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International journal of Sport Studies for Health: Vol.1, issue 4; e83782
published online: September 12, 2018
article type: Review Article
received: July 3, 2018
accepted: September 4, 2018
DOI: https://doi.org/10.5812/intjssh.83782
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Evolution of Dietary Intake Between Before, During and After Ramadan Observance in Tunisian Physically Active Men: A Systematic Review

authors:

avatar Omar Boukhris 1 , * , avatar Khaled Trabelsi 1 , avatar Hamdi Chtourou ORCID 1

UR15JS01: Education, Motricite, Sport et Sante (EM2S), High Institute of Sport and Physical Education, University of Sfax, Sfax, Tunisia

how to cite: Boukhris O, Trabelsi K, Chtourou H. Evolution of Dietary Intake Between Before, During and After Ramadan Observance in Tunisian Physically Active Men: A Systematic Review. Int J Sport Stud Health. 2018;1(4):e83782. https://doi.org/10.5812/intjssh.83782.

Abstract

Objective:

The present review was designed to systematize the literature on the evolution of dietary intake in Tunisian physically active subjects (i.e., physically active men and physical education students) between before, during and after Ramadan observance.

Evidence Acquisition:

Two electronic databases, PubMed and Science direct, were searched using a comprehensive strategy. Studies published prior to August 2018 were included if they assessed dietary intake during Ramadan in Tunisian physically active subjects. A narrative synthesis of findings was conducted.

Results:

Nine studies evaluated the dietary intake change between before, during and after Ramadan observance. Energy intake decreased in three studies and did not change in six studies. One study showed decreases in fat intake during Ramadan, two studies reported increases and six studies did not report significant changes. Protein intake decreased in three studies, increased in one study and did not change in five studies. Carbohydrate intake did not change in six studies and increased in three studies. Total water intake decreased in four studies and did not change in one study.

Conclusions:

The literature does not support that Ramadan fasting had adverse effect on dietary intake.

1. Context

Ramadan (i.e., 29 to 30 days) intermittent fasting (i.e., from dawn to sunset) from eating, drinking, smoking, and certain other behaviors is a fundamental rule of Islam (1). The daytime fasting depends on the climatic conditions as Ramadan advances ~11 days each year and could, therefore, occur in all season (2). Likewise, daytime fasting is strongly influenced by the geographical location of Muslims (3) and could be, in some countries, longer than 18 h in summer. In other countries located at the poles, the duration of the fast could be longer, which represents a real challenge for the fasters. In this context, a previous study reported an increase in the risk of accidents during Ramadan due to changes in the lifestyle (4). This implies some loss of cognitive and/or physical performances (5-7), both of which are important elements of performance. Therefore, a good diet is essential to be in good health.

Every day, Muslims take two main meals called Sahour and Iftar (8). The requirement to eat only in a short period of time leads to a disturbed circadian rhythm and to several changes in food intake timing (4). During Ramadan, changes are not only related to food intake timing, but the quantity and type of meals is different to that eaten in pre- or post-Ramadan (9, 10). In fact, a precious study showed that Ramadan is accompanied with higher lipid and protein intakes (11). Conversely, a decrease in carbohydrate consumption was observed during this month (11). Such dietary changes can in turn impact both the utilization and the storage of substrates, and entail to variations of body composition (1). Such a contradiction in the literature is probably due to different cultures in Islamic countries. In reality, variability of results depended on the region and conditions surrounding Ramadan fasting (12, 13). In this respect, many authors reported that the dietary intake during Ramadan remains substantially the same compared to the control period (i.e., before Ramadan) (14, 15). However, other studies have shown a decrease in daily calorie intake during Ramadan (16, 17). Amongst the changes affecting daily habits during Ramadan observance, we can distinctively observe either qualitatively or quantitatively dietetic-related changes.

Nowadays, no-previous study provided a systematic literature reviews on Ramadan intermittent fasting and subsequent effect on dietary intake in Tunisian physically active subjects. Systematic literature analysis provide a synthesis of the published results about a precise topic (e.g., dietary intake) from which conclusions could be drawn and decisions made by gathering data from different sources (18, 19). Therefore, the present review was designed to systematize the literature on the evolution of dietary intake in Tunisian physically active subjects between before, during and after Ramadan observance.

