Mental Health, Sleep, and Physical Activity Among Young Saudi Women During Ramadan: A Comparative Cohort Study

Abstract

Purpose

This study investigated mental health outcomes of young adult women in relation to physical activity and sleep patterns before, during, and after Ramadan.

Participants and Methods

A prospective repeated-measures cohort study was conducted in the Department of Physical Therapy at Jazan University, Saudi Arabia. Healthy women aged 18–30 years were recruited through convenience sampling, with exclusions for chronic illness, pregnancy, lactation, psychological disorders, or recent hospitalization. Self-reported data were collected online at three time points: before Ramadan, during Ramadan, and after Ramadan. The study assessed physical activity using the International Physical Activity Questionnaire–Short Form, sleep quality using the Pittsburgh Sleep Quality Index, and emotional states using the Depression, Anxiety, and Stress Scale-21.

Results

Thirty young adult females participated in the study. Physical activity showed a gradual increase, with significant improvements from pre-Ramadan to Ramadan (p =0.039) and from pre-Ramadan to post-Ramadan (p =0.009). Sleep was significantly disrupted during Ramadan, with shorter duration (p <0.001) and poorer global sleep quality (p =0.002), followed by marked improvement post-Ramadan (all pairwise p ≤.001). Stress levels peaked during Ramadan and declined significantly afterward (p =0.010), whereas depression and anxiety remained stable across all phases (p >0.05). Regression analyses showed that poorer sleep quality significantly predicted higher depression, anxiety, and stress before and during Ramadan (all p ≤.002), but not after Ramadan. Physical activity and BMI were not associated with mental health outcomes.

Conclusion

The study found that while depression and anxiety stayed stable across the Ramadan periods, stress decreased after Ramadan. Sleep quality consistently related to mental health, whereas increased physical activity during Ramadan showed no link to emotional well-being. Overall, sleep and stress emerged as the key factors influencing well-being throughout the Ramadan cycle.

Plain Language Summary

This study explored how Ramadan fasting influences physical activity, sleep, and mental health in young women. Thirty healthy women aged 18–30 years in Saudi Arabia completed online surveys before, during, and after Ramadan to report their activity levels, sleep patterns, and emotional well-being.

Physical activity increased during Ramadan and stayed higher afterward compared to before fasting. In contrast, sleep was noticeably disrupted during Ramadan, with shorter sleep duration and poorer sleep quality. After Ramadan, both sleep duration and overall sleep quality improved significantly.

Mental health patterns showed mixed results. Depression and anxiety levels remained steady across all three phases. Stress levels rose during Ramadan but dropped significantly once Ramadan ended. Poor sleep quality was strongly linked to higher depression, anxiety, and stress before and during Ramadan, but this connection disappeared after Ramadan. Increased physical activity did not show a direct relationship with mental health outcomes.

Overall, Ramadan fasting was associated with more physical activity, temporary sleep disturbances, and improvements in stress and sleep quality after fasting. Sleep quality emerged as an important factor for emotional well-being, suggesting that supporting healthy sleep habits may help young women maintain resilience during lifestyle changes such as Ramadan fasting.

Introduction

Ramadan is a spiritually significant month observed by Muslims worldwide. During this period, adults abstain from food, drink, smoking, and other routine activities for approximately 11 to 20 hours each day, over a span of 29 to 30 days based on the lunar calendar.1 The two main meals during Ramadan are Suhoor (consumed before sunrise) and Iftar (taken after sunset to break the fast).2 Nighttime hours are typically reserved for eating, praying, and socializing, in accordance with Islamic practices, resulting in marked shifts in daily lifestyle behaviors.3

These behavioral changes have been associated with various health benefits, including reductions in body fat, waist and hip circumference, body mass index(BMI), decreased inflammatory markers, and improved metabolic regulation.1,4–7 Altered sleep schedules, delayed bedtimes, and reduced sleep duration are common and may influence both physical activity and mental well-being.8 Evidence regarding physical activity during Ramadan remains inconsistent: while some studies report no significant change across pre, during, and post Ramadan phases, others, such as research conducted in Nigeria and Qatar, indicate notable reductions. These mixed findings highlight the need for further investigation, particularly among female populations in Saudi Arabia, where cultural norms and gender specific lifestyle patterns may shape activity behaviors differently.8,9

