Digestive_Tract_1

SIBO: Yes, a diagnosis but also a symptom

When a patient is diagnosed with small intestinal bacterial overgrowth (SIBO), they often breathe a sigh of relief! Finally, the doctor has found what is wrong with me! In reality, the detective work has just begun.Digestive_Tract_1

SIBO is a condition in which microbes overgrow in the small intestine. We have many microbes living in our intestines but most reside in our colon (large intestine). Normally, the small intestinal environment should not be suitable for the survival of an overgrowth of these bugs.

The prevalence of SIBO in the general population is unknown. Research studies reveal anywhere from 0-20% of healthy individuals have SIBO. For those with irritable bowel syndrome, incidence of SIBO ranges widely from 4-64% or even higher depending on testing methods and testing criteria. This wide range in prevalence reveals the conundrum that SIBO presents; there is no gold standard to define or diagnose SIBO. Glucose and lactulose breath testing are most commonly used in the clinical setting but interpretation varies from institution to institution. 

Before I get started on my thoughts about SIBO, let me state clearly, that this is an area that has been researched, but much more work has to be done.  We need more studies to better understand the potential role of diet, probiotics, medications, food borne illness and their relationship with the onset and treatment of SIBO.  I am providing my musings based on research I have read in the medical literature, discussions with researchers, personal experience (I unfortunately have had SIBO), and professional experience as a registered dietitian– about 65% of my patients have been diagnosed with this condition. 

Although, it is possible that you may never determine how and why you developed SIBO, it is important to attempt to uncover the reason your developed an overgrowth of bacteria in your small intestine. SIBO has a good chance of re-occurring if you don’t find the root cause. Sometimes the cause is modifiable, to decrease rate of relapse –sometimes it is not. 

Here are my thoughts:

Step #1:  Attempt to uncover possible risk factors for the development of SIBO.  SIBO is a symptom per se, something changed the environment or function in the small intestine to allow microbes to overgrow. The medical team and the patient should work together to identify possible causes. The patient’s job is to provide an accurate account about the onset of symptoms to the doctor. The doctor assimilates this information along with testing and a physical exam to create the most viable potential causes. The dietitian tends to have a greater duration of time with the patient and is often a valuable player in helping piece the history together. This is just one reason why it is essential that medical professionals collaborate to provide the best care for the patient.  As a patient, encourage your health team to work collaboratively. 

Some potential causes of SIBO: Infection (such as food borne illness), untreated celiac disease, poor motility in the intestine linked with IBS or previous abdominal surgeries, GERD (gastro-esophageal reflux) treated with proton pump inhibitors (PPI) medication, chronic pancreatitis, hypothyroidism or diabetes, to name a few. What changed the small intestinal environment? What changed the small intestine motility?

Step #2: Is the potential cause treatable? If so, then treat.  For instance, if you can treat the new celiac patient with a nourishing gluten free diet and treat the SIBO with suitable antibiotics,  that patient might be all set. If you can lower the PPI dose or change from a PPI to an H2 Blocker, to treat heartburn or reflux, the small bowel pH (the amount of acid in the small bowel) might be less altered. Less acid in the small intestine may allow bacteria to overgrow. For example, the doctor might try try Pepcid (H2 blocker) versus Nexium (PPI) to manage the GERD symptoms. Perhaps this change in medication, will minimize the impact on the acid conditions in the small intestinal environment enough—so SIBO doesn’t relapse. Severe constipation or incomplete emptying of the colon, can impact small intestinal motility, a potential risk factor for SIBO too. If a SIBO patient presents with ongoing constipation—perhaps initiate a bowel regimen and check for pelvic floor dyssynergia. If a patient developed SIBO after a bout with food poisoning——(common food borne pathogens can lead to partial small bowel paralysis)—perhaps these patients might benefit from Iberogast, an herbal prokinetic, or low dose erythromycin at night (50 milligrams dose) to stimulate small bowel cleansing. Additionally, spacing meals out 3-4 hours vs. grazing will allow the migrating motor complex (MMC)–the housekeeper of the small intestine– to initiate a cleansing wave to cleanse the small bowel of food and bacteria. The MMC only occurs in the fasting state. 

I understand from a patient’s perspective that having numerous tests come back negative can  feel defeating, in a way. No one wants to be diagnosed with a life threatening illness, that is for sure. But, when illness, takes your quality of life away, it can be daunting.  When small intestinal bacterial overgrowth testing proves to be positive, patients often rejoice. Just remember, the detective work has just begun.

