Metabolic diseases have become a public health problem worldwide. Effective, novel and natural therapies are urgently needed to treat metabolic diseases. As natural bioactive compounds, polysaccharides have many physiological and medicinal properties. Recently, herb-derived polysaccharides have shown beneficial effects in the treatment of metabolic diseases, but the underlying mechanisms remain unclear. This review comprehensively summarizes the pharmacological progress and clinical evidence of herb-derived polysaccharides in the treatment of three metabolic diseases, namely type 2 diabetes mellitus, nonalcoholic fatty liver disease and obesity, and more importantly, discusses the molecular mechanism involved. Existing evidence has proved that herb-derived polysaccharides can maintain glucose homeostasis, promote insulin secretion, improve insulin resistance, reduce weight gain and hepatic steatosis, inhibit lipogenesis, alleviate oxidative stress and inflammation, and improve gut microbiota disorders in rodents with metabolic diseases. Notably, so far, human clinical trials of herb-derived polysaccharides for these three metabolic diseases remain rare. All in all, herb-derived polysaccharides may have good potential as drug candidates for the prevention and management of metabolic diseases. More high-quality clinical trials are needed to further validate its effectiveness and safety in human subjects.