Sleep health represents another critical dimension. Research on sleep patterns involving more than 12,000 Saudi adolescents shows that female adolescents are approximately 23% more likely to sleep less than 7 hours per night compared to males, highlighting a gender-based vulnerability to insufficient sleep.10 Saudi females, in particular, tend to reports poor sleep quality, heightened emotional stress, and more disrupted sleep routines, and studies have demonstrated strong associations between inadequate sleep and adverse mental health outcomes such as anxiety, depression, and stress.11–13 During Ramadan, documented changes in sleep patterns, dietary intake, and physical activity may further challenge women who already experience compromised sleep health.14,15 Chronotype adds another layer of complexity, as individuals whose biological sleep-wake preferences misalign with Ramadan’s delayed schedule are more susceptible to circadian disruption, sleep loss, and mood disturbances.16 Additionally, emerging epigenetic evidence suggests that females may be more prone to insomnia symptoms, with anxiety, depression, and stress potentially moderated by the CRY2 gene methylation.17

Physiological responses to Ramadan fasting may also contribute to mental health risks. Study done by Bahijri et al,18 revealed increased hypercortisolism and insulin resistance were revealed during Ramadan, are associated with stress-related conditions such as hypertension and diabetes mellitus. Elevated serum cortisol levels strongly correlated with perceived stress,19 anxiety and depression20,21 and heightened fatigue and tension have been observed among young adults during fasting periods.

Collectively, these findings highlight growing concerns about the mental health of young adults during Ramadan, particularly young women who must balance personal, familial, and social responsibilities alongside the physiological and behavioral demands of fasting. For many females, Ramadan brings additional obligations, such as changes in meal preparation, meal timing and content, household tasks, and family organization, including childcare, which may further intensify daily stress and disrupt established routines. Despite these gender-specific pressures, limited research has explored how Ramadan-related changes in sleep and physical activity intersect with mental health among young adult females in Saudi Arabia. To address this gap, the present study investigates mental health outcomes in relation to physical activity and sleep patterns among young adult Saudi females across the pre, during, and post Ramadan phases.

Materials and Methods

Study Design

This was a prospective, repeated-measures cohort study conducted at the Department of Physical Therapy, College of Nursing and Health Sciences, Jazan University, Saudi Arabia. Healthy females aged 18 to 30 years were included in the study. Individuals with chronic disorders, pregnant and lactating mothers, those with psychological problems, and those admitted to the hospital one month before or during Ramadan were excluded. Convenient sampling was employed.

Data Collection

Data were collected between February and April 2025 using a self-administered, three-wave online questionnaire. The survey was administered at three distinct time points: the last week of Sha’ban (pre-Ramadan), the last week of Ramadan (during Ramadan), and the last week of Shawwal (post-Ramadan) (Figure 1). These time points were selected to align with the recall periods of the International Physical Activity Questionnaire-Short Form (IPAQ-SF) and the Depression, Anxiety, and Stress Scale-21 (DASS-21), which assess behaviors and symptoms over the past week, and the Pittsburgh Sleep Quality Index (PSQI), which reflects sleep quality over the past month. This approach ensured that responses captured each entire phase rather than short-term fluctuations. The questionnaire consisted of four sections: (1) socio-demographic information; (2) physical activity assessed using the IPAQ-SF; (3) sleep quality evaluated using the PSQI; and (4) emotional states measured using the DASS-21. The online survey was created in Google Forms and distributed electronically to participants.

Figure 1.

Three time points of data collection.

Sample Size

The sample size for this study was determined by the study’s exploratory nature and the voluntary participation of individuals during Ramadan. Recruitment during Ramadan is naturally constrained by cultural and logistical factors, which limited the number of eligible and willing participants. Consequently, the final sample of 30 participants reflects the feasible and realistic participation rate for this population. Although no a priori power analysis was conducted, effect sizes were reported for all analyses, and statistical methods appropriate for small samples were employed to support the reliability of the findings.22,23

Outcome Measures

International Physical Activity Questionnaire–Short Form (IPAQ-SF)

The International Physical Activity Questionnaire-Short Form (IPAQ-SF) is a widely used self-report measure designed to assess physical activity levels over the past seven days. Developed in 1998, the IPAQ-SF captures activity across four categories: vigorous-intensity activity, moderate-intensity activity, walking, and sitting. Total physical activity is calculated in metabolic equivalent minutes per week (MET-min/week), and individuals are classified as having low, moderate, or high levels of physical activity based on standardized scoring criteria.24 The IPAQ-SF has demonstrated moderate reliability (r =0.74) and validity (r =0.72) in various populations.25 In this study, the Arabic version of the IPAQ-SF was used to assess participants’ physical activity. This version has shown a significant correlation with objective measures of physical activity (r =0.61) and moderate reliability (r =0.71), supporting its suitability for use in Arabic-speaking populations.26

