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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introdu&#231;&#227;o</span><p id="par0005" class="elsevierStylePara elsevierViewall">O processo de mineraliza&#231;&#227;o &#243;ssea inicia&#8208;se na vida intrauterina e estende&#8208;se da inf&#226;ncia at&#233; o in&#237;cio da idade adulta&#46; No entanto&#44; &#233; durante a inf&#226;ncia e a adolesc&#234;ncia que ocorre o maior crescimento e desenvolvimento do tecido &#243;sseo&#44; esses per&#237;odos s&#227;o fundamentais para aquisi&#231;&#227;o de massa &#243;ssea&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">O aumento do ac&#250;mulo da massa &#243;ssea est&#225; diretamente relacionado a menor risco de fraturas e osteoporose no futuro e &#233; sens&#237;vel &#224; influ&#234;ncia de m&#250;ltiplos fatores modific&#225;veis e n&#227;o modific&#225;veis&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">3</span></a> Determinantes que ocorrem nos per&#237;odos da gesta&#231;&#227;o e primeira inf&#226;ncia podem afetar os valores de massa mineral &#243;ssea na adolesc&#234;ncia&#44; &#233; poss&#237;vel que o <span class="elsevierStyleItalic">catch&#8208;up</span> de estatura na inf&#226;ncia tamb&#233;m possa ter efeitos na massa &#243;ssea&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Evid&#234;ncias de estudos em animais sugerem que o <span class="elsevierStyleItalic">catch&#8208;up</span> de estatura ocorra devido&#44; em grande parte&#44; a um atraso na senesc&#234;ncia na placa de crescimento&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">4&#44;5</span></a> Dessa forma&#44; ap&#243;s um per&#237;odo de inibi&#231;&#227;o do crescimento&#44; essas placas mant&#234;m uma maior capacidade de prolifera&#231;&#227;o dos condr&#243;citos&#44; s&#227;o menos senescentes e&#44; portanto&#44; mostram uma taxa de crescimento maior do que o esperado para a idade&#44; resultam no <span class="elsevierStyleItalic">catch&#8208;up</span> de estatura&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Apesar dessa hip&#243;tese mais recente de que o aumento da prolifera&#231;&#227;o de condr&#243;citos com consequente crescimento principalmente dos ossos longos geraria <span class="elsevierStyleItalic">catch&#8208;up&#44;</span> ainda s&#227;o inconclusivos os poss&#237;veis efeitos desse processo sobre massa &#243;ssea em longo prazo&#44; aponta que tanto o crescimento em estatura na inf&#226;ncia pode associar&#8208;se &#224; massa mineral &#243;ssea na vida adulta<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">7</span></a> como pode indicar que o <span class="elsevierStyleItalic">catch&#8208;up</span> n&#227;o influencia a massa mineral &#243;ssea&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Assim&#44; este estudo objetivou analisar o efeito do <span class="elsevierStyleItalic">catch&#8208;up</span> de estatura na idade escolar sobre a massa &#243;ssea em adolescentes pertencentes a uma coorte brasileira de nascimento feita em S&#227;o Lu&#237;s&#8208;MA&#46; A hip&#243;tese &#233; que possa trazer efeitos ben&#233;ficos sobre a massa &#243;ssea em adolescentes&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">M&#233;todos</span><p id="par0030" class="elsevierStylePara elsevierViewall">Estudo de coorte&#44; com informa&#231;&#245;es da pesquisa &#8220;Determinantes ao longo do ciclo vital da obesidade&#44; precursores de doen&#231;as cr&#244;nicas&#44; capital humano e sa&#250;de mental &#8211; Coortes RPS&#8221;&#44; desenvolvida pela Universidade Federal do Maranh&#227;o&#44; Faculdade de Medicina de Ribeir&#227;o Preto e Universidade Federal de Pelotas e financiado pelo Departamento de Ci&#234;ncia e Tecnologia&#46; Para este estudo foram usados os dados de S&#227;o Lu&#237;s &#40;MA&#41;&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Popula&#231;&#227;o e coleta de dados</span><p id="par0035" class="elsevierStylePara elsevierViewall">Essa coorte tem tr&#234;s momentos&#58;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Momento 1 &#8208; Nascimento</span><p id="par0040" class="elsevierStylePara elsevierViewall">O estudo perinatal da Coorte de S&#227;o Lu&#237;s &#40;SL&#41; foi iniciado ao nascimento em dez hospitais p&#250;blicos e privados da cidade&#44; de mar&#231;o de 1997 a fevereiro de 1998&#46; A amostra&#44; de base populacional&#44; incluiu 96&#44;3&#37; dos nascimentos do per&#237;odo&#44; excluiu os nascimentos n&#227;o hospitalares