Adherence

Participants in the intermittent fasting arm were highly adherent on fasting days. More than half of the women were described as very happy to follow the protocol. The fasting days themselves were not presented as the main obstacle for participants. Novelty and media attention may have contributed to motivation and adherence, but this was not established as a formal mechanism. Patients worried that benefits might be temporary and could revert if regular practice stopped. Barriers to adherence arose from competing daily responsibilities and waning personal interest. The airflow required by harmonica playing could trigger severe coughing in some participants, creating a direct physiological barrier to sustained practice. Physical discomfort including exhaustion and lightheadedness during or after playing was a reported barrier. The unexpected adherence issue was difficulty eating enough on non-fasting days. Transforming harmonica playing from a short-term prescription into a self-sustaining hobby through intrinsic motivation and structured skill development is the recommended strategy for addressing sustainability concerns.