Objectives We conducted a randomized trial among overweight long-distance drivers to study the effects of structured lifestyle counseling on body weight and cardiometabolic risk factors. Methods Men with waist circumference >100 cm were randomized into a lifestyle counseling (LIFE, N=55) and a reference (REF, N=58) group. The LIFE group participated in monthly counseling on nutrition, physical activity, and sleep for 12 months aiming at 10% weight loss. After 12 months, the REF group participated in 3-month counseling. Assessments took place at 0, 12, and 24 months. Between-group differences in changes were analyzed by generalized linear modeling. Metabolic risk (Z score) was calculated from components of metabolic syndrome. Results The mean body weight change after 12 months was -3.4 kg in LIFE (N=47) and 0.7 kg in REF (N=48) [net difference -4.0 kg, 95% confidence interval (95% CI) -1.9– -6.2]. Six men in LIFE reduced body weight by ≥10%. Changes in waist circumference were -4.7 cm in LIFE and -0.1 cm in REF (net -4.7 cm, 95% CI -6.6– -2.7). Metabolic risk decreased more in the LIFE than REF group (net -1.2 points, 95% CI -0.6– -2.0). After 24 months follow-up, there were no between-group differences in changes in body weight (net -0.5 kg, 95% CI -3.8–2.9) or metabolic risk score (net 0.1 points; 95% CI -0.8–1.0) compared to baseline. Conclusions Weight reduction and decreases in cardiometabolic risk factors were clinically meaningful after 12 months of counseling.