Pittsburgh Sleep Quality Index (PSQI)

The Pittsburgh Sleep Quality Index (PSQI) is a self-report questionnaire designed to assess multiple dimensions of sleep, capturing both subjective experiences and objective indicators. Its applicability in both clinical and non-clinical settings make it a valuable tool for understanding individual sleep patterns and disturbances. The total score ranges from 0 to 21, with higher scores indicating poorer sleep quality. According to the literature, the PSQI demonstrates reliability coefficients ranging from.70 to.85.27 In this study, the Arabic version of the PSQI was utilized to assess sleep quality among participants. This version has shown moderate reliability (r =0.694) and validity (r =0.69) within the Saudi population.28

Depression, Anxiety, and Stress Scale–21 (DASS-21)

The Depression, Anxiety, and Stress Scale-21 (DASS-21) is a self-report instrument designed to assess mental health across three domains: depression, anxiety, and stress. It comprises 21 items, divided equally into three subscales with seven items each. The total score for each subscale is used to classify symptom severity into five categories: normal, mild, moderate, severe, and extremely severe. Higher scores on each subscale indicate greater levels of depression, anxiety, or stress. The overall reliability of the DASS-21 is high, with a reported coefficient of r=0.939.29 For this study, we utilized the Arabic version of the DASS-21 to collect data.

Statistical Analysis

Statistical analyses were conducted using IBM SPSS Statistics Version 28. Descriptive statistics were generated for all baseline and outcome variables. Normality was assessed using the Shapiro–Wilk test, and because the data were non‑normally distributed, results are reported as medians and interquartile ranges (IQRs).

Changes in physical activity, sleep duration, sleep quality, and mental health outcomes (depression, anxiety, stress) across the three time points (Pre‑Ramadan, Ramadan, Post‑Ramadan) were examined using the Friedman test, with Wilcoxon signed‑rank tests for pairwise comparisons. Effect sizes were calculated using Kendall’s W for Friedman tests and r for Wilcoxon tests.

Rank‑based multiple regression analyses were performed to assess associations between sleep quality, physical activity, BMI, and mental health outcomes at each time point. All variables were rank‑transformed due to non‑normality. Model fit indices (R, adjusted R², F, p) and unstandardized coefficients (B) with 95% confidence intervals were reported. Assumptions were evaluated using residual diagnostics, Cook’s distance, and variance inflation factors, all of which indicated that the models were appropriate for the dataset.

All analyses were two‑tailed, with statistical significance set at p <0.05.

Ethical Consideration

This study obtained institutional ethical clearance from the local institutional review committee. All participation was voluntary, and informed consent was obtained from each participant prior to data collection. Participants were assured that their responses would remain confidential, their identities would not be revealed, and the data would be used solely for research purposes. The study was conducted in compliance with the ethical principles outlined in the Declaration of Helsinki.

Results

A cohort of 30 females was included for the analysis. Participants’ baseline and socio-demographic data are presented in Table 1. Their median (IQR) age was 22 (20–28) years, and BMI was 24.32 (22.5–25.6) kg/m². The majority were married (56.67%), followed by single individuals (40%). Most participants were non-smokers (86.67%), had completed a Bachelor’s degree (66.67%), and resided in urban households (80%).

Table 1.

Baseline and Socio- Demographic Variable of the Study Participants (n=30)

Variable	Median (IQR), Frequency (%)
Age	22 (20–28) years
BMI	24.3 (22.5–25.6) kg/m2
Marital status
Single	12 (40%)
Married	17 (56.67%)
Widowed	1 (3.33%)
Educational qualification
No formal education	2 (6.67%)
Middle school	3 (10%)
High school	4 (13.33%)
Diploma	1 (3.33%)
Bachelor degree	20 (66.67%)
Working status
Working	19 (63.33%)
Not working	11 (36.67%)
Smoking
Non-smokers	26 (86.67%)
Current-smokers	3 (10%)
Ex-smokers	1 (3.33%)
Household
Urban	24 (80%)
Rural	6 (20%)

Abbreviations: IQR, Inter Quartile Range; BMI, Body Mass Index; kg, kilogram; m, meter.

Physical Activity

The IPAQ-SF was used to calculate the physical activity of participants and categorise it into low, moderate, and high physical activity based on their last 7 days of activity. The median (IQR) of participants’ MET-minutes/week across three time points are presented in Figure 2.