2. Evidence Acquisition

2.1. Protocol

Based on the guidelines of the preferred reporting items for systematic reviews and meta-analysis (PRISMA), this systematic review was prepared (20).

2.2. Eligibility Criteria

Single-group pre-post design and crossover design studies were included in the systematic review. All the included studies compared the outcomes before, during and after Ramadan intermittent fasting. All articles that assessed dietary intake and/or energy intake and/or carbohydrate intake and/or fat intake and/or protein intake were included.

Samples were required to consist of Tunisian physically active men, with a mean participant age of 18 years or older.

Only articles, written in English or French, published or accepted for publication in peer-reviewed journals were considered. No restrictions in terms of study design, setting or time frame were considered.

Articles that were strictly descriptive (i.e., review articles), conference proceedings, and articles carried on athletes or subject carrying diseases were excluded.

2.3. Information Sources and Search

Two electronic databases, PubMed and Science direct, were searched without any time limits or Filters. The last search was completed in August 25, 2018. The following combination of keywords was used when searching: [(Ramadan) OR (Ramadan fasting) OR (Ramadan observance) AND [(dietary intake)) OR (energy intake)] AND [Tunisian].

Otherwise, to minimize the risk of missing important manuscripts, the reference lists of the selected studies were verified in addition to the related Google Scholar’ citations from other journals. Specialists in the field were also contacted for possible upcoming studies. Also, target journals (i.e., Clinical Journal of Sport Medicine, International Journal of Sport Nutrition and Exercise Metabolism, Asian Journal of Sports Medicine, Chronobiology International, Journal of the International Society of Sports Nutrition) were hand-searched for possible accepted studies in the field.

2.4. Study Selection

The method of studies selection is outlined in Figure 1. Duplicate studies were removed from the first search results using EndNote.

Titles and abstracts of the selected studies were independently screened by two authors (Omar Boukhris and Khaled Trabelsi) for eligibility and resolved disagreements by consensus. Full texts of the selected manuscripts were subsequently screened for eligibility and disagreements once more resolved by consensus.

2.5. Data Collection Process

Using a pilot-tested extraction form, the two reviewers (Omar Boukhris and Khaled Trabelsi) independently collected data (i.e., including study characteristics (i.e., study design, methodology of dietary intake assessment), participant characteristics (i.e., age, number of participants, sex, and findings) and resolved disagreements by consensus.

Flowchart of studies selection
Flowchart of studies selection
Figure 1.

Flowchart of studies selection

3. Results

3.1. Study Selection

Nine studies were considered eligible for this systematic review.

3.2. Study Characteristics

Data of the nine selected studies are presented in Table 1 in order of publication date. The included studies showed a range of study designs: All of subjects participating in the studies are men. Mean age of physically active undertaking training during Ramadan observance varied from 18 to 27 years. The total population size included in this review was 93.

3.3. Dietary Intake

A total of nine studies, published between 2007 and 2018, describing the change of dietary intake between before and during Ramadan observance for Tunisian physically active subjects are shown in Table 1.

3.3.1. Energy Intake

Compared to pre- and post- Ramadan, six studies indicated that daily energy intakes remained similar during Ramadan (14, 21-25). However, three studies showed a decrease of energy intake (26-28).

3.3.2. Fat Intake

Six studies revealed no-changes during Ramadan in comparison to the control period (14, 21-24, 28). On the other hand, one study reported that the fat intake was lower during Ramadan than control periods (26). However, Trabelsi et al. (27) and Boukhris et al. (25) showed that the fat intake increased during the month of Ramadan.

3.3.3. Carbohydrate Intake

Three studies showed that carbohydrate intake decreased during Ramadan in comparison to control periods (21, 26, 27). However, six studies have reported the absence of change in carbohydrate intake between periods during and outside Ramadan (14, 22, 23, 25, 27, 28).

3.3.4. Protein Intake

Three studies observed increased protein ingestion during compared to before or after Ramadan (21, 23, 27). Conversely, one study showed a decrease in protein intake during Ramadan compared to control periods (26). However, the absence of change in protein consumption during Ramadan compared to control periods was reported by six studies (14, 22-25, 28).