e os nascimentos em hospitais onde ocorriam menos de 100 partos por ano&#46; Usou&#8208;se amostragem sistem&#225;tica com estratifica&#231;&#227;o proporcional de acordo com o n&#250;mero de nascimentos em cada maternidade&#44; de um em cada sete partos&#46; O total de 2&#46;541 nascimentos hospitalares incluiu mulheres residentes em S&#227;o Lu&#237;s&#44; nascidos vivos&#44; natimortos e partos &#250;nicos e m&#250;ltiplos&#46; Exclu&#237;ram&#8208;se partos m&#250;ltiplos e natimortos e a amostra final totalizou 2&#46;443 nascimentos&#46; As perdas devido a recusa ou impossibilidade de localizar a m&#227;e ocorreram em 5&#44;8&#37; dos casos&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Momento 2 &#8211; Idade escolar</span><p id="par0045" class="elsevierStylePara elsevierViewall">A coorte de S&#227;o Lu&#237;s foi seguida aos 7&#47;9 anos por meio de delineamento complexo de amostragem&#44; em 2005&#47;06&#44; com o uso da vari&#225;vel peso ao nascer para definir a amostra necess&#225;ria para a avalia&#231;&#227;o na idade escolar&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">10</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Para a investiga&#231;&#227;o do <span class="elsevierStyleItalic">catch&#8208;up</span> de estatura&#44; foi calculado o Z<span class="elsevierStyleItalic">&#8208;</span>score do comprimento ao nascer para a idade gestacional por meio de um aplicativo do <span class="elsevierStyleItalic">Internacional Fetal and Newbord Growth Consortium for the 21st Century &#40;Intergrowth 21</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">st</span></span>&#41;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">11</span></a> e o Z<span class="elsevierStyleItalic">&#8208;</span>score da altura na idade escolar foi calculado com o uso como refer&#234;ncia das curvas de crescimento da Organiza&#231;&#227;o Mundial da Sa&#250;de&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">12</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">A vari&#225;vel <span class="elsevierStyleItalic">catch&#8208;up</span> de estatura na idade escolar foi definida a partir da diferen&#231;a entre o Z<span class="elsevierStyleItalic">&#8208;</span>score do escolar e o Z<span class="elsevierStyleItalic">&#8208;</span>score do nascimento&#44; com o uso da defini&#231;&#227;o proposta por Ong et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">13</span></a> que consiste em definir como <span class="elsevierStyleItalic">catch&#8208;up</span> uma mudan&#231;a de Z&#8208;score &#8805; 0&#44;67&#46; Foram consideradas como crescimento normal aquelas crian&#231;as cujas mudan&#231;as nos Z&#8208;scores dos &#237;ndices antropom&#233;tricos estudados estiveram entre &#8722;0&#44;669 e 0&#44;669&#46; Ao definir <span class="elsevierStyleItalic">catch&#8208;up</span> como a diferen&#231;a entre o Z&#8208;score de altura do escolar e o Z&#8208;score de comprimento do nascimento&#44; das 805 crian&#231;as seguidas foram exclu&#237;das aquelas em que o comprimento ao nascer for ignorado&#44; total de 691 crian&#231;as&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Momento 3 &#8211; Adolesc&#234;ncia</span><p id="par0060" class="elsevierStylePara elsevierViewall">Em 2015&#44; esses participantes foram convidados a retornar para nova avalia&#231;&#227;o aos 18&#47;19 anos&#46; Para localiz&#225;&#8208;los foram desenvolvidas duas estrat&#233;gias&#58; busca no alistamento militar &#40;apenas para os meninos&#41; e nas escolas &#40;tanto para os meninos quanto para as meninas&#41;&#46; Para a busca nas escolas&#44; foi feita a localiza&#231;&#227;o dos participantes a partir do censo escolar de 2014 com a compara&#231;&#227;o do nome da m&#227;e&#44; da data de nascimento e do nome do participante &#40;para aqueles que vieram em 2005&#47;2006&#41; e do nome da m&#227;e e da data de nascimento do participante &#40;para aqueles que n&#227;o vieram no seguimento&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">De janeiro a novembro de 2016&#44; esses adolescentes foram agendados para fazer a avalia&#231;&#227;o&#44; total de 659&#46; Nessa etapa&#44; foram investigadas&#44; entre outras&#44; as condi&#231;&#245;es de nutri&#231;&#227;o&#44; composi&#231;&#227;o corporal&#44; origem de doen&#231;as cr&#244;nicas complexas&#44; doen&#231;as mentais&#44; situa&#231;&#227;o socioecon&#244;mica e demogr&#225;fica&#44; renda&#44; h&#225;bitos de vida e habilidades cognitivas por meio