For more about SIBO, consider reading my long winded post here.  For dietitians in practice, you can purchase my patient ready SIBO handout ($10) to use with your patients, if you’d like.  The SIBO handout can be found here.

popchips Sea Salt Potato

Popchips give-a-way!

Good news! I have another give-a-way today!! :)

One of my favorite salty snacks are popchips! Have you tried them? I can seriously wolf down the whole bag in one sitting. Seriously.  {Don’t tell anybody!}popchips Sea Salt Potato

When popchips reached out and asked if I wanted to share my love of popchips with my blog followers…I did not hesitate saying, YES!!

But let me give you a little background…on popchips.

I truly love the Sea Salt popchips for a few reasons.  They appear to fit the low FODMAP guidelines (but like other brand name foods have not yet been tested). They have less fat and calories than most chips.  They are super tasty!  And, I really can eat the whole bag and my tummy is okay with that! I try not too…but sometimes I can’t help myself.  What I like about popchips:

  • no fake colors
  • no fake flavors
  • no fluorescent orange fingertips
  • no cholesterol or trans fat
  • gluten free

For this give-a-way, I want to share the love with my friend, Zlata and fellow FODMAPer who is also doing a popchips give-a-way! Zlata has some amazing low FODMAP recipes on her site too! She has been a huge advocate of my work…and I so appreciate that! Since sharing is caring, here is how Zlata and I are working the give-a-way together, for a chance to win: 

  •  You must follow @katescarlata and @lifeandthymez on Instagram (I post a lot! Many low FODMAP tips & pretty pics.)
  • Tag a friend in the Instagram post that you’d want to share some popchip love with and maybe tell us why you need the popchips!  And you and your friend will be entered for a chance to win 3 bags of the Sea Salt Popchips!

  That’s it! If you meet those two criteria, you’ll be entered to win!

 Note: there will be a winner and their tagged friend chosen by me and a winner & tagged friend chosen by Zlata, so there will be FOUR lucky winners!

 

 

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Pelvic floor dysfunction

Happy Tuesday! Caution: I am ready to delve into a private topic today. I will be talking about constipation, specifically, dyssynergic defecation. This topic might not be your favorite cocktail party chatter …but hey, someone has to do it! So, here I go.Unknown-9

I have talked a bit about pelvic floor dysfunction in the past on my blog but not in detail. I won’t take a major deep dive on this topic but wanted to expand your knowledge a bit. I see many, many patients in my clinical practice that have been diagnosed with a pelvic floor disorder.

I asked Satish Rao, MD, Director of the Digestive Health Center at Georgia Regents University and world-renown motility specialist to provide some details for you, “Pelvic floor disorders encompass many problems that include: dyssynergic defecation, rectal prolapse, excessive perineal descent and fecal incontinence and others. Pelvic floor disorders affect 20% of the population and profoundly affects quality of life, particularly in elderly. Recognizing the problem, defining the underlying mechanism(s) and providing appropriate treatment(s) are cornerstones for successful management. This requires a multidisciplinary approach involving gastroenterologist, registered dietitian, biofeedback therapists and motility labs.”

So, what the heck is dyssynergic defecation? Dyssynergic defecation occurs when the muscles and nerves in the rectum do not work properly or in a coordinated fashion. Symptoms often present as constipation or sense of incomplete emptying. Treatment is pelvic floor physical therapy and/ or biofeedback.

According to IFFGD ( International Foundation for Functional Gut Disorders ) website, a great resource for individuals with functional gut disorders:

“It is not clear what causes dyssynergic defecation.

Muscles in the abdomen, rectum, anus, and pelvic floor must all work together in order to facilitate defecation. Most patients with dyssynergic defecation exhibit an inability to coordinate these muscles. Most often this problem of coordination consists either of:

  • impaired rectal contraction or tightening rather than relaxing (paradoxical contraction) the anal muscles during defecation, or
  • not enough relaxation of the anal muscles.

This lack of coordination (dyssynergia) of the muscles that are involved in defecation is primarily responsible for this condition.

In addition, at least one-half (50–60%) of patients with dyssynergic defecation also show evidence of a decrease in sensation in the rectum. In other words, there is a problem with their ability to perceive the arrival of stool in the rectum.