3.3.5. Total Water Intake

Six studies assessed total water intake during Ramadan in physically active men. Trabelsi et al. (21, 22, 24, 27) reported a decrease in total water intake during in comparison to before Ramadan. However, Bouhlel et al. (28) reported that fluid intake did not change during Ramadan in comparison with control periods.

Table 1.

Changes of Dietary Intake During Ramadan

Study SubjectsAgeGenderTraining Program Measures Methods of Assessment Findings
Souissi et al. (14)1222.6 ± 1.3Male-One week before Ramadan; The second week of Ramadan; The fourth week of Ramadan; Two weeks after RamadanDietary records during 3 days of each week of physical testing.No change of dietary intake
Abedelmalek et al. (26)922.1 ± 0.2Male-The first week of Ramadan; The fourth week of Ramadan; Three weeks after RamadanDietary records during 3 days of each week of physical testing.Decrease of the mean energy and macro-nutrient intake during compared to after Ramadan
Trabelsi et al. (21)1026.6 ± 3.0MaleAerobic exercise (i.e., jogging and swimming) for recreational purposes for at least 3 times/weekThree days before Ramadan; The 15th day of Ramadan; The 29th day of Ramadan; 21 days after RamadanDietary records (7 days before Ramadan and during 3 days of each week of Ramadan).No-changes of energy and fat intake; protein intake increased during compared to before Ramadan; a significant decrease of carbohydrate intake was observed during compared to before Ramadan; total water intake decreased during compared to before Ramadan.
Trabelsi et al. (27)1223.8 ± 4MaleFour two-hour training sessions each weekOne day before the beginning of Ramadan; At the end of the first week of Ramadan; At the end of the fourth week of RamadanDietary records (7 days before Ramadan and during 3 days of each week of Ramadan)Compared to before and during Ramadan: The total daily energy intake was significantly lower; the fractional contribution of protein and fat to the daily diet was greater; the fractional contribution of carbohydrates to the daily diet was lower; total water intake was significantly higher.
Trabelsi et al. (22)924 ± 3MaleBodybuilding (hypertrophic program) for recreational purposes at least three times /weekTwo days before Ramadan; On the 29th day of RamadanDietary records (7 days before Ramadan and during 3 days of each week of Ramadan).No-changes of dietary intake; total water intake decreased during compared to before Ramadan.
Trabelsi et al. (23)1026.6 ± 3.0MaleAerobic training (continuous exercise) at least three times/weekThree days before Ramadan; The 15th day of Ramadan; The 29th day of Ramadan; 21 days after RamadanDietary records (7 days before Ramadan and during 3 days of each week of Ramadan).Energy, fat and carbohydrate intake did not change during compared to before Ramadan; protein consumption was significantly higher during the period between the beginning and Mid-Ramadan compared to before Ramadan; total water intake was significantly higher before than during Ramadan.
Bouhlel et al. (28)1021.8 ± 1.9MaleThey trained for 16 h/week (soccer, handball, basketball, volleyball, gymnastics, and athletics)One week before Ramadan; At the end of the first week; During the fourth week of RamadanDietary records (One week before Ramadan and during each day of Ramadan).No change of protein, fat, carbohydrate and fluids intake; energy intake was lower during compared to before Ramadan.
Trabelsi et al. (24)825 ± 3MaleBodybuilding (hypertrophic program) for recreational purposes at least three times/weekTwo days before Ramadan; On the 29th day of RamadanDietary records (7 days before Ramadan and during 3 days of each week of Ramadan).No change of dietary intake; total water intake decreased during compared to before Ramadan.
Boukhris et al. (25)1321.2 ± 2.9MaleThey regularly practice physical exercise (e.g., jogging) for at least 3 hours per week15 days before Ramadan; First ten days of Ramadan; Last ten days of Ramadan; 10 days after Ramadan; 20 days after RamadanDietary records (7 days before Ramadan, during each day of Ramadan, 20 days after Ramadan) followed by an interview with a nutritionist.No change of energy intake; fat intake increased during Ramadan in comparison with control periods; there was no-significant differences in the fractional contribution of protein intake; the fractional contribution of carbohydrate in percentage was significantly higher after 10 days of Ramadan compared to during and after 20 days of Ramadan.