Figure 2.

Median Physical Activity Values (IPAQ-SF) Across Three Time Points.

A Friedman test was conducted to examine differences in physical activity across three time points. The test revealed a non-significant difference in physical activity across conditions, χ²(2) = 4.20, p = 0.122, with a 95% CI ranging from [0.120 to 0.133]. The calculated effect size (Kendall’s W) was.072, indicating a small effect. Although the overall difference did not reach statistical significance, mean ranks suggested a gradual increase in physical activity over time, pointing to a potential upward trend.

Exploratory pairwise comparisons using Wilcoxon signed-rank tests revealed significant increases in physical activity over time (Table 2). Physical activity increased from pre-Ramadan to Ramadan, Z = –2.067, p =0.039, 95% CI [0.024, 0.048], with a moderate effect size (r = 0.38). Activity levels were also significantly higher post-Ramadan compared with pre-Ramadan, Z = –2.602, p =0.009, 95% CI [0.001, 0.011], with a large effect size (r = 0.47). These findings indicate that physical activity increased during Ramadan and remained elevated afterwards.

Table 2.

Pairwise Comparisons of Physical Activity Across Ramadan Phases Using Wilcoxon Signed-Rank Tests

Comparison	Z	p	Effect Size (r)	95% CI
Pre-Ramadan vs Ramadan	−2.067	0.036	0.38	[0.024, 0.048]
Pre-Ramadan vs Post-Ramadan	−2.602	0.006	0.47	[0.001, 0.011]
Ramadan vs Post-Ramadan	−0.154	0.900	0.03	[0.881, 0.919]

Abbreviation: CI, Confidence Interval.

Sleep

The PSQI was utilized to assess participants’ sleep quality, duration, and global sleep score. Table 3 and Figure 3 summarize the PSQI sleep scores across the three time points.

Table 3.

Summary of Sleep Parameters Across Three Time Points Based on PSQI Scores

Components	Pre-Ramadan	Ramadan	Post-Ramadan
Sleep Quality
Very Good	10 (33.33%)	10 (33.33%)	17 (56.67%)
Fairly Good	15 (50%)	14 (46.67%)	9 (30%)
Fairly Bad	4 (13.33%)	5 (16.67%)	3 (10%)
Very Bad	1 (3.33%)	1 (3.33%)	1 (3.33%)
Sleep Duration  Median (IQR)	6 (5, 7)	6 (3, 6)	8 (5,8)
Global PSQI score  Median (IQR)	7.5 (5, 10.25)	8.5 (5,11)	4.5 (1, 8).

Abbreviation: IQR, Inter Quartile Range.

Figure 3.

Median Global Sleep Scores Across Three Time Points.

Sleep Duration

A Friedman test was conducted to assess differences in sleep duration across three time points. The test revealed a statistically significant difference in sleep duration across conditions, χ²(2) = 19.91, p <0.001, with a 95% CI [0.000 to 0.003]. Mean ranks indicated that sleep duration was lowest during Ramadan (1.50), increased post-Ramadan (2.58), and was intermediate pre-Ramadan (1.92), suggesting a significant disruption during Ramadan followed by recovery afterward. The effect size calculated was 0.343, indicating a moderate to large effect.

Pairwise comparisons using Wilcoxon signed-rank tests found that the sleep duration was significantly higher post-Ramadan compared to during Ramadan, Z = −4.085, p <0.001, with a 95% CI [0.000, 0.003] (Table 4). The effect size calculated was r = 0.75, indicating a large effect. Similarly, sleep duration post-Ramadan was significantly greater than pre-Ramadan, Z = −3.390, p =0.001, 95% CI [0.000, 0.003], with a large effect size (r = 0.62). In contrast, sleep duration during Ramadan was significantly lower than pre-Ramadan, Z = −2.057, p =0.040, 95% CI [0.023, 0.045], with a moderate effect size (r =0.38). These findings indicate that Ramadan was associated with a reduction in sleep duration, which significantly improved following the fasting period.

Table 4.

Pairwise Comparisons of Sleep Duration Across Time Points Using Wilcoxon Signed-Rank Tests

Comparison	Z	p (Exact)	Effect Size (r)	95% CI
Ramadan vs Post-Ramadan	−4.085	0.000	0.75	[0.000, 0.003]
Pre-Ramadan vs Post-Ramadan	−3.390	0.001	0.62	[0.000, 0.003]
Pre-Ramadan vs Ramadan	−2.057	0.040	0.38	[0.023, 0.045]

Abbreviation: CI, Confidence Interval.