de equipamentos como Bodpod e absorciometria de emiss&#227;o dupla de raios X &#40;DXA&#41;&#44; exames laboratoriais e question&#225;rios estruturados e validados&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Para a an&#225;lise da massa &#243;ssea neste trabalho foi usado o Z&#8208;score da coluna lombar &#40;L1&#8208;L4&#41;&#44; fornecido pelo equipamento DXA Lunar GE&#44; calibrado diariamente&#46; Nessa avalia&#231;&#227;o&#44; o participante&#44; com roupa padr&#227;o&#44; deitava na cama anexa ao aparelho e era feito um <span class="elsevierStyleItalic">scanner</span> do corpo inteiro&#44; da coluna e do f&#234;mur&#46; O adolescente n&#227;o poderia usar objetos met&#225;licos ou pinos&#47;placas nos ossos&#46; Esse aparelho mede a diferen&#231;a entre a densidade mineral &#243;ssea do paciente e a densidade mineral &#243;ssea m&#233;dia da popula&#231;&#227;o de mesma idade&#44; sexo e etnia&#46; Adolescentes com Z&#8208;score igual ou abaixo de &#8722;2&#44;0 DP &#40;desvio&#8208;padr&#227;o&#41; foram considerados &#8220;abaixo da faixa esperada para a idade&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">14</span></a> Por&#233;m&#44; para an&#225;lise estat&#237;stica foi usado o Z&#8208;score cont&#237;nuo&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Neste estudo foi necess&#225;ria a avali&#231;&#227;o dos indiv&#237;duos que participaram dos tr&#234;s momentos&#44; pois eram necess&#225;rios o comprimento ao nascer&#44; a altura aos 7&#47;9 anos e a massa &#243;ssea na adolesc&#234;ncia&#44; total de 297 adolescentes&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Modelo te&#243;rico&#44; vari&#225;veis e an&#225;lise estat&#237;stica</span><p id="par0080" class="elsevierStylePara elsevierViewall">Inicialmente foram feitas an&#225;lises descritivas para obten&#231;&#227;o das frequ&#234;ncias absolutas e relativas para vari&#225;veis categ&#243;ricas&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Para analisar o efeito do <span class="elsevierStyleItalic">catch&#8208;up</span> estatural em escolares e massa &#243;ssea em adolescentes&#44; foi constru&#237;do modelo te&#243;rico com os gr&#225;ficos ac&#237;clicos direcionados&#44; do ingl&#234;s <span class="elsevierStyleItalic">Directed Acyclic Graphs</span> &#40;DAG&#41;&#44; gerados com aux&#237;lio do <span class="elsevierStyleItalic">software</span> DAGitty vers&#227;o 3&#46;0&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">15</span></a> Os DAGs s&#227;o diagramas causais que permitem ao pesquisador visualizar a pergunta de estudo&#44; estabelecer pressupostos causais entre vari&#225;veis&#44; definir um conjunto m&#237;nimo de vari&#225;veis para estimar o efeito da exposi&#231;&#227;o no desfecho&#44; controlar o confundimento e evitar ajustes desnecess&#225;rios&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">16</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Neste estudo&#44; com base na literatura&#44; o modelo prop&#245;e representar graficamente a influ&#234;ncia do <span class="elsevierStyleItalic">catch&#8208;up</span> de estatura na idade escolar sobre a massa &#243;ssea na adolesc&#234;ncia&#44; conforme a <a class="elsevierStyleCrossRef" href="#fig0005">figura 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">O conjunto para ajuste m&#237;nimo necess&#225;rio indicado pelo DAG&#44; a fim de controlar confundimento&#44; foi composto pelas vari&#225;veis&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Momento 1 &#8208; Nascimento</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Tabagismo na gesta&#231;&#227;o&#58; sim ou n&#227;o</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Sexo da crian&#231;a&#58; feminino ou masculino</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Idade gestacional imputada em meses</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Restri&#231;&#227;o do crescimento intrauterino&#44; definido por Kramer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">17</span></a> com base na raz&#227;o de peso ao nascimento calculado pelo aplicativo <span class="elsevierStyleItalic">The Internacional Fetal and Newbord Growth Consortium for the 21</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">st</span></span><span class="elsevierStyleItalic">Century &#40;Intergrowth 21</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">st</span></span>&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">11</span></a> equivalente &#224; raz&#227;o entre o peso do RN e a m&#233;dia de peso para IG&#46; Segundo Kramer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">17</span></a> a raz&#227;o de peso ao nascimento &#8805; 0&#44;85 foi definida como sem restri&#231;&#227;o do crescimento intrauterino &#40;RCIU&#41; e raz&#227;o de peso ao nascimento<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;85 foi definida como RCIU</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0125" class="elsevierStylePara elsevierViewall">Idade escolar</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Renda familiar em sal&#225;rios m&#237;nimos&#58; menor do que um&#44; de um a menos do que quatro e quatro ou mais</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Alturas materna e paterna&#58; vari&#225;veis cont&#237;nuas &#40;metros&#41;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0140" class="elsevierStylePara elsevierViewall">A amamenta&#231;&#227;o exclusiva at&#233; o sexto m&#234;s&#58; sim ou n&#227;o&#44; obtida a partir do tempo de amamenta&#231;&#227;o e idade da introdu&#231;&#227;o da alimenta&#231;&#227;o complementar&#46;</p></li></ul></p><p id="par0145" class="elsevierStylePara elsevierViewall">A indica&#231;&#227;o dessas vari&#225;veis para ajuste m&#237;nimo ocorreu baseada no crit&#233;rio da porta de tr&#225;s&#44; o qual considera a necessidade de ajuste para uma vari&#225;vel que &#233; causa comum a outras duas&#44; em um determinado caminho causal&#44; e n&#227;o indica ajuste para uma vari&#225;vel colisora&#44; aquela causadora por outras duas&#44; em um mesmo caminho causal&#46; Por meio do princ&#237;pio de porta de tr&#225;s&#44; ajustes equivocados e desnecess&#225;rios s&#227;o evitados nas an&#225;lises de dados&#44; o que poderia levar a erros de estimativa&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">15&#44;18&#44;19</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Optou&#8208;se pelo m&#233;todo de infer&#234;ncia causal para a esta an&#225;lise em busca de uma maior aproxima&#231;&#227;o da causalidade&#44; bem como a finalidade de eliminar o vi&#233;s relacionado a diferen&#231;as nas distribui&#231;&#245;es das vari&#225;veis nos grupos expostos e n&#227;o expostos&#46; Esse m&#233;todo possibilita ainda comparar situa&#231;&#245;es diferentes no mesmo indiv&#237;duo&#44; ele &#233; avaliado tanto como tratado &#40;exposto&#41; como n&#227;o tratado &#40;n&#227;o exposto&#41;&#44; visto que os dados e as estimativas observados &#40;factuais&#41; contribuem para estimar aqueles n&#227;o observados &#40;contrafactuais&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">20</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Usou&#8208;se a t&#233;cnica de pareamento por escore de propens&#227;o do tipo <span class="elsevierStyleItalic">vizinho mais pr&#243;ximo</span>&#44; na qual o indiv&#237;duo tratado &#233; pareado com o controle que tiver o escore de propens&#227;o mais pr&#243;ximo atrav&#233;s da rotina <span class="elsevierStyleItalic">nnmatch</span> do comando <span class="elsevierStyleItalic">teffects&#46;</span> Pareamento por escore de propens&#227;o foi usado para remover vi&#233;s de sele&#231;&#227;o associado com diferen&#231;as nas distribui&#231;&#245;es das covari&#225;veis no grupo daqueles que sofreram <span class="elsevierStyleItalic">catch&#8208;up</span> e aqueles que n&#227;o sofreram&#46; Para cada crian&#231;a foi atribu&#237;do um peso ou uma propens&#227;o de estar no grupo&#46; De acordo com Rosenbaum e Rubin&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">21</span></a> o escore de propens&#227;o &#233; a probabilidade condicional de receber um tratamento dadas as caracter&#237;sticas preestabelecidas&#44; visto que tanto em amostras grandes como em pequenas &#233; comprovada sua efici&#234;ncia para remover o vi&#233;s originado das vari&#225;veis observadas&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">22</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Ap&#243;s a obten&#231;&#227;o da estimativa de efeito causal&#44; foi verificado o balanceamento por meio da rotina <span class="elsevierStyleItalic">tebalance summ</span>&#44; para checar se o equil&#237;brio entre os grupos &#40;tratados e n&#227;o tratados&#41; foi atingido&#44; ou seja&#44; se as vari&#225;veis preditoras apresentaram diferen&#231;as padronizadas iguais ou pr&#243;ximas a zero e taxas de vari&#226;ncias iguais ou pr&#243;ximas a um&#46; O n&#237;vel de