4. Discussion

This is the first systematic review, to the best of our knowledge, to investigate the evolution of dietary intake between before, during and after Ramadan intermittent fasting in Tunisian physically active subjects. It is worth noting that during Ramadan, peoples are faced with a change in the eating habit including food intake schedule since they have the opportunity to eat only during the night.

However, this does not mean that this change in eating time will induce a decrease in food intake because usually peoples try to have the same number of usual meals (i.e., two or three meals). Broadly, the effects of Ramadan intermittent fasting on dietary intake may be summarized as neutral. To maintain energy balance, some sedentary people still eat enough; however, others consume less food to overcome any sleep difficulties at night or for the exploitation of the opportunity of fasting to lose weight (29, 30). Additionally, it seems that with the proper coaching encouragement, an athlete, during the feed period of the day, could consume enough food and fluid to overcome the effect of the daytime fasting. Nevertheless, these statements could not be generalized due to differences (i) in people’s desire to eat extra-food and/or (ii) in the training load during Ramadan.

In term of qualitative analysis of food, the composition of meals varies according to local eating habits (31). In the present review, six studies indicated that, in comparison to pre- and post-Ramadan, the daily energy intake was maintained during Ramadan (14, 21-25). However, other reports indicated, (i) in Saudi subjects, increases of total energy intake (32) or (ii) in Indian Muslims, decreases of daily energy intake (33). In the present systematic review, three studies showed a decrease of energy intake (26-28). Evidently, in Islamic countries, this contrariness is probably related to differences in food habits (11).

Concerning the fat intake, six studies revealed no-changes during Ramadan in comparison to control periods (14, 21-24, 28). On the other hand, one study reported that the fat intake was lower during Ramadan than control periods (26). However, two studies showed that the fat intake increased during the month of Ramadan (25, 27). An increase in lipid intake can lead to an increase in the consumption of saturated fatty acids, which could contribute to an increase of low density lipoprotein (LDL) cholesterol concentrations (34), and subsequently might lead to atherosclerosis.

Previous studies observed a high ingestion of protein during compared to before or after Ramadan (21, 23, 27). These findings could be explained by the large consumption of receipts based on meat, chicken and eggs during Ramadan (35). These results were in agreement with others studies which indicated the higher consumption of protein (32, 36). Indeed, most sports nutrition guidelines recommend an after training protein intake (37) could be better for recovery and adaptation process within the exercised muscles. Therefore, athletes who train during Ramadan are advised to change their training times to be in the early morning or the late the evening (38). On the contrary, one study reported a decrease of protein intake during Ramadan compared to control periods (26). However, the most of studies have noticed no-changes on the consumption of protein during Ramadan in comparison with control periods (14, 22-25, 28).

Concerning the portion of carbohydrate, some studies demonstrated that the diet is characterized by a decrease in carbohydrate intake during Ramadan (21, 26, 27). Changes in foods compositions during the fasting month indicate a slight reduction in the carbohydrate contribution to energy intake, which may cause a decrease in blood glucose concentration toward the end of the day (39). Furthermore, a low carbohydrate diet may reduce the buffering capacity of the blood during intense muscular contractions (40). Therefore, it is recommended to ingest a low glycemic index at Sahour meal to prolong the release of sugars into the blood (41). However, six studies have noticed no-changes on the diet of carbohydrate between periods during and outside Ramadan (14, 22-25, 28).

Total water intake decreased in some studies (21-24, 27) and did not change in Bouhlel et al. (28). The decrease in water intake may induce a state of dehydration. This latter may negatively affect cognitive and physical performances (9, 42, 43). Therefore, physically active subjects practicing physical activity during Ramadan are advised to increase water intake (600 mL/h of fluid) during the hours of darkness (43).

The literature does not support the association of Ramadan fasting with any changes of dietary intake in Tunisian physically active subjects.

References

  • 1.

    Chtourou H. Effects of Ramadan fasting on health and athletic performance. New York, NY: Omics International; 2015. https://doi.org/10.4172/978-1-63278-030-0-031.

  • 2.

    Chtourou H, Aloui A, Hammouda O, Haddad M, Souissi N, Chaouachi A, et al. Martial arts and Ramadan fasting with special reference to taekwondo. In: Haddad M, editor. Performance optimization in taekwondo: From laboratory to field. OMICS International; 2014. p. 147-56. https://doi.org/10.13140/2.1.1161.8244.

