Extrusion is a thermomechanical technology that has been widely used in the production of various starch-based foods and can transform raw materials into edible products with unique nutritional characteristics. Starch digestibility is a crucial nutritional factor that can largely determine the human postprandial glycemic response, and frequent consumption of foods with rapid starch digestibility is related to the occurrence of type 2 diabetes. The extrusion process involves starch degradation and order–disorder structural transition, which could result in large variance in starch digestibility in these foods depending on the raw material properties and processing conditions. It provides opportunities to modify starch digestibility by selecting a desirable combination of raw food materials and extrusion settings. This review firstly introduces the application of extrusion techniques in starch-based food production, while, more importantly, it discusses the effects of extrusion on the alteration of starch structures and consequentially starch digestibility in various foods. This review contains important information to generate a new generation of foods with slow starch digestibility by the extrusion technique.