of trained cyclists, Ramadan fasting did not negatively impact their cognitive performance, while others have found that when fasting athletes’ sleep schedule was controlled, the effects on physical performance were negligible. Another study in fact found improved abilities in the mornings, with functional decline in the late afternoon. It has not been studied if the shifts in cortisol or insulin during fasting may have any effect on this. Moreover, further research is required to assess the effects that decreased REM sleep during fasting has on cognitive performance.
What might this all mean? Our performance level during Ramadan may be robust enough to not be negatively impacted by the fatigue we subjectively feel. Alleviating that subjective tiredness may lie in paying attention to how well we sleep and understanding the patterns of our sleep.
Strengthening Our Biological Clock in Ramadan Through the Prophetic Example
In addition to the shift in our eating habits and mealtimes during Ramadan, other factors may affect our sleep pattern during Ramadan. All of us have a built-in biological clock, which is essential in optimizing and regulating our sleep and other important biological processes, including hormonal and metabolic functions. These circadian rhythms take a major cue from sunlight and the day-night cycle to set this clock. Melatonin is a marker for the circadian rhythm, and signals our brains to know when it is time to sleep and when it is time to wake up. Normally, melatonin rises as the body prepares to sleep.
Modern industrial life has posed serious challenges to these fundamentally important biological rhythms. Artificial light makes nighttime darkness optional, disrupting our circadian rhythms, pushing them to a later schedule than the normal solar cycle, which means our biological nighttime starts later at night and finishes later in the morning. Exposure to light at night inhibits the release of melatonin, throws the 24-hour circadian rhythm out of sync with the solar day, and alters our primitive innate natural sleep-wake cycle. Studies showed that when teenagers lived in the wilderness, sleeping and waking in natural light, without the presence of artificial light, their bodies returned to a natural alignment with the 24-hour solar cycle. These results reveal just how powerful these biological rhythms are—and how significant a challenge artificial light can pose to their proper functioning.
When we then take into account that short-term fasting has also been reported to decrease melatonin levels, finding ways to strengthen our natural circadian clock in Ramadan becomes even more important. We can strengthen our circadian clock sleep schedules by getting sunlight in the morning. Exposure to sunlight in the early morning hours will reinforce our circadian rhythms, and can help counterbalance the effects of exposure to artificial light. Spending as little as 10 minutes outdoors in the morning will help push our circadian clock slightly earlier, more in sync with the solar day. This makes us feel more alert during the daytime and more ready for sleep at night. Reducing exposure to artificial light in the night and having a darkened bedroom is critical to sleeping well and maintaining a more natural circadian rhythm.
If we look at the example of the Prophet ﷺ and earlier generations, their typical sleeping lifestyle was closest to a natural circadian rhythm. Being awake at Fajr and starting the day with sunrise, maximizing the exposure of sunlight in the first half of the day, and sleeping after Isha at nightfall reinforces our natural body clock. Moreover, the Sunnah nap taken between Dhuhr and Asr is also consistent with this rhythm, as we all have an innate propensity to feel sleepy in the afternoon, even after adequate nocturnal sleep, a phenomenon called the “circadian dip”. Just as we have a significant drop in body core temperature and alertness at night that predisposes us to sleep, there is a similar but smaller drop in the middle of the day from the circadian dip.
The sleeping habits of previous generations may arguably have helped them be able to reach a spiritual and physiologic state where they eventually could sleep less—and worship more—at night. Like fasting, sleeplessness is one of the tools an earnest seeker on the path of spiritual purification (tazkiyah) uses as a means of striving (mujahadah) against the self, and indeed Ramadan challenges us specifically in our sleep in that regard, as part of the soul’s refinement that takes place in the month. This however does not necessarily mean we ignore our health, as eating and sleeping healthy, if done with the right intention, can help us maximize both the quality and quantity of our worship (ibadah) and other noble pursuits, and thus be acts of worship themselves. Here are some tips on how to sleep well, both in Ramadan and at other times of the year:
1. Get enough hours in a consolidated block of sleep
The month of Ramadan is usually an exception for standard sleep recommendations, but try to sleep a regular set of hours on most days when possible. Everyone has a different physiologic need in terms of the total sleep hours they need. Generally it is recommended to have a consolidated block of sleep at night and a short nap in the afternoon if you get sleepy (if that afternoon nap does not affect your ability to fall sleep at night). The brain tracks sleep in 24-hour cycles and we can get it in one stretch or multiple broken naps. With multiple naps however, we typically do not feel rested enough or fresh during those naps. Moreover, for people who have insomnia, they need a consolidated block of sleep as fragmenting sleep makes their insomnia worse.