  • 3.

    Chtourou H, Chtourou L, Trabelsi K, Tahri N, Souissi N. Possible gastrointestinal disorders for athletes during Ramadan: An overview. Biol Rhythm Res. 2017;49(1):51-60. https://doi.org/10.1080/09291016.2017.1333196.

  • 4.

    Maughan RJ, Bartagi Z, Dvorak J, Zerguini Y. Dietary intake and body composition of football players during the holy month of Ramadan. J Sports Sci. 2008;26 Suppl 3:S29-38. [PubMed ID: 19085450]. https://doi.org/10.1080/02640410802409675.

  • 5.

    Chtourou H, Hammouda O, Souissi H, Chamari K, Chaouachi A, Souissi N. The effect of ramadan fasting on physical performances, mood state and perceived exertion in young footballers. Asian J Sports Med. 2011;2(3):177-85. [PubMed ID: 22375237]. [PubMed Central ID: PMC3289213].

  • 6.

    Chtourou H, Hammouda O, Chaouachi A, Chamari K, Souissi N. The effect of time-of-day and Ramadan fasting on anaerobic performances. Int J Sports Med. 2012;33(2):142-7. [PubMed ID: 22318530]. https://doi.org/10.1055/s-0031-1286251.

  • 7.

    Bouguerra L, Ben Abderrahman A, Chtourou H, Zouhal H, Tabka Z, Prioux J. The effect of time-of-day of training during Ramadan on physiological parameters in highly trained endurance athletes. Biol Rhythm Res. 2017;48(4):541-55. https://doi.org/10.1080/09291016.2016.1276271.

  • 8.

    Abedelmalek S, Denguezli M, Chtourou H, Souissi N, Tabka Z. Does Ramadan fasting affect acylated ghrelin and growth hormone concentrations during short-term maximal exercise in the afternoon? Biol Rhythm Res. 2015;46(5):691-701. https://doi.org/10.1080/09291016.2015.1048949.

  • 9.

    Aloui A, Chtourou H, Hammouda O, Chaouachi A, Chamari K, Souissi N. The challenge of rapid weight loss prior to competition for Muslim combat sport athletes during Ramadan. Biol Rhythm Res. 2013;44(6):876-84. https://doi.org/10.1080/09291016.2013.780698.

  • 10.

    Aloui A, Chtourou H, Briki W, Tabben M, Chaouachi A, Souissi N, et al. Rapid weight loss in the context of Ramadan observance: Recommendations for judokas. Biol Sport. 2016;33(4):407-13. [PubMed ID: 28090146]. [PubMed Central ID: PMC5143776]. https://doi.org/10.5604/20831862.1224098.

  • 11.

    el Ati J, Beji C, Danguir J. Increased fat oxidation during Ramadan fasting in healthy women: An adaptative mechanism for body-weight maintenance. Am J Clin Nutr. 1995;62(2):302-7. [PubMed ID: 7625336]. https://doi.org/10.1093/ajcn/62.2.302.

  • 12.

    Chtourou H, Briki W, Hammouda O, Aloui A, Souissi N, Chaouachi A. The effect of the time-of-day of training during Ramadan on soccer players’ chronotype and mood states. Sport Sci Health. 2014;10(2):143-7. https://doi.org/10.1007/s11332-014-0185-x.

  • 13.

    Chtourou H, Hammouda O, Aloui A, Souissi N, Chaouachi A. The optimal time of day for training during Ramadan: A review study. J Fast Health. 2014;2(1):46-52.

  • 14.

    Souissi N, Souissi H, Sahli S, Tabka Z, Dogui M, Ati J, et al. Effect of Ramadan on the diurnal variation in short-term high power output. Chronobiol Int. 2007;24(5):991-1007. [PubMed ID: 17994351]. https://doi.org/10.1080/07420520701661914.

  • 15.

    Chaouachi A, Chamari K, Roky R, Wong P, Mbazaa A, Bartagi Z, et al. Lipid profiles of judo athletes during Ramadan. Int J Sports Med. 2008;29(4):282-8. [PubMed ID: 17879887]. https://doi.org/10.1055/s-2007-965338.