signific&#226;ncia adotado foi de 5&#37;&#46; Todas as an&#225;lises foram feitas no <span class="elsevierStyleItalic">software</span> Stata 14&#46;0&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">O projeto atende aos crit&#233;rios da Resolu&#231;&#227;o n&#176; 466&#47;2012 do Conselho Nacional de Sa&#250;de e suas complementares&#46; Os entrevistados foram convidados a participar da pesquisa&#46; Ao concordar&#44; assinaram o Termo de Consentimento Livre e Esclarecido&#46; Foi facultada a desist&#234;ncia sem qualquer preju&#237;zo para o entrevistado e sua fam&#237;lia em qualquer etapa da pesquisa&#46; O projeto foi aprovado pelo Comit&#234; de &#201;tica em Pesquisa do Hospital Universit&#225;rio &#40;UFMA&#41; sob parecer n&#250;mero 1&#46;302&#46;489&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Resultados</span><p id="par0170" class="elsevierStylePara elsevierViewall">Dos participantes que retornaram no seguimento aos 18&#47;19 anos&#44; 73 &#40;24&#44;58&#37;&#41; passaram por <span class="elsevierStyleItalic">catch&#8208;up</span> de estatura na inf&#226;ncia&#59; 16 adolescentes &#40;5&#44;39&#37;&#41; apresentaram massa &#243;ssea abaixo do esperado para a idade&#46; O Z&#8208;score m&#233;dio da coluna lombar foi &#8722;0&#44;34 &#40;&#177; 1&#44;01&#41;&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">As caracter&#237;sticas gestacionais e socioecon&#244;micas maternas e as caracter&#237;sticas das crian&#231;as pertencentes &#224; coorte de acordo com a massa &#243;ssea est&#227;o descritas na <a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0180" class="elsevierStylePara elsevierViewall">Na an&#225;lise n&#227;o ajustada houve associa&#231;&#227;o entre <span class="elsevierStyleItalic">catch&#8208;up</span> de estatura na idade escolar e a massa &#243;ssea na adolesc&#234;ncia &#40;Coef<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;35&#59; IC 95&#37; 0&#44;085&#8211;0&#44;617&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;010&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0185" class="elsevierStylePara elsevierViewall">Ap&#243;s pareamento por escore de propens&#227;o para as vari&#225;veis propostas pelos modelos te&#243;ricos dos DAG&#44; n&#227;o foi observado efeito entre <span class="elsevierStyleItalic">catch&#8208;up</span> de estatura na idade e massa &#243;ssea &#40;Coef<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;598&#59; IC 95&#37; &#8722;0&#44;116&#8211;&#44;313&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;101&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a>&#41;&#46; Isso sugere que&#44; ap&#243;s o pareamento e a remo&#231;&#227;o das diferen&#231;as em rela&#231;&#227;o &#224; altura do pai&#44; altura da m&#227;e&#44; idade gestacional imputada&#44; restri&#231;&#227;o de crescimento intrauterino&#44; sexo da crian&#231;a&#44; tabagismo na gesta&#231;&#227;o e renda familiar na idade escolar&#44; parece n&#227;o houver efeito do <span class="elsevierStyleItalic">catch&#8208;up</span> de estatura na inf&#226;ncia sobre a massa &#243;ssea de coluna lombar na idade adulta jovem&#46; Foi avaliado o balanceamento entre os grupos &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabela 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discuss&#227;o</span><p id="par0190" class="elsevierStylePara elsevierViewall">No presente estudo&#44; a an&#225;lise de dados mostrou que provavelmente n&#227;o h&#225; efeito do <span class="elsevierStyleItalic">catch&#8208;up</span> de estatura na massa &#243;ssea dos adolescentes &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;101&#41;&#46; Acredita&#8208;se que esse resultado no limiar da signific&#226;ncia seja devido ao tamanho da amostra&#44; sobretudo no grupo tratado &#40;73 participantes&#41;&#46; Outra poss&#237;vel explica&#231;&#227;o seria o fato de analisar uma amostra jovem&#44; o que dificulta perceber poss&#237;veis efeitos&#46; Por&#233;m&#44; embora jovens&#44; 16 &#40;5&#44;39&#37;&#41; participantes foram considerados indiv&#237;duos com massa &#243;ssea abaixo do esperado para a idade&#44; chegaram ao Z&#8208;score de &#8722;2&#44;9 na coluna lombar&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Apesar da perda nos seguimentos&#44; o uso do pareamento por escore de propens&#227;o foi considerado um ponto forte deste estudo por promover a redu&#231;&#227;o de vieses associados com diferen&#231;as nas distribui&#231;&#245;es das covari&#225;veis