The longer we are awake, the more we accumulate sleep debt or the pressure to fall asleep. This also can make it harder for us to wake up for suhur if he have not had enough duration of sleep. Getting in a consolidated block (e.g 4-5 hours) of sleep at night could make it easier to wake up for suhur and salatul-Fajr.
2. Get daylight to strengthen your circadian rhythm
Increase your exposure to sunlight, especially in the first half of the day. Even as little as 10 minutes can help and the early morning is the best. This will help recalibrate your body clock to a more natural rhythm and better sleep pattern.
3. Avoid artificial light at night, including electronic devices and entertainment
Avoiding or decreasing exposure to artificial light will also strengthen our circadian rhythm. Make sure your bedroom is dark when you sleep; it is critical for falling asleep and for sleeping well throughout the night. If you need to get up to use the bathroom during the night, use a small nightlight without turning on an overhead light.
Keep electronic devices out of the bedroom. Tablets, phones and laptops—these devices emit light that when used at bedtime can interfere with your sleep cycle. The easiest and most effective way to prevent this is to keep your bedroom gadget and screen free. Make the last hour before bed an electronic curfew/digital-free time to allow your body to prepare for sleep.
As Ramadan is about nourishing ourselves spiritually, many individuals and families curb watching television and consuming media in the month of Ramadan. Along with decreasing exposure to artificial light to improve sleep, this adjustment in schedule will also help increase sleep duration and reduce sleep deprivation.
4. Eat right
A healthy, balanced diet will help you to sleep well, but timing is important. Some people find that a very empty stomach at bedtime is distracting, so it can be useful to have a light snack, but a heavy meal soon before bed can also interrupt sleep. Some recommend a warm glass of milk, which contains tryptophan, which acts as a natural sleep inducer.
5. Make your bedroom a cave
Make your bedroom quiet, dark, and a little bit cool. An easy way to remember this: it should remind you of a cave. While this may not sound romantic, it seems to work for bats. Bats are champion sleepers. They get about 16 hours of sleep each day. Maybe it’s because they sleep in dark, cool caves. It is very important that your bed and bedroom are quiet and comfortable for sleeping.
6. Do wudu (ablution) before you sleep and sleep in a state of dhikr (remembrance of God)
The Messenger of Allah ﷺ advised us to always perform ablution (wudu) before sleeping. Not only is this a great source of blessing on its own, but he ﷺ also indicated the angels pray for the one who sleeps in a state of purification.2
Performing wudu may also aid in falling asleep as it may cause a shift in body temperature. Research shows that sleepiness is associated with a drop in body temperature. This is the same reason a hot bath 1-2 hours before bedtime can also be useful, as it will raise your body temperature, causing you to feel sleepy as your body temperature drops again.
Reciting Qur’an and several supplications and litanies of dhikr when going to bed is well established in many narrations of the Prophet ﷺ. This not only has immense spiritual benefit but also the associated calming, meditative effect that can promote good sleep.
7. Sleep in the right position
It is recommended to sleep on the right side while facing the Qiblah if possible and keeping the right hand placed under the right cheek as per the practice of the Messenger ﷺ. From a medical standpoint, people sleep better on their side and worst on their back if they have sleep apnea. Side sleeping can improve the quality of sleep by reducing sleep apnea and snoring.
8. Take the short mid-day nap (Qaylulah) of the Sunnah.
The risk of heart disease is shown to be greatly reduced by regular 30 minute naps. The Qaylulah can be about 15 to 30 minutes in duration. A 15 minute nap is enough time to turn the nervous system off and can recharge the whole system. For those who work, using the lunch break to find a spot or the car to catch a half hour nap will go a long way in improving productivity. Apart from setting your own alarm on your phone, have a family member or friend call you as well to wake you up in time.