  • 16.

    Bouhlel E, Zaouali M, Miled A, Tabka Z, Bigard X, Shephard R. Ramadan fasting and the GH/IGF-1 axis of trained men during submaximal exercise. Ann Nutr Metab. 2008;52(4):261-6. [PubMed ID: 18617733]. https://doi.org/10.1159/000140517.

  • 17.

    Chennaoui M, Desgorces F, Drogou C, Boudjemaa B, Tomaszewski A, Depiesse F, et al. Effects of Ramadan fasting on physical performance and metabolic, hormonal, and inflammatory parameters in middle-distance runners. Appl Physiol Nutr Metab. 2009;34(4):587-94. [PubMed ID: 19767792]. https://doi.org/10.1139/H09-014.

  • 18.

    Cook DJ, Mulrow CD, Haynes RB. Systematic reviews: synthesis of best evidence for clinical decisions. Ann Intern Med. 1997;126(5):376-80. [PubMed ID: 9054282].

  • 19.

    Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: Elaboration and explanation. BMJ. 2015;350:g7647. [PubMed ID: 25555855]. https://doi.org/10.1136/bmj.g7647.

  • 20.

    Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Ann Intern Med. 2009;151(4):264. https://doi.org/10.7326/0003-4819-151-4-200908180-00135.

  • 21.

    Trabelsi K, El Abed K, Trepanowski JF, Stannard SR, Ghlissi Z, Ghozzi H, et al. Effects of Ramadan fasting on biochemical and anthropometric parameters in physically active men. Asian J Sports Med. 2011;2(3):134-44. [PubMed ID: 22375232]. [PubMed Central ID: PMC3289216].

  • 22.

    Trabelsi K, Stannard SR, Maughan RJ, Jammoussi K, Zeghal K, Hakim A. Effect of resistance training during Ramadan on body composition and markers of renal function, metabolism, inflammation, and immunity in recreational bodybuilders. Int J Sport Nutr Exerc Metab. 2012;22(4):267-75. [PubMed ID: 22855788].

  • 23.

    Trabelsi K, el Abed K, Stannard SR, Jammoussi K, Zeghal KM, Hakim A. Effects of fed- versus fasted-state aerobic training during Ramadan on body composition and some metabolic parameters in physically active men. Int J Sport Nutr Exerc Metab. 2012;22(1):11-8. [PubMed ID: 22248495].

  • 24.

    Trabelsi K, Stannard SR, Ghlissi Z, Maughan RJ, Kallel C, Jamoussi K, et al. Effect of fed- versus fasted state resistance training during Ramadan on body composition and selected metabolic parameters in bodybuilders. J Int Soc Sports Nutr. 2013;10(1):23. [PubMed ID: 23617897]. [PubMed Central ID: PMC3639860]. https://doi.org/10.1186/1550-2783-10-23.

  • 25.

    Boukhris O, Hsouna H, Chtourou L, Abdessalem R, BenSalem S, Tahri N, et al. Effect of Ramadan fasting on feelings, dietary intake, rating of perceived exertion and repeated high intensity short-term maximal performance. Chronobiol Int. 2018;In press. https://doi.org/10.1080/07420528.2018.1513943.

  • 26.

    Abedelmalek S, Souissi N, Takayuki A, Hadouk S, Tabka Z. Effect of acute maximal exercise on circulating levels of interleukin-12 during Ramadan fasting. Asian J Sports Med. 2011;2(3):154-60. [PubMed ID: 22375234]. [PubMed Central ID: PMC3289209].

  • 27.

    Trabelsi K, Rebai H, El-Abed K, Stannard SR, Khannous H, Masmoudi L, et al. Effect of Ramadan fasting on body water status markers after a rugby sevens match. Asian J Sports Med. 2011;2(3):186-94. [PubMed ID: 22375238]. [PubMed Central ID: PMC3289207].

  • 28.

    Bouhlel H, Shephard RJ, Gmada N, Aouichaoui C, Peres G, Tabka Z, et al. Effect of Ramadan observance on maximal muscular performance of trained men. Clin J Sport Med. 2013;23(3):222-7. [PubMed ID: 23160275]. https://doi.org/10.1097/JSM.0b013e318275d213.