A survey of 100 patients with the dyssynergic defecation found that in nearly one-third (31%) the problem began in childhood. About an equal number (29%) appeared to have developed the problem after a particular event, such as pregnancy or an injury. In the remaining 4 out of 10 persons (40%), no cause was identified that may have brought on the condition.”

IFFGD has a good review of dyssynergic defecation here.  

How is dyssynergic defecation diagnosed?  IFFGD has a good review here.  Most practitioners can get the information they need with anorectal manometry testing. This is the test I recommend.  A small, flexible sensor is placed in your rectum (about the size of rectal thermometer.)  This is connected to a computer and a recording device that measures the pressure and strength of your anal and rectal muscles.  The test measures coordination of muscles, reflex action, sensation, strength and weakness of rectal and anal muscles. 

Outside of the low FODMAP diet, I have found that physical therapy and biofeedback for dyssynergic defecation are cornerstones of symptom management for many of my patients.  I have found in my practice–that  patients of all ages, men and women, have had issues with dyssynergic defecation.

Unfortunately, I have also found that many {not all, thankfully!} GI doctors do not order or are somewhat resistant to order testing for this condition. I think many practitioners feel that undergoing the testing, the follow up physical therapy and biofeedback is invasive, time-consuming, and that most patients would not partake in it.  Interestingly, in my practice, I find patients are very amenable to do most testing and treatment as they want to be an active participant in getting their life back!

The purpose of this post is to educate you on dyssynergic defecation.  To encourage you to discuss testing with your GI doctor if you feel that this condition may be playing a role in your GI symptoms.

I believe this disorder has been a contributor to relapsing SIBO that many of my patients experience as well.  If you are not emptying your colon properly and it remains full of stool, this impacts the motility of your small bowel.

I would love your feedback if you feel comfortable sharing your story.  I realize it is a personal one.  Have you tried physical therapy or biofeedback for dyssnergic defecation? Has it helped?

 

Kale and Blueberry Salad

Blueberry Kale Salad with Pine Nuts

Summertime means salad time! And I love adding nuts and fruit to my salads!  This week, I concocted a nice quick fix salad that I thought I would share with you.

I am a big fan of kale.  I can honestly say I crave it.  I was so happy when the Monash University researchers tested it and found it to be low FODMAP.  Kale is rich in calcium, antioxidants, Vitamin K, A and C and manganese.  I particularly enjoy baby kale! Kale Salad Ingredients

For this recipe, I toasted some pine nuts in a skillet, washed up the baby kale and blueberries and whipped up a lemon mustard dressing.

Sooooo…..good.Kale and Blueberry SaladYour body will thank you for eating this salad.  A nutritional powerhouse!

Blueberry Kale Salad with Pine Nuts

Ingredients

  • Serves 4
  • 4 cups baby kale
  • 1 cup blueberries
  • 1/4 cup pine nuts
  • Lemon Mustard dressing:
  • 2 tablespoons fresh lemon juice
  • 1/3 cup olive oil
  • 2 teaspoons Dijon mustard (check ingredients)
  • Salt and pepper, to taste

Instructions

  1. In medium skillet over medium heat, add pine nuts and cook until light toasted.
  2. In medium serving bowl or platter, add kale.
  3. Mix up Lemon Mustard Dressing by adding ingredients to a mason jar and shake until blended or in a small bowl and whisk with a fork until blended and emulsified.
  4. Top salad with blueberries, toasted pine nuts and drizzle with salad dressing to your taste.
http://blog.katescarlata.com/2015/06/18/blueberry-kale-salad-with-pine-nuts/

cartoon

Primer on Carbs

Hello Friends.  I hope you had a wonderful weekend and that your week is off to a great start!  I enjoyed a wonderful weekend at our little Maine cottage.  The weather was picture perfect!Maine boats

Maine is a special place–especially in the summertime.Maine buoys

Today I thought I would talk a bit about carbohydrates {sound fun?!?} and how FODMAPs fit in the spectrum of carbohydrates.cartoon

Ha! Ha!

The low FODMAP diet is not a low carbohydrate diet but rather a diet modified in a group of small chain carbohydrates that are commonly malabsorbed by the human body. FODMAPs are rapidly fermented by gut bacteria and pull water into the intestine, stretching the intestine and causing pain, bloating, diarrhea and/or constipation in those with a sensitive gut. 