For people who do not have the liberty to take a Qaylulah nap, taking a 15 min break as time off from their busy schedule for relaxing, praying or meditating could be helpful.
9. Have a regular bed and wake time, even on weekends
One of the best ways to train your body to sleep well is to go to bed and get up at more or less the same time every day, even on weekends and days off. This regular rhythm will make you feel better and will give your body something to work from.
10. Have a sleep ritual
You can develop your own rituals of things to remind your body that it is time to sleep. Some people find it useful to do relaxing stretches or breathing exercises for 15 minutes before bed each night, or sit calmly with a cup of caffeine-free tea.
11. Sleep when sleepy
Only try to sleep when you actually feel tired or sleepy, rather than spending too much time awake in bed.
12. Avoid caffeine within four hours of your desired bedtime
Having caffeine too close to bedtime may keep you from being able to fall asleep right after Taraweeh and waking up in time for Suhoor. It is best to avoid consuming any caffeine (in coffee, tea, cola drinks, chocolate, and some medications) for at least 4-6 hours before going to bed, as it acts as a stimulant and interferes with the ability to fall asleep.
13. Keep your bed for sleeping
It is also important to not use your bed for anything other than sleeping and sex, so that your body comes to associate the bed with sleep. If you use your bed as a place to watch TV, eat, read, work on your laptop, pay bills, and other things, your body may lose the association of bed with sleep. This can create major sleep problems especially in people suffering from insomnia.
14. No clock-watching
Many people who struggle with sleep tend to watch the clock too much. Frequently checking the clock during the night can wake you up (especially if you turn on the light to read the time) and reinforces negative thoughts such as “Oh no, look how late it is, I’ll never get to sleep” or “It’s so early, I have only slept for 5 hours, this is terrible.”
15. Get up & try again
If you haven’t been able to get to sleep after about 20 minutes or more, get up and do something calming or boring until you feel sleepy, then return to bed and try again. Sit quietly on the couch with the lights off (bright light will tell your brain that it is time to wake up), or read something boring like the phone book. Avoid doing anything that is too stimulating or interesting, as this will wake you up even more.
16. Keep daytime routine the same
Even if you have a bad night's sleep and are tired it is important that you try to keep your daytime activities the same as you had planned. That is, don’t avoid activities because you feel tired. This can reinforce insomnia.
A great day starts with a good night’s sleep! Ramadan is not only a period of fasting and spiritual growth, but also an underutilized opportunity to ring in a holistic lifestyle that could allow us to reap lasting spiritual and health benefits if consistently practiced throughout the year. May God make our sleeping, eating and all our activities a means to bring us closer to Him.
1. The eating of meals exclusively at night during Ramadan has been proposed to increase the nocturnal body temperature. Because REM sleep is inversely proportional to core temperature (Krueger and Takahashi, 1997), a nocturnal increase in temperature would be expected to decrease REM sleep (Libert et al., 1988).
2. The Messenger of Allah (Allah bless him and give him peace) said, “When you go to bed, you should perform the ablution (wudu) for the prayer, and then lay down on your right side. Then say, ‘O Allah, I have turned my face to You and I have surrendered myself to You and I have committed my back to You out of fear and desire for You. There is no place of safety or refuge from You except with You. I have believed in Your book which You revealed and Your Prophet whom You sent.’ If you die that night, you will die in fitra (natural state). And make these the last words you utter.'” [Bukhari]
It is reported that the Messenger of Allah (Allah bless him and give him peace) said, “Purify these bodies, and Allah will purify you. There is not a slave who spends his night in a state of purification except that an angel spends the night besides him. And whenever the slave turns over during the night, the angel says: ‘O Allah, forgive Your slave, for he went to sleep in a state of purification.’” [Tabarani, al-Mu`jam al-Kabir]. Retrieved from http://seekershub.org/ans-blog/2014/06/30/on-the-rewards-of-sleeping-in-a-state-of-ritual-purity-wudu/ May 24, 2016.