no grupo de tratados e n&#227;o tratados atrav&#233;s do emprego da t&#233;cnica de infer&#234;ncia causal&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Destaca&#8208;se tamb&#233;m o fato de a massa &#243;ssea ter sido avaliada pelo DXA&#44; considerado padr&#227;o&#8208;ouro&#46; Al&#233;m disso&#44; a sa&#250;de &#243;ssea durante os primeiros anos de vida&#44; assim como na puberdade&#44; &#233; determinante importante da massa &#243;ssea em idades mais avan&#231;adas e essa avalia&#231;&#227;o precoce foi poss&#237;vel neste estudo&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Estudos que relacionam a adolesc&#234;ncia e a sa&#250;de dos ossos t&#234;m conquistado cada vez mais evid&#234;ncia em pesquisas internacionais&#46; O per&#237;odo da inf&#226;ncia e da adolesc&#234;ncia &#233; caracterizado por taxa de forma&#231;&#227;o &#243;ssea muito importante&#44; com predom&#237;nio da forma&#231;&#227;o sobre a reabsor&#231;&#227;o&#59; na idade adulta&#44; esses processos estabilizam e&#44; a partir dos 45&#8208;50 anos&#44; ocorre predom&#237;nio da reabsor&#231;&#227;o &#243;ssea&#44; principalmente no sexo feminino&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">23</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">Apesar de estudos indicarem associa&#231;&#227;o entre o <span class="elsevierStyleItalic">catch&#8208;up</span> na inf&#226;ncia e desfechos adversos na idade adulta&#44;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">24</span></a> o presente estudo&#44; numa amostra de adolescentes&#44; obteve resultado concordante ao feito por Leunissen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">8</span></a> em uma coorte de 312 adultos jovens&#44; que tamb&#233;m n&#227;o achou associa&#231;&#227;o entre <span class="elsevierStyleItalic">catch&#8208;up</span> de estatura e massa &#243;ssea na idade adulta&#46; Os autores demonstraram&#44; por meio de regress&#227;o linear&#44; que os indiv&#237;duos que nasceram pequenos para a idade gestacional &#40;PIG&#41;&#44; com posterior <span class="elsevierStyleItalic">catch&#8208;up</span> que resultou em altura normal na idade adulta&#44; n&#227;o apresentaram diferen&#231;as nos par&#226;metros de massa &#243;ssea quando comparados com os indiv&#237;duos nascidos adequados para a idade gestacional &#40;AIG&#41;&#44; que alcan&#231;aram altura normal &#40;controles&#41;&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Ay et al&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">25</span></a> tamb&#233;m n&#227;o observaram associa&#231;&#227;o entre <span class="elsevierStyleItalic">catch&#8208;up</span> de estatura com a massa &#243;ssea do corpo todo &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;7&#59; IC 95&#37; 0&#44;25&#8211;1&#44;76&#41; e da coluna lombar &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;7&#59; IC 95&#37; 0&#44;26&#8211;1&#44;81&#41; em estudo de coorte feito na Holanda com o objetivo de examinar a associa&#231;&#227;o entre caracter&#237;sticas familiares&#44; do nascimento&#44; do per&#237;odo p&#243;s&#8208;natal e padr&#245;es de crescimento na vida fetal e inf&#226;ncia com a massa &#243;ssea medida atrav&#233;s do DXA em 252 crian&#231;as em seis meses&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">No entanto&#44; Fewtrell et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">7</span></a> ao estudar crescimento&#44; conte&#250;do e densidade mineral &#243;ssea&#44; mostraram uma associa&#231;&#227;o do crescimento substancial de altura ocorrido entre o nascimento e o acompanhamento de rec&#233;m&#8208;nascidos pr&#233;&#8208;termo com maior massa &#243;ssea&#46; Eles tamb&#233;m demonstraram que o comprimento &#233; um forte preditor de massa &#243;ssea&#44; isso sugere que o aprimoramento do crescimento linear precoce pode ser ben&#233;fico para a sa&#250;de &#243;ssea&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Com resultado semelhante ao anterior&#44; Mikkola et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">26</span></a> ao examinar a &#225;rea &#243;ssea&#44; o conte&#250;do mineral &#243;sseo e a densidade mineral &#243;ssea em 178 mulheres na idade adulta em uma coorte de Helsinque&#44; mostraram&#44; por meio de modelos de regress&#227;o linear&#44; que o crescimento em altura antes dos sete anos foi associado ao conte&#250;do mineral &#243;sseo no colo do f&#234;mur &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41; e