Carbohydrates, for most of us, make up the majority of our calorie intake or about 40-75% of energy needs. I do believe that carb needs varies person to person depending on activity level, weight management needs, genetics and personal tolerance to them.  

Carbohydrate digestion begins in the mouth.  Starch degrading enzymes are found in the saliva (salivary amylase) and help the body begin the digestive process.  Take home message: Chew well and chew slowly.

Carbohydrates are either absorbed in the small intestine or escape digestion when the human body lacks enzymes to break them into digestible components. Digestible carbohydrates are those that are hydrolyzed by enzymes released in the GI tract. Carbohydrates that escape digestion in the small intestine are often but not always fermented by gut microbes. Various gut microbes harbor their own carb digesting enzymes and have the ability to break apart undigested carbohydrates and ferment them in the large intestine…creating gas! Got gas? Well,  that is the result of microbes fast at work breaking down carbs your body did not digest! Can’t wait to learn more? Here is a scientific paper on how carb digestion is impacted by our gut microbes.

Carbohydrates are often classified by their degree of polymerization (DP)–the number of sugar units that are linked together.

Monosaccharides: 1 chain sugars : Glucose and Fructose

Disaccharides: 2 chain sugars (DP2): Lactose and Sucrose

Oligosaccharides: 3-9 chains sugars: Raffinose, Starchyose, FOS/ small chain inulin

Sugar alcohols: Sorbitol, Mannitol, Xylitol, Lactitol, Maltitol

Polysaccharides:  >10 but often many more! Polysaccharides can be comprised of cellulose, hemicelluloses, pectins, b -glucans, fructans, gums, mucilages, algal polysaccharides & resistant starch.  Carbohydrates vary in fermentability.  Cellulose, sterculia, and methylcellulose are long chain fibers and are not fermented while water-soluble long chain carbohydrates: resistant starch, pectin, guar gum, and inulin are highly fermentable.  Although pectin, guar gum, resistant starch and longer chain inulins are NOT classified as FODMAPs   (remember FODMAPs are small chain carbs!}–they are rapidly fermented, and as such, may contribute to gas and GI symptoms in those with IBS. More research is needed in this area.

One of my favorite scientific papers on fiber and functional gut disorders can be assessed here. This is a great scientific review of dietary fiber and fermentation.

As many of your know already, FODMAPs are water-soluble short chain carbs that commonly escape digestion. The ability to digest lactose diminishes with age as the production of the enzyme lactase lessens.  Genetics also plays a role.  For instance, Asians and African Americans are more likely to exhibit lactose malabsorption than Caucasians.

Fructose, when in excess of glucose in a food is also poorly absorbed for up to 1 in 3 people.  Fructose does not require an enzyme to be digested but glucose does aid its absorption. Fructans and GOS are fibers; human lack digestive enzymes to aid their absorption.  And sugar alcohols are absorbed via pores in the small intestine. The larger size of sugar alcohols compared to the small pore size in the intestine lends itself to poor absorption.

So, in review, there are many types of carbohydrates in the diet: small well absorbed carbs such as glucose (1 chain carb), sucrose (2 chain carb) and most starches (multiple chain carbs).  These are well tolerated by most people.  Commonly malabsorbed carbs such as small chain FODMAPs and some poorly absorbed polysaccharides such as resistant starch, pectins and gums can be fermented rapidly resulting in gas production.  Research has shown that a low FODMAP diet can help with reduce IBS symptoms.  More research is needed to fully evaluate the impact of gums, pectins and resistant starch in individuals with IBS.  Because gut bacteria favor carbs for their nutrition, altering carb intake can impact our gut bacteria. Gut bacteria do cause gas, but they also help produce vitamins, help keep our immune system strong, and aid digestion.

The low FODMAP diet has been shown to reduce some gut microbes that produce  butyrate, a short chain fatty acid linked with reducing colon cancer risk.  The role of diet and our gut microbiome is in the early stages and there is much more to learn.  But, due to the potential negative long-term impact on gut bacteria, the low FODMAP diet is recommended to be followed for 2-6 weeks in the full elimination phase.  Following up with the re-challenge phase of the low FODMAP diet is important to allow for eating a more varied and nutritious diet as possible without triggering symptoms.