Global PSQI Sleep Score

A Friedman test was conducted to assess differences in global sleep scores across three time points: pre-Ramadan, during Ramadan, and post-Ramadan. The test revealed a statistically significant difference in global sleep scores across conditions, χ²(2) = 12.00, p =0.002, with a 95% CI [0.000, 0.005]. The calculated effect size was 0.207, indicating a moderate effect.

Pairwise comparisons using Wilcoxon signed-rank tests found that global sleep scores were significantly lower post-Ramadan compared to during Ramadan, Z = −3.186, p =0.001, with a 95% CI [0.000 to 0.003] (Table 5). The effect size of r = 0.58 indicates a large effect. Similarly, global sleep scores post-Ramadan were significantly lower than pre-Ramadan, Z = −3.600, p <0.001, 95% CI [0.000, 0.003], with a large effect size (r = 0.66).

Table 6.

DASS −21 Scores Across Three Time Points

Variable	Phase	Median	IQR
Depression	Pre-Ramadan	6.00	0.00–18.00
	Ramadan	8.00	1.50–14.00
	Post-Ramadan	4.00	0.00–11.00
Anxiety	Pre-Ramadan	7.00	0.00–18.00
	Ramadan	10.00	3.50–15.50
	Post-Ramadan	2.00	0.00–10.00
Stress	Pre-Ramadan	10.00	1.50–18.50
	Ramadan	12.00	3.00–24.50
	Post-Ramadan	3.00	0.00–7.00

Abbreviation: IQR, Inter Quartile Range.

Table 5.

Pairwise Comparisons of Global Sleep Scores (PSQI) Across Three Time Points Using Wilcoxon Signed-Rank Tests

Comparison	Z	p	Effect Size (r)	95% CI
Ramadan vs Post-Ramadan	−3.186	0.001	0.58	[0.000, 0.003]
Pre-Ramadan vs Post-Ramadan	−3.600	0.000	0.66	[0.000, 0.003]
Pre-Ramadan vs Ramadan	−1.010	0.312	0.18	[0.307, 0.365]

Abbreviation: CI, Confidence Interval.

Mental Health

The DASS-21 was utilized to assess the mental health of the participants across three time points. Table 6 and Figure 4 present the mental health scores (depression, anxiety, and stress) assessed at three time points. These symptoms peaked during Ramadan, with elevated median scores and wider IQRs, followed by a marked reduction post-Ramadan.

Table 7.

Pairwise Comparisons of Stress Scores Across Three Time Points Using Wilcoxon Signed-Rank Tests

Comparison	Z	p	Effect Size (r)	95% CI
Post-Ramadan vs During Ramadan	–2.370	0.018	0.43	[0.000, 0.095]
Post-Ramadan vs Pre-Ramadan	–1.984	0.047	0.36	[0.000, 0.207]
During Ramadan vs Pre-Ramadan	–1.553	0.120	0.28	[0.033, 0.300]

Abbreviation: CI-Confidence Interval.

Figure 4.

Median Scores for Depression, Anxiety, And Stress (DASS-21) Across Three Time Points.

Stress

A Friedman test was conducted to assess differences in stress levels across three time points. The test revealed a statistically significant difference in stress scores across conditions, χ²(2) = 9.31, p =0.010, with a 95% CI [0.000,0.095]. The calculated effect size was 0.155, indicating a moderate effect. These findings suggest that stress levels varied meaningfully across the three time periods.

Pairwise comparisons using Wilcoxon signed-rank tests found that the Stress levels post-Ramadan were significantly lower than during Ramadan, Z = −2.370, p = 0.018, with a 95% CI [0.000, 0.095] (Table 7). The calculated effect size was 0.43, indicating a moderate effect. Similarly, stress levels post-Ramadan were significantly lower than pre-Ramadan, Z = −1.984, p =0.047, with a 95% CI [0.000, 0.207], and a small to moderate effect size (r = 0.36).

Depression & Anxiety

Depression and anxiety scores did not differ significantly across the three time points. Both the Friedman test and Wilcoxon pairwise comparisons showed no meaningful changes, indicating that depression and anxiety levels remained stable throughout the Ramadan period.