tamb&#233;m ao conte&#250;do mineral &#243;sseo na coluna vertebral &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; Conclu&#237;ram que o aprimoramento da altura nas meninas &#233; importante para obter esqueleto maior e consequentemente maior massa &#243;ssea&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Resultados como esses refor&#231;am a hip&#243;tese levantada neste estudo&#44; de que a melhoria do crescimento linear em crian&#231;as &#63;&#63;pode ser importante para maximizar a massa &#243;ssea&#46; Apesar de n&#227;o termos investigado dosagem hormonal&#44; &#233; poss&#237;vel que o horm&#244;nio do crescimento&#44; GH e fator de crescimento insulina&#8208;s&#237;mile tipo 1 &#40;IGF&#8208;1&#41;&#44; importantes na manuten&#231;&#227;o da massa &#243;ssea e determinantes do crescimento &#243;sseo longitudinal&#44; da matura&#231;&#227;o esquel&#233;tica e da aquisi&#231;&#227;o de massa &#243;ssea durante a inf&#226;ncia&#44; adolesc&#234;ncia e na vida adulta&#44;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">27&#8211;30</span></a> possam tamb&#233;m participar desse processo por meio de sua a&#231;&#227;o sobre a prolifera&#231;&#227;o e diferencia&#231;&#227;o dos condr&#243;citos na placa de crescimento dos ossos longos&#44;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">31</span></a> processo que levaria ao <span class="elsevierStyleItalic">catch&#8208;up</span>&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Ainda que a osteoporose seja uma doen&#231;a da idade adulta&#44; ela deve ser prevenida e monitorada&#44; promover&#8208;se a sa&#250;de &#243;ssea durante toda inf&#226;ncia e a adolesc&#234;ncia&#46; Ao pediatra caberia a orienta&#231;&#227;o sobre a import&#226;ncia de h&#225;bitos de vida saud&#225;veis e atividade f&#237;sica&#44; com o objetivo de garantir que a crian&#231;a e o adolescente desenvolvam adequada massa &#243;ssea&#44; prevenir agravo&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">32</span></a> Embora n&#227;o tenhamos encontrado efeito significante do <span class="elsevierStyleItalic">catch&#8208;up</span> de estatura na inf&#226;ncia sobre a massa &#243;ssea na coluna lombar em uma amostra de adolescentes no nordeste do pa&#237;s&#44; ressalta&#8208;se que este &#233; um dos primeiros estudos brasileiros a investigar essa tem&#225;tica&#44; sugere que novas pesquisas sejam feitas&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Financiamento</span><p id="par0240" class="elsevierStylePara elsevierViewall">Funda&#231;&#227;o de Amparo &#224; Pesquisa do Estado do Maranh&#227;o &#40;Fapema&#41; e Conselho Nacional de Desenvolvimento Cient&#237;fico e Tecnol&#243;gico &#40;CNPq&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflitos de interesse</span><p id="par0245" class="elsevierStylePara elsevierViewall">Os autores declaram n&#227;o haver conflitos de interesse&#46;</p></span></span>"
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                  "titulo" => "Momento 2 &#8211; Idade escolar"
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            0 => "Crescimento"
            1 => "Estatura"
            2 => "Densidade &#243;ssea"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To analyze the effect of height catch&#8208;up at school age on the bone mass of adolescents of a Brazilian birth cohort&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A cohort study using data obtained from the three moments &#40;birth&#44; 7&#47;9 years and 18&#47;19 years of age&#41; of the Cohorts&#8208;RPS study&#46; Height catch&#8208;up was defined based on the difference between the schoolchild&#39;s <span class="elsevierStyleItalic">z</span>&#8208;score and birth <span class="elsevierStyleItalic">z</span>&#8208;score&#46; The adolescents&#8217; bone mineral mass was analyzed using the <span class="elsevierStyleItalic">z</span>&#8208;score index for the lumbar spine measured by dual emission X&#8208;ray absorptiometry&#46; A theoretical model was developed for the proposed analysis using directed acyclic graphs paired through the nearest&#8208;neighbor matching propensity score using the STATA software&#44; version 14&#46;0&#46; The level of significance was set at 5&#37;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Of the 297 studied children&#44; 24&#46;5&#37; achieved height catch&#8208;up&#46; The bone mass below the expected for age was observed in 5&#46;39&#37; of the subjects&#46; The mean lumbar