  • 29.

    Angel JF, Schwartz NE. Metabolic changes resulting from decreased meal frequency in adult male Muslims during the Ramadan fast. Nutr Rep Int. 1975.

  • 30.

    Hallak MH, Nomani MZ. Body weight loss and changes in blood lipid levels in normal men on hypocaloric diets during Ramadan fasting. Am J Clin Nutr. 1988;48(5):1197-210. [PubMed ID: 3189206]. https://doi.org/10.1093/ajcn/48.5.1197.

  • 31.

    Sobhani I, Rigaud D, Merrouche M, Vatier J. [Digestive and nutritional changes induced by Ramadan fasting. Methodological requirements and pertinence of scientific observations]. Gastroenterol Clin Biol. 1997;21(11):811-2. French. [PubMed ID: 9587530].

  • 32.

    Frost G, Pirani S. Meal frequency and nutritional intake during Ramadan: A pilot study. Hum Nutr Appl Nutr. 1987;41(1):47-50. [PubMed ID: 3558007].

  • 33.

    Chandalia HB, Bhargav A, Kataria V. Dietary pattern during Ramadan fasting and its effect on the metabolic control of diabetes. Practical Diabetes Int. 1987;4(6):287-90. https://doi.org/10.1002/pdi.1960040610.

  • 34.

    Mattson FH, Grundy SM. Comparison of effects of dietary saturated, monounsaturated, and polyunsaturated fatty acids on plasma lipids and lipoproteins in man. J Lipid Res. 1985;26(2):194-202. [PubMed ID: 3989378].

  • 35.

    Agoumi A, Jesus Oliveras Lopez M, Martinez Martinez F, Lopez Garcia de la Serrana H. Evaluation of dietetic changes in the period of Ramadan. J Nutr Food Sci. 2015;5:375. https://doi.org/10.4172/2155-9600.1000375.

  • 36.

    Adlouni A, Ghalim N, Benslimane A, Lecerf JM, Saile R. Fasting during Ramadan induces a marked increase in high-density lipoprotein cholesterol and decrease in low-density lipoprotein cholesterol. Ann Nutr Metab. 1997;41(4):242-9. [PubMed ID: 9363296]. https://doi.org/10.1159/000177999.

  • 37.

    Hawley JA, Tipton KD, Millard-Stafford ML. Promoting training adaptations through nutritional interventions. J Sports Sci. 2006;24(7):709-21. [PubMed ID: 16766500]. https://doi.org/10.1080/02640410500482727.

  • 38.

    Maughan RJ, Fallah J, Coyle EF. The effects of fasting on metabolism and performance. Br J Sports Med. 2010;44(7):490-4. [PubMed ID: 20484315]. https://doi.org/10.1136/bjsm.2010.072181.

  • 39.

    Larijani B, Zahedi F, Sanjari M, Amini MR, Jalili RB, Adibi H, et al. The effect of Ramadan fasting on fasting serum glucose in healthy adults. Med J Malaysia. 2003;58(5):678-80. [PubMed ID: 15190653].

  • 40.

    Filaire E, Maso F, Degoutte F, Jouanel P, Lac G. Food restriction, performance, psychological state and lipid values in judo athletes. Int J Sports Med. 2001;22(6):454-9. [PubMed ID: 11531040]. https://doi.org/10.1055/s-2001-16244.

  • 41.

    Jeukendrup AE, McLaughlin J. Carbohydrate ingestion during exercise: Effects on performance, training adaptations and trainability of the gut. In: Maughan RJ, Burke LM, editors. Sports nutrition: More than just calories-triggers for adaptation. 69. Basel, Switzerland: Karger Publications; 2012. p. 1-17. https://doi.org/10.1159/000329268.

  • 42.

    Tian HH, Aziz AR, Png W, Wahid MF, Yeo D, Constance Png AL. Effects of fasting during Ramadan month on cognitive function in Muslim athletes. Asian J Sports Med. 2011;2(3):145-53. [PubMed ID: 22375233]. [PubMed Central ID: PMC3289210].

  • 43.

    Shephard RJ. The impact of Ramadan observance upon athletic performance. Nutrients. 2012;4(6):491-505. https://doi.org/10.3390/nu4060491.