Association of Physical Activity and Sleep with Mental Health

A total of nine rank-based regression models were conducted to examine the associations between physical activity, sleep quality, BMI, and mental health outcomes across the three time points. Diagnostic checks indicated that the analyses were statistically appropriate and robust. Residuals fell within acceptable ranges, Cook’s distance values were low, and no influential outliers were detected. Multicollinearity was minimal in all models, with VIF values consistently below 1.4. These diagnostics confirmed that the rank-transformed regression models met the necessary assumptions and were suitable for the small sample size (Table 8).

Table 8.

Rank Based Regression Models Predicting Depression, Anxiety, and Stress

Outcome	Time Point	Model Fit (R, Adj. R2, F, p)	Significant Predictors (B, p, 95% CI)	Assumption Checks
Depression	Pre Ramadan	R =0.647; Adj. R2 =0.35; F(3,26) = 6.26, p =0.002	Sleep quality: B = 0.67, p =0.001, 95% CI [0.31, 1.02]	VIF = 1.01–1.41; Cook’s D =0.00–0.25; Residuals = –2.69 to 2.12
	Ramadan	R =0.623; Adj. R2 =0.32; F(3,26) = 5.49, p =0.005	Sleep quality: B = 0.62, p <0.001, 95% CI [0.30, 0.94]	VIF = 1.04–1.12; Cook’s D =0.00–0.18; Residuals = –2.02 to 1.63
	Post Ramadan	Model not significant	No significant predictors	VIF = 1.06–1.22; Cook’s D =0.00–0.14; Residuals = –1.91 to 1.53
Anxiety	Pre Ramadan	R =0.608; Adj. R2 =0.30; F(3,26) = 5.08, p =0.007	Sleep quality: B = 0.63, p =0.002, 95% CI [0.25, 1.00]	VIF = 1.01–1.41; C Cook’s D =0.00–0.27; Residuals = –2.92 to 2.37
	Ramadan	R =0.683; Adj. R2 =0.40; F(3,26) = 7.57, p =0.001	Sleep quality: B = 0.68, p <0.001, 9 5% CI [0.38, 0.98]	VIF = 1.04–1.12; Cook’s D =0.00–0.34; Residuals = –2.81 to 2.18
	Post Ramadan	Model not significant	No significant predictors	VIF = 1.06–1.22; Cook’s D =0.00–0.20; Residuals = –2.15 to 1.51
Stress	Pre Ramadan	R =0.607; Adj. R2 =0.30; F(3,26) = 5.07, p =0.007	Sleep quality: B = 0.62, p =0.002, 95% CI [0.24, 1.00]	VIF = 1.01–1.41; Cook’s D =0.00–0.24; Residuals = –3.05 to 1.90
	Ramadan	R =0.740; Adj. R2 =0.50; F(3,26) = 10.52, p <0.001	Sleep quality: B = 0.75, p <0.001, 95% CI [0.47, 1.02]	VIF = 1.04–1.12; Cook’s D =0.00–0.23; Residuals = –2.31 to 1.75
	Post Ramadan	Model not significant	No significant predictors	VIF = 1.06–1.22; Cook’s D =0.00–0.17; Residuals = –1.94 to 1.66

Abbreviations: CI, Confidence Interval; VIF, Variance Inflation Factor.

Depression

Sleep quality significantly predicted depression before and during Ramadan, but not after Ramadan. Before Ramadan, poorer sleep quality was associated with higher depression scores (B = 0.67, p =0.001, 95% CI [0.31, 1.02]). During Ramadan, sleep quality remained a significant predictor (B = 0.62, p <0.001, 95% CI [0.30, 0.94]). After Ramadan, the model was not significant, and no predictors, including sleep quality, were associated with depression.

Anxiety

Sleep quality significantly predicted anxiety before and during Ramadan, but not after Ramadan. Before Ramadan, sleep quality was a significant predictor (B = 0.63, p =0.002, 95% CI [0.25, 1.00]). During Ramadan, sleep quality continued to predict anxiety (B = 0.68, p <0.001, 95% CI [0.38, 0.98]). After Ramadan, none of the predictors were significant, and the model did not account for meaningful variation in anxiety.

Stress

Sleep quality significantly predicted stress before and during Ramadan, but not after Ramadan. Before Ramadan, sleep quality was a significant predictor (B = 0.62, p =0.002, 95% CI [0.24, 1.00]). During Ramadan, sleep quality remained a strong predictor (B = 0.75, p <0.001, 95% CI [0.47, 1.02]). After Ramadan, the model was not significant, and no predictors, including sleep quality, were associated with stress.

