## 4 Discussion
Some studies suggest that the quality of nutrients, rather than their quantity, plays a role in the development of obesity [45]. Mothers' primary role in creating the home food environment and serving as role models for eating behaviors has been identified as a contributor to early childhood overweight and obesity [46; 47]. Additionally, lower education attainment and low socioeconomic status within families have been associated with frequent consumption of sweetened drinks, fast food, and a lower intake of fruits and vegetables [6; 48; 49]. Access to convenience foods,decreased availability of physical activity opportunities during childhood and adolescence, and the use of food as a reward or for socializing contribute to the risk of obesity and overweight [50; 51; 52]. The misuse of food in these contexts promotes unhealthy relationships with food, further increasing the risk of developing obesity [43]. With BMI being reported as 25-40% heritable, obesity can also have genetic, epigenetic, metagenomic, and environmental factors [53]. Given the growing evidence of the role of diet in adiposity and cardiovascular disease risk, effective strategies, including policy support and targeted actions, are needed to prevent the escalating burden of non-communicable diseases in South Africa [53]. While the studies included in the review make an important contribution to determining the relationship between diet and adiposity in female South African adolescents, evidence from studies that have a more holistic approach, that have used a variety of study designs, and that have used different tools may be required to establish if a definitive relationship exists [54]. In addition, nationwide research is essential for providing a national perspective that considers the differences that exist in a country such as South Africa, whose population exhibits a wide range of socio-economic statuses. Because there is no single dietary assessment method that is able to measure intake perfectly [55], the FFQ and the 24-h recall methods were used to assess usual diet in the reported studies, as they are well known and extensively used methods for providing detailed food intake data. The limitation of these assessment methods is that they do not take into consideration changes in people's food intake over days, weeks, months, and even years throughout the lifecycle [56]. Furthermore, because of self-reporting and measurement inaccuracies, these dietary intake assessment methods have inherent limitations that cannot be ignored [57]. Biochemical markers used in combination with a number of dietary intake assessment methods could be a more effective measure, as they provide greater accuracy than simply using one dietary assessment [55; 57]. Another important consideration to make in the interpretation of the results is that most of the studies included in this systematic review focused on black South African adolescents; therefore, the findings cannot be generalized to other subgroups found in South Africa [16; 18]. In the reported research studies, weight and height measurements were used to calculate the BMI-for-age, which was used as a proxy or indicator for overweight or obese. It is important to note that BMI disregards other contributing factors such as sex, ethnicity, muscle mass, and body fat distribution [58]. The use of dietary intake without considering physical activity as factors that contribute to the incidence of obesity is a limitation of the study. The findings from the review, however, add to the concerns regarding the high levels of obesity, which are a major burden to the South African health system [59]. To address these concerns, population-level interventions targeting the school food environment that are directed at reducing overweight and obesity rates in adolescents are recommended [60].