Evolutionary medicine portrays metabolic diseases as a problem of contemporary obesogenic lifestyles in a globalised world within the context of mismatch to past environments. Over a single generation, there has been a dramatic rise in the global rate of such diseases including type 2 diabetes (T2DM) and obesity affecting high-, medium- and low-income countries. Relatively little attention has been paid, however, to evidence from prehistory that may document metabolic conditions or how to interpret them within a broader ecological context. While diabetes and obesity are very challenging to diagnose in the bioarchaeological record, two other metabolic conditions, gout and DISH, are easily identifiable and can yield useful information about the past, allowing inferences about the possible existence of T2DM in individuals. We present evidence from the bioarchaeological record for these conditions and how they have been used to reconstruct the health of past populations. We also provide an overview of ecological and life history models that can be used to contextualise bioarchaeological data in efforts to reconstruct the evidence for past metabolic diseases, particularly as subsistence patterns underwent major transitions. The evidence suggests that metabolic disorders are not restricted to our modern, industrialised world, but are likely have much deeper origins than are typically recognised in clinical, biomedical research. Continued use of bioarchaeological data can assist in reconstructing much more evidence for the conditions in which chronic non-communicable diseases were able to develop and afflict human populations.