With global population aging, age-related glucose and lipid metabolic dysregulation has become a critical public health challenge. Acupuncture, a safe non-pharmacological intervention, is widely used to manage such metabolic disorders. Impairment of the gut–brain axis (GBA) is a key pathogenic driver of this condition, and has emerged as a novel target for exploring acupuncture’s therapeutic mechanisms. This review synthesizes recent research on acupuncture regulating the GBA in elderly individuals with glucose and lipid dysregulation. Evidence shows acupuncture acts via multiple GBA nodes: reversing gut microbiota dysbiosis, restoring intestinal/blood–brain barrier integrity, inhibiting gut-derived pro-inflammatory factors, and reestablishing hypothalamic metabolic regulation. These findings provide theoretical support for precise clinical application of acupuncture, and offer new directions for targeted intervention research in age-related metabolic disorders.