Once a mainstay of the school day, physical education classes have fallen by the wayside for many American students, despite a massive push by doctors, nutritionists and even the first lady to get children more active.
The message has come fast and furious -- childhood obesity is a national epidemic.
But physical education advocates say more and more students are being allowed to opt out of gym class in favor of activities like marching band, ROTC, even an extra art class.
Students in some school districts are even allowed to complete their physical education requirements online ; They promise to exercise on their own time and just click their way through to course completion.
"This is a serious issue," said Keith Ayoob, director of the nutrition clinic at the Rose F. Kennedy Center in the Albert Einstein College of Medicine in New York. "If they don't get anything in school they're probably not going to get it."
Being obese and overweight is the No. 1 health problem in children, Ayoob said. And a study this year in the New England Journal of Medicine reported that obese children were twice as likely to die of disease by age 55.
According to the "Shape of the Nation" report, released in June by the National Association for Sport and Physical Education, 22 states -- 43 percent -- allow required physical education credits to be completed online.
And only five states -- Illinois, Iowa, Massachusetts, New Mexico and Vermont -- require p.e. at every grade level.
"We've seen over time that children and students are becoming more sedentary and not just in school," said NASPE president Lynn Couturier. ""Even after school, if they're going home a lot of them are choosing activities that are not physically active."
Schools, Couturier said, are making cuts to recess and intramural sports, leaving interscholastic sports, where only skilled athletes make the team. That cycle, she said, denies opportunities for exercise to those who need it most.
NASPE, along with the American Heart Association, recommend that students get 30 minutes per day of physical education instruction for elementary school children and 45 minutes per day for middle and high school children.
But only one state -- Alabama -- follows the guidelines at each school level, the NASPE reported.
"In my experience kids should be getting physical activity every single day and they don't," Ayoob said.
Though the state of Florida does mandate the 150 minutes of physical education for elementary school children, it requires one credit of physical education as a graduation requirement for high school students.
And while waivers to opt out of high school phys ed have been around in Florida since the late 1980s, a state law gave elementary school parents the option to opt in 2008 and middle school parents to do the same last year.
Several other states have variations on physical education opt-outs.
Nichole Wilder, physical education coordinator for the Florida Department of Education, said that 40 to 80 percent of middle school students have opted out of physical education in some districts since the waiver became available to them in 2009.
Waivers for middle school students can be granted if the child is required to enroll in remedial academic classes. Parents can also request that their child be excused because they participate in physical activity outside of school that's equal to their gym class-- such as gymnastics or soccer -- or if the child wants to take another course in place of physical education, whether it be art instruction or an extra math class.
Different waivers exist at the high school level, but playing on a team sport or participating in marching band can both go toward whittling away at the one-credit graduation requirement.
Wilder admitted that it was essential that students stay physically active, but sometimes it's difficult to find a place for it during school hours.
"It comes [down] to the number of class periods that are available during the school day," she said.
Couturier agreed, noting that there is increasing pressure for schools to perform well on standardized testing and comply with the No Child Left Behind Act, "which leaves less time for physical education and subjects that aren't core."
Still, NAPSE doesn't condone any version of an opt-out or waiver program for physical education.
"We like to think it's a valuable part of children's curriculum," she said. "If you sign up for math club you don't get out of taking math. If you sign up for the school play, you don't get out of English."
But, according to Ayoob, even kids enrolled in gym class aren't getting out of it what they need.
"Gym is a term that's often used loosely," he said, pointing to 45-minute long physical education classes that take 20 minutes just to get the kids changed and organized. "Some of my kids get gym once a week, three times a week, maybe."