Discussion

Our study aimed to examine mental health in relation to physical activity and sleep among young adult females in Saudi Arabia across three time points: Pre-Ramadan, Ramadan, and Post-Ramadan. We found that physical activity increased during Ramadan, and sleep quality was poor, with higher total sleep scores. While depression and anxiety levels showed no change, stress levels varied notably.

Physical Activity Patterns During Ramadan: A Comparative Perspective

Our study revealed a notable increase in physical activity during Ramadan compared to the pre-Ramadan period, with this elevated trend persisting into the post-Ramadan phase. This pattern aligns with findings from Taif, Saudi Arabia, where medical students showed higher activity levels during Ramadan, possibly influenced by the adoption of a Mediterranean-style diet associated with better energy and well-being.30

Importantly, our study focused exclusively on adult females, of whom approximately half were married and employed, with 80% residing in urban areas. Their increased physical activity during Ramadan may be attributed to heightened household responsibilities commonly undertaken during this period. This behavioral shift likely contributed to the observed rise in activity levels. Supporting this, a qualitative study by Almaqhawi et al in Saudi Arabia found that physical activity during Ramadan is influenced by changes in daily routines and personal motivation, reinforcing the idea that lifestyle adjustments during the holy month play a significant role in shaping movement patterns.31

However, contrasting evidence exists. A study conducted in Nigeria during the COVID-19 pandemic reported a reduction in physical activity for one-third of participants, attributed to lockdown restrictions.8 Similarly, in Qatar, objective measurements using step counts indicated a decline in physical activity during Ramadan, suggesting that contextual and cultural factors play a critical role in shaping movement behaviors during this period.32

Sleep Patterns During Ramadan: A Comparative Perspective

Sleep duration is notably affected during the month of Ramadan, with our study revealing the lowest sleep duration and worst PSQI global scores at the Ramadan timepoint compared to pre-Ramadan and post-Ramadan periods. This pattern aligns with findings from Jordanian university students, who also experienced increased sleep disturbances during Ramadan.9 Similarly, a study that measured the sleep quality among student-athletes during Ramadan and pre-Ramadan, using wrist-actigraphy, shows that there was a significant reduction in sleep duration during the Ramadan period and overall poor sleep quality with excessive daytime sleepiness.33 The observed variation in sleep duration is primarily attributed to disruptions in circadian rhythm and hormonal fluctuations triggered by the unique lifestyle changes during Ramadan, most notably, the mandatory fasting from dawn to dusk and irregular feeding schedules.14,34 These behavioral shifts contribute to increased insulin resistance during morning and evening hours, along with elevated levels of high-sensitivity C-reactive protein (hsCRP). Additionally, an altered circadian cortisol rhythm, commonly reported among the Saudi Arabian population, further compounds the impact on sleep regulation during this period. Following Ramadan, a recovery in sleep duration is typically observed, suggesting a gradual re-stabilization of physiological rhythms.35

Mental Health During Ramadan: A Comparative Perspective

While Ramadan fasting is known to influence various physiological and behavioral patterns, our study highlights its nuanced impact on emotional states. Using the DASS-21 scale, we observed that depression and anxiety levels remained relatively stable across the three time points, suggesting that these emotional domains were not significantly affected by the timing of Ramadan. However, stress levels demonstrated a meaningful variation. Notably, stress was significantly lower in the post-Ramadan period compared to both the Ramadan and pre-Ramadan phases.

We observed that depression and anxiety levels remained relatively stable across the three time points. Similarly, Elsahoryi et al used the DASS-21 to examine the impact of Ramadan intermittent fasting on mental health, physical activity, and sleep among university students in Jordan through multivariate analysis, and they likewise reported no significant changes across the mental-health domains.9 Complementing our findings, Alsowaid et al examined the effects of Ramadan fasting on mental health among female students at the University of Bahrain and reported no notable changes in anxiety levels.36 However, preliminary evidence from a systematic review of other studies suggests that fasting interventions may have a positive influence on mental health outcomes.37

Consistent with our study findings, Lone et al reported heightened tension and fatigue among Saudi medical students during Ramadan compared to the pre- and post-Ramadan periods, highlighting the psychological impact of fasting.20 Similarly, Solianik et al observed increased parasympathetic activity and elevated anger levels among amateur weightlifters during fasting, suggesting a physiological basis for mood disturbances.38 These findings may help explain the elevated stress levels observed in our participants. Notably, 50% of our sample comprised married women, whose additional responsibilities related to homemaking, parenting, and adjustments to the Ramadan routine likely contributed to their stress, an observation that aligns with the findings of Harbi et al39. Our participants’ stress was reduced after the Ramadan time point, which is similar to the study conducted by Akan et al, who examined the Ramadan fasting impact on mental health and its hormonal impact. They found that distress index scores were significantly reduced after Ramadan when compared to pre-Ramadan. These changes can be due to the psycho-neuro-endocrine mechanism.40