And I know some of you really struggle with carbohydrates in general.  I do think that carbohydrate tolerance can be very variable depending on the microbes that inhabit our gut, the degree of inflammation occurring in the small intestine (whether from microbes, inflammatory bowel disease, untreated celiac disease, autoimmune conditions and SIBO) to name a few potential causes.  Work with a gastroenterologist and registered dietitian well-versed in digestive health to help properly evaluate the function of your GI tract and guide you on eating most varied and nutritious diet possible.

low FODMAP feta dip

Whipped Feta Dip

This recipe is amaze! So yummy!

If you like feta cheese, it’s feta, but better.

This recipe is perfect for your next gathering. Serve with rice crackers, thinly sliced sourdough white baguette (if you tolerate it) and carrot sticks.

low FODMAP feta dip

Whipped Feta Dip

Ingredients

  • 6 ounces feta cheese, in brine
  • 2 tablespoons fresh squeezed lemon juice
  • 1/3 cup olive oil
  • 1/8 teaspoon crushed red pepper,optional

Instructions

  1. Remove feta from brine and add to food processor, fit with steel blade.
  2. Add lemon juice and olive oil.
  3. Blend until creamy.
  4. Garnish with crushed pepper flakes mixing gently into mixture.
http://blog.katescarlata.com/2015/06/11/whipped-feta-dip/

Comfort food at it’s best.feta dip

I hope your week is going well.  I am having a great week. I bought new running shoes. Yay! I visited with my tax accountant who said I owed less $ than I anticipated….so I went shopping :) and bought 2 new dresses!  I am working on some very exciting projects which I will share with you soon! I feel grateful everyday that I work as dietitian, in a field, I absolutely love!

Oh…and most importantly, I have selected our Crunchmaster cracker give-a-way winner!! The winner is Luci C.! Thanks everyone for entering!

 

 

 

 

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FODMAP updates & Give-A-Way

Happy Tuesday and Hello FODMAPers!

The food database for FODMAPs continues to grow thanks to Monash University researcher’s hard work.  Spaghetti squash and chestnuts get the green light. Watching the low FODMAP grow-up has been exciting!  I have been following the updates on the low FODMAP diet since 2009. And, yes, the diet is evolving.  If you are new to the diet, you will find numerous out-dated food lists online.  Dietary analysis of FODMAP content is an ongoing process, so be sure you are retrieving the most up-to-date information! It can be frustrating and confusing at times as different lists show different information.

Monash shared one of my favorite spaghetti squash recipes when they provided their update on their food analysis. How cool is that?!  If you are a spaghetti squash fan, do check this recipe out!

IMG_1754On other low FODMAP notes, I am still reviewing the study abstracts provided at DDW, (digestive disease week conference) and found an interesting Italian study looking at the low FODMAP diet and rifaximin (antibiotic) in small intestinal bacterial overgrowth (SIBO) patients. This study looked at the benefit of treating SIBO with rifaximin and the low FODMAP diet or rifaximin and normal diet or low FODMAP with placebo (not an antibiotic). Findings: After 12 days, the low FODMAP and rifaximin group AND the normal diet and rifaximin  group had significant improvements with bloating and abdominal distention, but the placebo + low FODMAP diet noted only slight improvement in symptoms. Researchers summarized this study saying that patients with IBS and SIBO seem to benefit best from combo approach of low FODMAP diet and antibiotic therapy.  For those interested, I do have a $10 e-booklet with my thoughts on SIBO based on my clinical observations and hours of research I have spent learning more about this condition, found here.  There is no consensus or evidenced based therapy on how to treat SIBO from dietary standpoint…yet.  But, I have find the low FODMAP as this study notes, offers the best relief along with antibiotics without OVER-restricting the diet.

GIVE-A-WAY!!  Today, I want to give you the opportunity to win a 6 pack of one of my favorite crackers.  Crunchmaster reached out offering a give-a-way for my blog…and of course, I say, YEEEEEES, thank you! Unknown-8Crunchmaster 7 Ancient Grain crackers have not been tested for FODMAP content YET! Brand name testing of foods is coming…but it will be a while before we have a full database of this information!  Companies, of course, can inquire with Monash University to learn more here.  But, these Crunchmaster 7 Ancient Grain crackers are gluten free and primary made of brown rice and potato starch with a smattering of healthy ingredients such as quinoa seeds, sesame seeds, millet and flax. I tolerate these crackers and really enjoy the taste!  Want a win a 6-pack?  Well, then leave a comment and say, “YES, I want the crackers!” And you will be entered to win!