spine <span class="elsevierStyleItalic">z</span>&#8208;score was &#8722;0&#46;34 &#40;&#177;1&#46;01&#41;&#46; After the adjustment&#44; no effect was observed between height catch&#8208;up at school age and bone mass in adolescents &#40;Coeff<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;598&#59; 95&#37; CI &#8722;0&#46;117 to 1&#46;313&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;101&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Even using the directed acyclic graphs and the causal inference method by adjusting the propensity score&#44; the height catch&#8208;up did not seem to affect bone mass in adolescents&#44; a result perhaps related to the sample size&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Analisar o efeito do <span class="elsevierStyleItalic">catch&#8208;up</span> de estatura na idade escolar na massa &#243;ssea em adolescentes em uma coorte brasileira de nascimento&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudo de coorte&#44; utilizando dados dos tr&#234;s momentos &#40;nascimento&#44; aos 7&#47;9 anos e 18&#47;19 anos&#41; da pesquisa Coortes&#8208;RPS&#46; <span class="elsevierStyleItalic">Catch&#8208;up</span> de estatura foi definida a partir da diferen&#231;a entre o Z&#8208;score do escolar e Z&#8208;score do nascimento&#46; Para a an&#225;lise da massa &#243;ssea em adolescentes foi utilizado o &#237;ndice Z&#8208;score da coluna lombar medido pela densitometria por dupla emiss&#227;o de raio X&#46; Para an&#225;lise proposta&#44; foi constru&#237;do modelo te&#243;rico usando os gr&#225;ficos ac&#237;clicos direcionados e pareado por escore de propens&#227;o do tipo vizinho mais pr&#243;ximo utilizando o <span class="elsevierStyleItalic">software</span> STATA vers&#227;o 14&#46;0&#46; O n&#237;vel de signific&#226;ncia adotado foi de 5&#37;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Das 297 crian&#231;as&#44; 24&#44;58&#37; realizaram o <span class="elsevierStyleItalic">catch&#8208;up</span> estatural&#46; Massa &#243;ssea abaixo do esperado para a idade foi de 5&#44;39&#37;&#46; O Z&#8208;score m&#233;dio da coluna lombar foi &#8722;0&#44;34 &#40;&#177; 1&#44;01&#41;&#46; Ap&#243;s ajuste&#44; n&#227;o foi observado efeito entre <span class="elsevierStyleItalic">catch&#8208;up</span> de estatura na idade escolar e massa &#243;ssea no adolescente &#40;Coef<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;598&#59; IC 95&#37; &#8722;0&#44;117&#8211;1&#44;313&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;101&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#227;o</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Mesmo com os gr&#225;ficos ac&#237;clicos direcionados e o m&#233;todo de infer&#234;ncia causal por ajuste do escore de propens&#227;o&#44; o <span class="elsevierStyleItalic">catch&#8208;up</span> de estatura parece n&#227;o afetar a massa &#243;ssea em adolescentes&#44; resultado talvez relacionado ao tamanho da amostra&#46;</p></span>"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Como citar este artigo&#58; Rodrigues LS&#44; Batista RF&#44; Sim&#245;es VM&#44; Rodrigues MR&#44; Barbieri MA&#44; Bettiol H&#44; et al&#46; Does height catch&#8208;up in schoolchildren have an effect on bone mass in adolescents&#63; Analysis in a Brazilian birth cohort&#46; J Pediatr &#40;Rio J&#41;&#46; 2019&#59;95&#58;607&#8211;13&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Trabalho vinculado ao Departamento de Sa&#250;de P&#250;blica&#44; Universidade Federal do Maranh&#227;o&#44; S&#227;o Lu&#237;s&#44; MA&#44; Brasil&#46;</p>"
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        "descripcion" => array:1 [
          "pt" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Modelo te&#243;rico elaborado pelos autores do tipo vizinho mais pr&#243;ximo da associa&#231;&#227;o entre <span class="elsevierStyleItalic">catch&#8208;up</span> de estatura e massa &#243;ssea&#46;</p>"
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Massa &#243;ssea</th></tr><tr title="table-row"><th class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sim&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sim&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o restrito&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">144&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8722;0&#44;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sim&nbsp;\t\t\t\t\t\t\n
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