Association of Sleep with Mental Health: A Comparative Perspective

Our study found that sleep quality was significantly associated with depression, anxiety, and stress before and during Ramadan, indicating that poorer sleep was consistently associated with poorer mental health. These associations were no longer significant post-Ramadan. Physical activity did not show any significant correlations with mental health indicators at any time point. Supporting our findings, a meta-analysis involving 10,196 adults reported that improved sleep quality was associated with reductions in depression and anxiety, though stress levels remained unchanged.41 Similarly, a cross-sectional study among medical students in Croatia using the DASS-21 and PSQI scales found that poor sleep quality was linked to higher scores for depression, anxiety, and stress, with female students experiencing more pronounced mental health challenges and sleep disturbances than males.42 Additionally, a meta-analysis of randomized controlled trials revealed a dose-response relationship, where improvements in sleep quality led to corresponding enhancements in overall mental health.43

Study Limitations

This study has several limitations that should be acknowledged. First, the sample consisted solely of adult females, predominantly married and residing in urban areas, which limits the generalizability of the findings to males, adolescents, or rural populations. Second, the small sample size (n = 30), driven by voluntary participation and the constraints of Ramadan-based recruitment, reduces statistical power and necessitates cautious interpretation of the results. Third, the reliance on self-reported instruments such as the DASS-21 and PSQI may introduce reporting bias or subjective inaccuracies. Additionally, important confounding factors, including dietary intake, socioeconomic status, pre-existing health conditions, and concurrent stressors such as academic or family pressures, were not controlled for and may have influenced the observed associations. Lastly, the absence of objective measures of physical activity and sleep (eg., actigraphy or wearable devices) limits the precision of the behavioral assessments. Given these constraints, the findings should be viewed as preliminary and exploratory, providing a foundation for more rigorous future research.

Conclusion

This study explored the interplay between mental health, physical activity, and sleep across the pre-Ramadan, Ramadan, and post-Ramadan periods among young adult women in Saudi Arabia. While depression and anxiety remained stable, stress levels declined after Ramadan, and sleep quality consistently correlated with mental health indicators. Although physical activity increased during Ramadan, it did not show a significant association with emotional outcomes. Overall, the findings highlight sleep and stress as key factors influencing well-being across the Ramadan cycle.

Future Directions

Future studies should incorporate objective measures of sleep and physical activity and recruit larger, multicenter samples to enhance generalizability across different regions and populations. Longitudinal designs that track participants throughout the entire Ramadan month would provide deeper insight into daily fluctuations in sleep, stress, and activity patterns. Additionally, public-health and campus-based interventions, such as sleep-hygiene programs, stress-management workshops, and culturally tailored support for women balancing academic, professional, and household roles, should be developed and evaluated to identify practical strategies that promote well-being during Ramadan.

Funding Statement

Princess Nourah bint Abdulrahman University Researchers Supporting Project number (PNURSP2026R714), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia.

Data Sharing Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Ethics Approval and Informed Consent

Ethical clearance for this study was granted by the Institutional Review Board of King Abdullah Bin Abdulaziz University Hospital, Riyadh, Saudi Arabia (IRB Registration No. HA‑01‑R‑104; Log No. 25‑0051; Approval Category: Expedited‑1). All participation was voluntary, and informed consent was obtained from each participant prior to data collection. Participants were assured that their responses would remain confidential, their identities would not be revealed, and the data would be used solely for research purposes. The study was conducted in compliance with the ethical principles outlined in the Declaration of Helsinki.

Author Contributions

KB; Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Writing-Original Draft, Writing-Review & Editing

RRS; Conceptualization, Investigation, Project Administration, Writing-Original Draft, Writing-Review & Editing, Writing-Review & Editing

MMA; Data Curation, Formal Analysis, Funding acquisition, Investigation, Project Administration, Writing-Original Draft, Writing-Review & Editing

SA; Data Curation, Investigation, Funding acquisition, Writing-Original Draft, Writing-Review & Editing

All authors gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agreed to be accountable for all aspects of the work.

Disclosure

The authors report no conflicts of interest related to this work.