Have a great week!

 

Research Study: Looking for Participants.

My friends at U. Michigan are researching the role of diet in fecal incontinence.  I know…a sensitive and private subject for many.  Diet can help this condition….but of course, we need to prove this with research!  So, if you experience fecal incontinence and would like to participate in this study to help researchers, the medical community and ultimately patients gain a better understanding of the impact of diet on this condition, kindly contact U. Michigan research team via phone or email: (734) 647-3374 or email at FI-Diet-Study@umich.edu   Don’t worry you don’t need to go to Michigan to participate, much of the study is completed via phone or Skype.

“Dietary study for accidental bowel leakage due to loose/watery stools.” Study informationFI flyer

fodmaps101

FODMAPs 101 and SIBO educational handouts

Hello Friends.

Just wanted to be sure you knew that I have uploaded a free FODMAPs 101 educational handout.  This is an introductory guide about FODMAPs.  For dietitians in practice, you may find this guide works well for educating your patients.  It works well with my other FODMAP educational tools found here. fodmaps101

For those with a new diagnosis of small intestinal bacterial overgrowth (SIBO), I have a new SIBO guide too!

This is not a free handout.  Small intestinal bacterial overgrowth is a condition that has not been widely studied.  I created my recommendations based on my personal experience with this condition, clinical observations in my patients, research that I have gathered from clinical papers and personal perspectives via dialogue with leading SIBO experts, such as Mark Pimentel from Cedar Sinai. There are NO evidenced based diets for SIBO and often diet needs to be adjusted to individual tolerance.  My philosophy is to implement the least restrictive diet as possible to nourish the body adequately.  I believe, a low FODMAP diet is a good starting point, adjusting and adding in foods as tolerated.

lavendar mint iced tea

Lavender Mint Iced Tea

Hello Summer weather! I am so happy when the sun is shining and I can be dressed in short sleeves. :) Russ, Lucy and I have been having way too much this Spring at our new Maine cottage. The weather has been amazing!  Being able to walk to the beach in the mornings has been priceless for all three of us.  Hearing and seeing the waves crashing on the shore is so good for the body and the soul.  Lucy, our chocolate lab, is especially in her glory!  As expected, she truly loves swimming in the ocean!  Click here to see my Lucy!

With the warmer weather, hydration becomes more important as we lose more water from our body through sweat.  I am a big fan of water as my primary hydration source {your body is about 60-65% water}…but sometimes it’s fun to get a bit fancier.  Today is all about fancy.  I made some delicious lavender mint iced tea today…and I thought I would share the recipe with you!lavendar mint iced teaUsing fresh edible herbs and flowers is not only fun…but pretty.  I was inspired to try lavender and mint tea after my daughter Chelsea had shared she tried some iced tea infused with both herbs last weekend in Woodstock, NY. IMG_4663To infuse the tea with lavender, I purchased culinary grade lavender from a local farm.  I added about 1 teaspoon of the flower buds into my hot tea. Be sure to purchase lavender deemed for culinary use as some lavender plants have been sprayed with pesticides and you don’t want to ingest the residues. There are many dried culinary lavender products online. FODMAPers: To my knowledge, lavender has not been officially tested for FODMAP content–so use at your discretion.IMG_1847I created iced tea with lavender infused black tea, fresh mint, organic lemonade and plenty of ice. Just a hint of sweet from the lemonade in this refreshing drink!IMG_1877

Feeling fancy?  Well, then, give this recipe a whirl!

Lavender Mint Iced Tea

Ingredients

  • ~6 servings
  • 4 cups hot black tea
  • 1 teaspoon fresh lavender buds or 1/4 teaspoon dried lavender (purchase culinary grade lavender)
  • 1 1/2 cup lemonade (I used Santa Cruz organic lemonade)
  • 10 mint leaves, chopped
  • lavender stem and mint leaves for garnish

Instructions

  1. Prepare tea and add lavender buds to hot tea, stir to immerse and let sit for about 1 hour. Let tea come down to room temperature.
  2. Using fine mesh colander, strain out lavender and place cooled tea in glass pitcher.
  3. Add lemonade and mint to tea.
  4. Add ice to serving glass and pour in lavender mint tea.
  5. Garnish with fresh mint leaves and sprig of fresh culinary grade lavender sprig, if desired.
http://blog.katescarlata.com/2015/05/29/lavender-mint-iced-tea/